Let’s be perfectly honest. Many doctors have a difficult time dealing with patients in pain. Most medical schools devote relatively little time to teaching about pain management. The same can be said for schools of pharmacy. As a result, many health professionals are at a loss when it comes to both acute and chronic pain control. The opioid crisis has magnified the problem. Many prescribers have turned to non-opioid alternatives such as gabapentin for pain assistance. This is especially true around surgery. A new study suggests that this strategy may not be working very well (JAMA Internal Medicine, Nov. 1, 2022).
Gabapentin For Pain After Surgery:
The authors of the study in JAMA Internal Medicine outline the problem:
“Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain.
“Question: Is perioperative gabapentin use associated with in-hospital adverse clinical events among older adults after major surgery?”
A Reader Describes Gabapentin for Pain Control After Surgery:
Q. I was given gabapentin in the hospital following surgery. A few days post-surgery, the doctor removed drains along with a pressure bandage. At that point, I began to feel very light-headed and had awful diarrhea.
At home, I had several additional episodes of dizziness and diarrhea. On the fourth day home from the hospital, I began to feel extremely light-headed and called to my husband. He caught me as I was passing out, cracking my head on the kitchen counter as I went down.
My primary care physician checked me thoroughly and immediately took me off gabapentin. I haven’t had any issues since and will never take that drug again.
A. Doctors are turning to gabapentin for relieving pain after surgery, so that they can prescribe fewer opioids. Dizziness is a fairly common side effect of the drug, and diarrhea has also been reported.
The review in JAMA Internal Medicine (Nov. 1, 2022) criticized the prescribing of gabapentin to control pain in older adults after surgery. The authors noted that this medication is associated with delirium, dizziness, visual problems and pneumonia. You were fortunate that your fall did not result in serious complications.
“Delirium” After Gabapentin for Pain Management:
The last thing a patient needs after major surgery is “delirium.” It is garbage pail term for a collection of rapid mental changes. They may include disorientation, delusions, hallucinations, confusion, difficulty thinking, drowsiness, agitation, inability to pay attention and memory problems.
The authors of the JAMA Internal Medicine study conclude:
“In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. On the basis of these findings and those of meta-analyses of RCTs [randomized controlled trials] showing a weak opioid-sparing effect of gabapentin, clinicians should reconsider routine use of gabapentin for perioperative pain management among older adults and individualize the treatment decision after assessing the risk of immediate harms vs opioid-sparing benefits of perioperative gabapentin use.”
Gabapentin for Pain That is Chronic:
One physician described chronic pain patients to us many years ago:
“When I see a patient suffering severe chronic pain come in the front door I want to go out the back door.”
That’s because there are few good options. Drugs like hydrocodone or oxycodone used to be prescribed in huge quantities. Now gabapentin (Neurontin) and pregabalin (Lyrica) are on the ascendency and opioids are shunned. At last count, nearly 9 million people filled more than 44 million prescriptions for gabapentin. Another 9 million prescriptions were dispensed for pregabalin.
The Opioid Epidemic:
Doctors are dismayed by the opioid epidemic. Headlines about opioid overdoses and deaths has scared a lot of physicians into cutting back on prescribing drugs like hydrocodone or oxycodone.
Many of the overdose deaths are caused by illicit fentanyl. People OD because they have no idea how potent the narcotics are that they are snorting, swallowing or injecting.
According to the CDC (Nov. 3, 2017):
“Preliminary estimates of U.S. drug overdose deaths exceeded 60,000 in 2016 and were partially driven by a fivefold increase in overdose deaths involving synthetic opioids (excluding methadone), from 3,105 in 2013 to approximately 20,000 in 2016. Illicitly manufactured fentanyl, a synthetic opioid 50–100 times more potent than morphine, is primarily responsible for this rapid increase. In addition, fentanyl analogs such as acetylfentanyl, furanylfentanyl, and carfentanil are being detected increasingly in overdose deaths and the illicit opioid drug supply.”
Fentanyl powder does not come from your local pharmacy. Most of it is illicit and is coming from foreign countries (CBS news; New York Times, Aug. 10, 2017). China and Mexico are major sources of illegal fentanyl. It is being added to heroin or even counterfeit opioid pills that look like Percocet (CNN June 8, 2017) or Oxycontin. The government does not seem to know how to stem the flow of illicit fentanyl that is flooding the country.
Doctors and Opioids:
It is hardly any wonder that doctors have cut back on prescriptions for hydrocodone and oxycodone. Like the rest of us, they read horrifying reports about opioid deaths. The evening news often leads with graphic accounts of accidental overdoses.
Federal guidelines and restrictions have made it harder for physicians to prescribe opioids. The cutback in opioid prescribing has not stemmed the tide of opioid overdose deaths, though. We attribute them to illegal fentanyl derivatives.
Gabapentinoids: What Are They?
As a result of the negative publicity and constraints on opioids, many people who are in severe pain have been left without relief. Consequently, physicians are searching for other drugs they can prescribe instead of narcotics. They may turn to gabapentinoids (gabapentin and pregabalin).
Gabapentin (Neurontin) and pregabalin (Lyrica) are both used to treat nerve pain. Doctors prescribed these medications three times more often in 2015 than they did in 2002, despite no radical change in the number of patients with neuropathic pain (JAMA Internal Medicine, online Jan. 2, 2018).
The author advises his colleagues to use these drugs cautiously:
“The combination of a dearth of long-term safety data, small effect sizes, concern for increased risk of overdose in combination with opioid use, and high rates of off-label prescribing, which are associated with high rates of adverse effects, raises concern about the levels of gabapentinoid use. While individual clinical scenarios can be challenging, caution should be advised in the use of gabapentinoids, particularly for those individuals who are longterm opioid users, given the lack of proven long-term efficacy and the known and unknown risks of gabapentinoid use.”
A perspective published in the New England Journal of Medicine goes even further (Aug. 3, 2017).
The authors note that guidelines from the CDC recommend acetaminophen and NSAIDs as first line options for osteoarthritis and low back pain.
The physicians point out that:
“acetaminophen is often ineffective, and NSAIDs are associated with adverse effects that limit their use…”
They go on to say:
“The CDC guidelines also recommend gabapentinoids (gabapentin or pregabalin) as first-line agents for neuropathic pain. We believe, however, that gabapentinoids are being prescribed excessively — partly in response to the opioid epidemic”
“Patients who are in pain deserve empathy, understanding, time, and attention. We believe some of them may benefit from a therapeutic trial of gabapentin or pregabalin for off-label indications, and we support robust efforts to limit opioid prescribing. Nevertheless, clinicians shouldn’t assume that gabapentinoids are an effective approach for most pain syndromes or a routinely appropriate substitute for opioids.”
The CDC recently admitted that its restrictive opioid rules may have been overly aggressive. You can read about the new “Clinical Practice Guideline” at this link.
Gabapentin Side Effects:
The history of gabapentin (Neurontin) is fascinating. It was originally approved by the FDA for treating epilepsy in 1993. There is a tale of woe and intrigue about how the company that marketed Neurontin got into trouble with the FDA for illegal off-label marketing practices. We won’t go into that here, but you can read all about it in this article:
Gabapentin has become a go-to drug for doctors who are trying to control chronic pain problems. At last count, dispensed prescriptions have gone from 39 million in 2012 to 51 million in 2014 to 64 million in 2016 (Quintiles IMS, May, 2017, now IQVIA Institute). According to our most recent data, more than 10 million people take gabapentin daily. Many of them are taking gabapentin for pain, not for epilepsy.
Gabapentin can cause depression, dizziness, fatigue, drowsiness, digestive tract upset, trouble with balance, cognitive difficulties and visual problems.
The official prescribing information warns:
“Antiepileptic drugs (AEDs), including gabapentin, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.”
A Physician’s Perspective from the Other Side of the Stethoscope!
Dr. Bob describes his personal experience with opioids and gabapentin:
“As a physician I have heard from patients many varied stories of how different medications have affected them. I have come to believe just about any side effect relayed by patients as real, based upon my own personal experiences with taking more medications as I have gotten older.
“Pertinent here is that after having knee replacement surgery on both knees, I have had first-hand experiences with taking opioids and gabapentinoids. I also have my own frustrations to share—as a patient—dealing with medical prescribers who fail in the art of medicine by not attending to the nuances of effects I myself have relayed. Dealing with patients takes time, something that is not valued in our healthcare system. And many prescribers—especially surgeons, who inflict the most pain—have little patience for this most important follow up to their craft.
Dr. Bob’s observations:
“I have discovered the following after knee replacement surgery, most of which has come as a surprise to me:
1) not all opioids are equal in relieving pain with acceptable side effects. I have found that hydromorphone (Dilaudid) works best—for me. Its pain relieving effect lasted longer without the nausea and intense itching of other opioids.
2) to my surprise, the most problematic pain after knee surgery has been neuropathic [nerve] pain. Something as seemingly innocuous as dragging the bed sheet across my leg was very painful. I would also have shooting pains come out of nowhere around the incision site. I had thought a priori that I would experience a deep bone pain—but I did not—as, after all, bone had been cut, a prosthesis was inserted, and I would bear weight on this area.
3) Gabapentin gave me all sorts of bad side effects: brain fog, imbalance, sleepiness, and dysphoric mood. Lyrica did none of this. The most annoying side effect has been dry mouth. Most importantly is that Lyrica has been a miracle drug for alleviating the god-awful neuropathic pain. I could actually sleep at night without rolling around in discomfort.
“Bottom line is that patients do respond differently to medications and we as prescribers have to get over our ‘one- size-fits-all”’approach and our own discomfort with attending to the nuances of medicine.”
Pregabalin (Lyrica) Is also a Gabapentinoid:
If you watch television you have probably seen a commercial for Lyrica. There are so many we have lost count. Here are just a few:
We suspect that such commercials influence patients and physicians alike. Lyrica sales have gone from $1.9 billions in 2012 to $3.1 billion in 2014 to $4.4 billion in 2016 (Quintiles IMS, May, 2017, now IQVIA Institute).
Pregabalin Side Effects:
Pregabalin (Lyrica) can also cause adverse reactions. They include dizziness, unsteadiness, coordination problems, fatigue, dry mouth, edema, blurred vision, cognitive difficulties, confusion, depression and possibly suicidal thoughts, among other problems.
This is just a partial list. To read more, visit this link:
Tramadol: Another Option?
The other popular substitute for opioid pain relievers is tramadol. It was initially presented to doctors as a non-narcotic all-purpose pain reliever. But this medication can cause quite serious side effects and has potentially deadly interactions. Not only that, but it can trigger nasty symptoms if people stop taking it abruptly.
Tramadol Side Effects
What are tramadol’s side effects? Many people experience vertigo, unsteadiness, dizziness or trouble with coordination. Itching, dry mouth, digestive upset and headache are also common. Tramadol can also cause seizures, life-threatening allergic reactions, serious skin reactions and serotonin syndrome.
Read more about adverse reactions to tramadol at this link:
Are NSAIDs a Good Alternative for Chronic Pain?
While many patients can benefit from tramadol or one of the gabapentinoids, experts suspect that the push to move away from narcotics is leading doctors to overprescribe these alternatives. Unfortunately, there aren’t many other drug options for managing severe, chronic pain.
NSAIDs (nonsteroidal anti-inflammatory drugs) such as celecoxib, diclofenac, ibuprofen, meloxicam or naproxen are not that effective against chronic pain. They also carry a number of serious side effects including bleeding ulcers, irregular heart rhythms, heart attacks and strokes.
What Is Left?
Some pain patients tell us that the only way they can function is with an opioid such as hydrocodone. But scary headlines and regulations have made it very difficult for health professionals to prescribe such medicines. If there is one message to researchers, drug companies, the FDA and clinicians it is that we desperately need better and safer alternatives for controlling severe, chronic pain. We do not think gabapentin for pain management is the answer for everyone.
What Is Your Experience?
Please share your experience with gabapentin, pregabalin (Lyrica), tramadol and NSAIDs in the comment section below. There are hundreds of stories from other readers at these links:
Looking for other options?
You may find our one-hour interview with pain expert Dr. Sean Mackey helpful. He is Chief of the Division of Pain Medicine at Stanford University School of Medicine. Dr. Mackey says we need a revolution to change how we think about pain.
You can listen to our one-hour interview for free. Just click on the white arrow inside the green circle under his photograph or download the free mp3 file at the bottom of the page. Here is a link to the show:
Share your own story about gabapentin for pain in the comment section below. We recognize that many people do benefit from this drug, especially for nerve pain. We would like to better understand your experience.