How could a medicine that is supposed to relieve pain make someone suicidal? Turns out it happens far more often than most health professionals realize. If physicians and pharmacists do not warn patients that gabapentin can trigger thoughts of suicide it can lead to tragic consequences. That almost happened to one reader. Her story is described below, but first here’s an overview on gabapentin.
First Some Background
Neurontin (gabapentin) was approved as an adjunctive treatment for epilepsy in the U.S. in the mid-1990s. Because it wasn’t recommended as a first line approach for generalalized epilepsy, it didn’t become an overnight sensation.
The manufacturer (Warner-Lambert) apparently wanted a bigger piece of the pie. One way to grab a bigger market share for Neurontin was to market the drug for other conditions.
Off Label Promotion
It has been against the law for a pharmaceutical company to market a medication for an “off-label” or unapproved use. That’s because the FDA requires expensive and extensive studies to prove a drug works for a particular problem and is safe for that use.
In the case of Neurontin, the drugmaker began marketing the medication to treat a wide range of health problems including migraine headaches, pain, bipolar disorder, attention deficit hyperactivity disorder (ADHD) and goodness knows what else. In 2004 Pfizer, the parent company of Warner-Lambert, pleaded guilty to violating the law by promoting the drug for unapproved uses. The settlement with the Justice Department was $430 million.
You might think Pfizer would have learned a lesson, but in 2014 it once again agreed to pay $325 million to resolve claims that the company marketed Neurontin for unapproved uses.
The Damage Was Done
To this day the FDA has only approved gabapentin for treating epilepsy and the lingering nerve pain caused by shingles (postherpetic neuralgia). Nevertheless, doctors prescribe gabapentin for an amazing array of conditions ranging from bipolar disorder, fibromyalgia and headaches to diabetic neuropathy, restless leg syndrome and insomnia. (Find a list of unapproved off-label uses at the bottom of this article).
None of these uses has received a green light from the FDA. How well it works for all the off-label conditions remains quite controversial. The evidence supporting some of these uses leaves a lot to be desired.
Gabapentin for Pain: A Growing Phenomenon!
According to physicians writing in the New England Journal of Medicine (Aug. 3, 2017):
“…while working in inpatient and outpatient settings, we have observed that clinicians in our practice community are increasingly prescribing gabapentin and pregabalin for almost any type of pain. Our experience is supported by national prescribing data. In 2016, gabapentin was the 10th most commonly prescribed medication in the United States: 64 million gabapentin prescriptions were dispensed, up from 39 million in 2012. Brand-name pregabalin (Lyrica) ranked 8th in invoice drug spending (i.e., spending that excludes rebates and discounts) in 2016, with sales of $4.4 billion — more than double the amount from 2012…”
How Good is the Evidence for Off-Label Prescribing?
Here is what an “Examination of the Evidence for Off-Label Use of Gabapentin” concluded in the Journal of Managed Care Pharmacy (Nov-Dec, 2003):
“In the majority of circumstances where it has reported potential for indications not approved by the FDA (i.e., off-label use), gabapentin is not the optimal treatment. The reader should remain cautious regarding claims that gabapentin offers any benefit in treating conditions other than those with FDA approval.”
Since the drug is now available generically it is unlikely that drug companies or researchers will invest the money necessary to find out how well it works for things like PTSD, social phobia, insomnia or irritable bowel syndrome (IBS) or back pain.
Speaking of Back Pain:
Millions of people suffer from low back pain on any given day. It is estimated that as many as 80% of us will have a long bout of back pain sometime during our lives. What do doctors have to offer for this kind of debilitating pain?
We are in the middle of an opioid disaster. That means that many physicians are reluctant to prescribe hydrocodone or oxycodone for severe back pain. What’s left? Not surprisingly, gabapentin (GB) or a similar drug, pregabalin (abreviated PG and sold under the brand name Lyrica) are prescribed for pain. They are referred to as gabapentinoids.
An article in PLoS Medicine (Aug. 15, 2017) concludes:
“Existing evidence on the use of gabapentinoids in CLBP [chronic low back pain] is limited and demonstrates significant risk of adverse effects without any demonstrated benefit. Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for CLBP merits caution.”
Depression and Suicidal Thoughts
In 2009 the FDA realized that gabapentin and other anti-seizure medications could cause depression and suicidal thoughts. Some doctors must not have gotten that memo. Here is a terrible story from a visitor to this website:
“I was prescribed gabapentin for pain after back surgery. When I felt no relief, my doctor kept raising the dose.
“I got more and more tired and had trouble with my balance and swelling in my ankles. I stupidly did not connect the medication with my symptoms.
“The real problem began with mounting depression, which I felt was caused by pain and disability. Soon I decided that suicide was the only answer and began carefully planning my exit.
“I made my will, set up my bank accounts and planned how to shoot myself outside so as to leave the least mess for my children. I was dead serious (no pun intended).
“Meanwhile my physician continued to up my dosage until I was practically flattened with fatigue. If I had not worked for a different doctor who noticed my frame of mind and alerted me to the side effects of gabapentin, I would be dead by now. I want everyone taking this drug to be aware of these problems.
Gabapentin Side Effects:
The FDA approved gabapentin (Neurontin) for treating seizures and for the pain that may linger after shingles. As mentioned above, many doctors prescribe it “off-label” for other types of pain.
Fatigue is a common side effect of gabapentin; swollen feet are also a possible adverse reaction, which is probably why your ankles became swollen. Other adverse reactions include dizziness, fatigue, drowsiness, unsteadiness, visual problems, difficulty thinking, digestive tract upset and sexual difficulties. For a much more complete overview of the surprising side effects of gabapentin go to this link.
Depression and Suicidal Thoughts
The most serious problem with gabapentin in our estimation is the drug’s potential to trigger suicidal thoughts and actions.
The FDA warns:
“Patients, their caregivers, and families should be counseled that AEDs [anti-epilepsy drugs], including Neurontin, may increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm.”
We’re glad your employer alerted you to this problem. Too bad your doctor did not.
Many other people have also reported serious gabapentin adverse reactions on this website. At last count there were 600 comments at this link. Linda reported that her 83-year-old mom developed fever, tremors, chills and confusion. Andi described horrible withdrawal symptoms after she stopped gabapentin cold turkey.
Share your own experience with gabapentin, both positive as well as negative, in the comment section below. And please rate this article by voting at the top of the page.
Doctors Prescribe Gabapentin for These Off-Label Conditions
(Proof of efficacy may be insufficient to support such uses)
- Alcoholism & alcohol withdrawal seizures
- Bipolar disorder
- Diabetic neuropathy
- Essential tremor
- Generalized seizures
- Interstitial cystitis
- Irritable bowel syndrome (IBS)
- Multiple sclerosis (MS)
- Menopausal symptoms (hot flashes)
- Pain of various sorts
- Restless legt syndrome (RLS)
- Trigeminal neuralgia
People’s Pharmacy Perspective:
We’re not sure why health professionals are so enthusiastic about gabapentin. We are supposed to be living in the era of “evidence based medicine.” And yet the lack of evidence of effectiveness for many of the off-label uses does not seem to bother many prescribers.
If this drug were totally benign, with few side effects, then maybe we could see it. The authors of the PLoS Medicine article about chronic low back pain wrote that the use of gabapentinoids “merits caution.” We think that holds true for all off-label uses.