Gabapentin

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Welcome to Rumor vs Truth, your trusted source for facts.
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We dissect the evidence behind risky rumors and reveal clinical truths.
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Today, we'll gab about rumors around gabapentin.
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Hey Steve.
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You know, let me ask you a question.
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Have you ever looked at a medication list and thought, you know, why is gabapentin on here for everything?
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Yeah, it feels like that.
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Nerve pain, yeah, restless legs, sure, sleep, anxiety, your cats going crazy.
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Also, yes, yeah, it's everywhere.
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Yep.
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And to put it more in construction terms, it seems like it's like the duct tape of the pharmacy world.
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Today we're separating what's legit from what's just been flying under the radar, including some safety claims that don't always make it into the conversation.
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And some of the claims out there about the sedating med can be quite jarring.
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Yeah.
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This episode definitely won't make you fall asleep.
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With that, I'm your lively host, Don the Pharmacist.
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I'm Steve the Pharmacist. And this podcast offers continuing education credit for pharmacists, pharmacy technicians, prescribers, and nurses.
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Just log into your pharmacist letter, pharmacy technician's letter, or prescriber insights account, and look for the title of this podcast in the list of available CE courses.
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And for the purposes of disclosure, none of the speakers today have anything to disclose.
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Right.
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So gabapentin.
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Quite a story to tell, right?
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So let's back up a bit here.
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Um Gabin started as an anti-seizure medication approved by the FDA in 1993, uh, and is strictly similar to the neurotransmitter, the GAMA aminoutyric acid, or GABA for short, right?
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So this neurotransmitter slows down nerve firing, which can decrease dysfunctional signals in the brain that we see with seizures.
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That's right.
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And we also see dysfunctional firing and nerve-related or neuropathic pain.
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Uh, that's why gabapentin is also approved for post-herpetic neuralgia or nerve pain after having shingles, which is pretty specific.
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But the reality is gabapentin is now used far beyond seizures or post-herpetic neuralgia.
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In fact, about eight in ten U.S.
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gabapentin prescriptions are actually for off-label uses.
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But is this med really a jack of all trades?
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I do see gabapentin all the time.
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Uh I actually see this med so often for other neuropathic conditions, I never thought of it being not approved for them.
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Um and when one medication shows up on a medication list for pain, sleep, anxiety, restless legs, you name it, it becomes really easy for rumors to take root.
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And I think some people see it as a cure-all, others see gabapentin as a hidden danger.
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And both extremes really miss the real story.
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Uh, this actually has been a problem for gabapentin.
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Its manufacturer paid over 400 million dollars in the mid-2000s to settle criminal and civil lawsuits over uh illegal advertising for unproved uses, you know, things like include bipolar disorder, attention deficit disorder, and migraines.
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Wow.
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Well, this topic is already getting quite unnerving.
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Love it.
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Uh, but that kind of history tends to linger in the background even years later, obviously.
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So between widespread off-label use, you have the mixed evidence and a lot of associated association-based studies that don't prove cause and effect, it's no surprise gabapentin has become a magnet for bold claims.
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Today, we're going to separate what which concerns are valid, which are overblown, and where the real caution belongs.
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Right.
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And now let's start with why gabapentin is on so many med lists for pain.
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The claim is gabapentin is modestly effective for neuropathic pain.
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Okay, modestly effective.
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Seems like it's doing a lot of work there.
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Yeah, I agree.
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And a nice way to quantify modest here is with the number needed to treat.
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So, for example, in posturpetic neuralgia, uh, past meta-analysis, so a group of studies all kind of combined, found that about seven patients need to take gabapentin for at least two weeks for just one patient to get uh get at least 50% pain relief, which is considered meaningful pain relief.
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Uh now for diabetic neuropathy, uh, the number needed to treat is a little lower, about five to six, which is considered a little bit better.
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But overall, for a few people, it's a decent win.
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But for many patients, it's not based on these numbers here.
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Okay, so to unravel your nerdy talk there, and for someone in practice, what does it mean for them?
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Yeah, to boil that down, it means gabapentin may help, especially for true neuropathic pain syndromes, such as diabetic nerve pain or fibromyalgia, but we should set expectations.
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Again, it's only FDA approved for post-herpetic neuralgia.
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Uh, but we know it's commonly used for other pain syndromes that based on this, frankly, have less evidence.
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Yeah, dose-wise, I think a lot of clinicians assume that more is better.
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That's true pretty much with a lot of pain medications.
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Uh, but keep in mind that gabapentin, I'll be the nerdy one now, is the gap in absorption is sat saturable.
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So meaning absorption drops as the dose goes up.
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A good way to think of it as like a sponge.
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Uh, once it's fully soaked, pouring more water onto it doesn't really make it absorb a whole lot more.
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Most of it just seems to run off.
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gabapentintin works in a very similar way.
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Once the gut hits its absorption limit, much of that extra dose doesn't get into your bloodstream.
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It just pretty much gets wasted.
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Right.
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When we look at 900 milligrams a day, we absorb uh see absorption at only about 60%, and it goes down to 34% at 2400 milligrams a day.
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So you kind of see that trend there.
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And in its labeling, studies in posturopedic neuralgia didn't show much benefit uh when using doses above 1800 milligrams a day, even though patients have taken much higher doses that I've seen in practice.
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Right.
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And I do see that higher than that.
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And and above that dose, you might just be increasing the risk for adverse effects.
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Yeah, and not all pain is alike.
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So gabapentin isn't a universal cure either.
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For example, uh, you may see gabapentin is sometimes used for low back pain that doesn't involve things like a pinch nerve, but the evidence for gabapentin there is particularly weak.
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And it actually seems to perform similar to placebo according to studies.
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So if we're not treating neuropathic pain, we should be careful about reaching for neuropathic pain meds, right?
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Yep, good.
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And when patients aren't seeing that meaningful benefit, uh, we should double check that they've optimized those non-drug therapy options to help with pain.
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Uh, what comes to mind is like physical therapy, aerobic exercises, swimming is one of them.
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So yeah, definitely good to point those out.
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So when it comes to this claim that gabapentin is modestly effective for neuropathic pain, the verdict is true.
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The practical takeaway here is set expectations early and prioritize uh close pain reassessment.
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And if you don't see meaningful benefits, don't just keep titrating that gabapentin up forever.
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Yeah, true.
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Patient is already on a higher dose.
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Uh, keep an eye on adverse effects like dizziness and excessive sleepiness.
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Uh, drowsiness when starting or titrating doses is more common, but it should prove within two to four weeks.
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And remember that doses of up 800 milligrams per day, add a benefit, maybe limited.
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I like that.
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And consider pregabolin as a possible alternative here.
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It's closely related to gabapentin, hence the name, but it has more predictable pharmacokinetics.
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Its absorption is 90% or higher, and it doesn't have that saturable issue that you're talking about, Don.
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And I believe evidence suggests pregabilin works faster, has the benefit of having a narrower dosage range, and it can be titrated faster.
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And keep in mind that pregabolin is FDA proof for diabetic nerve pain and fibromyalgia, whereas gabapentin is not.
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And to help ease the pain of deciding neuropathic pain options, use our pharmacotherapy of neuropathic pain as well as our treating fibromyalgia charts.
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Cool.
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All right, so now we talked benefits, right?
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So what's the other end of it?
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It's risks.
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Uh and here's a big one that comes up with patients and clinicians.
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So the claim is gabapentin is addictive.
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Yeah, that can be a scary claim.
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And this is where terminology matters a lot.
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So when people say addictive, you have to mean very different things, right?
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It can be tricky to tease this out from other terms like dependence.
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Right.
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So let's tease out now.
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So clinically, addiction has a specific definition.
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It's a treatable chronic metal condition, and it's impacted by many things, you know, brain circuitry, our genetics environment, and the patient's life experiences.
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Uh, people with addiction use substances or engage in behaviors that are compulsive, and they often continue those behaviors despite harmful consequences.
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And gabapentin doesn't really fit that profile when I think about it.
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It isn't proven to strongly activate the brain's dopamine reward pathway the way that opioids, alcohol, and stimulants do when we think about those.
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There's no real high driving people to seek it out compulsively on its own.
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Right.
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Let's look at the other end now, which is physiological dependence.
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And that's different.
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You know, patients may end up depending on a medication uh to avoid withdrawal symptoms if they stop abruptly.
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Uh, in the case of gabapentin, withdrawal can involve like seizure, agitation, things like that.
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Yeah, and if gabapentin is being uh gabapentin is being discontinued, product labeling recommends tapering it over at least a week exactly to avoid those symptoms.
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So I'm glad you pointed those out.
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Yep.
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And it's also reports of withdrawal that can look a bit like alcohol or benzodazmine withdrawal.
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But there isn't good evidence that gabapentin leads to cravings or that psychological inability to quit.
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You know, in this case, withdrawal is real, but withdrawal does not equal addiction.
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And I'm sure some of the audience is now wondering then why is gabapentin a controlled substance in my state?
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Some states do, in fact, have it as a control.
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Uh, plus, certain states require gabapentin prescriptions to be logged into their prescription drug monitoring program or PDMP to track use, even if it isn't a controlled med in that state.
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Uh, and this is mostly because gabapentin can be misused.
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For example, some patients may use illicit gabapentin supply or higher doses than prescribed to boost the effects of other substances, such as opioids.
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Speaking of uh, speaking of that, opioids, when you combine gabapentin with opioids, you raise the risk of respiratory depression overdose, as we all know, can be deadly.
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Uh, 2017 study showed that 50% increased risk in opioid-related deaths when gabapentin is co-used.
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But remember, this misuse issue doesn't necessarily mean gabapentin is addictive.
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So give the answer away, but going back to that claim, gabapentin is addictive.
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The verdict is rumor with conditions.
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The nugget here is don't jump to viewing gabapentin as addictive, but do keep dependence and withdraw risks in mind and taper carefully when planning to stop therapy.
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And gabapentin may not be a good choice in a patient with substance use disorder history.
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Uh, this may be a good scenario to think about other neuropathic pain alternatives, uh, things that come to mind maybe duloxetine or venlofaxine.
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Yeah.
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Those are good ones.
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So also continue to follow your state laws and pharmacy policies around gabapentin to prevent, address, diversion, and misuse.
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And check out our controlled substance prescription validation CE course for more details.
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We know there's lots of documentation and liability involved with these meds.
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That is a great course and biased.
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I did update it, so leave that out there.
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Uh, and one common point of confusion to clear up really opioid reversal agents like naloxin or nalmifene will reverse opioid effects in an overdose, but they won't reverse sedation from gabapentin alone.
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Uh if there's an overdose with both on board, naloxin can or nalifene can still be lifesaving for an opioid part.
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Uh, but patients may still need oxygen to help a gabapapent if gabapentin is still having an effect.
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Yeah, very true.
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And next up, uh scary claim that's been getting attention the last couple years is that gabapentin causes dementia.
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Very strong and punchy claim causes dementia, but what does the evidence actually say with that?
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Yeah, the short version here is there are observational studies showing an association.
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Others don't.
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Uh, and the designs make it hard to tease apart cause and effect.
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For example, a 2023 matched cohort study from Taiwan found higher dementia risk in people prescribed gabapentin or pregaplin.
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And the signal looked stronger in patients under 50 years old.
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So that's interesting.
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Uh, and a 2025 retrospective cohort study in chronic low back pain patients also reported increased dementia and mild cognitive impairment diagnoses in patients who were prescribed six or more gabapentin prescriptions.
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Right.
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So going back to the word association, all hammered in, saying association does not mean causation, right?
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And to establish causation, we would need a randomized control trial before we could say causation, right?
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Yeah, you're absolutely right.
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These study designs that they used are vulnerable to effects from other factors that can impact the outcome.
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People prescribed gabapentin may have more chronic pain, more comorbidities, taking other medications that may have links to dementia risks, uh, or things like more depression or sleep problems.
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And those factors themselves can impair cognitive outcomes, as we know.
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And there are many factors we got to need to control for to really get solid results, which only a randomized controlled trial can do.
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Right.
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And plus, just because someone has a prescription for gabapendent doesn't mean they actually took it.
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So you have to take that into account.
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Plus, this association isn't even seen across all studies.
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Uh, one study looking at adults 50 and older with chronic pain didn't find a higher dementia risk with gabapendent after adjusting for other factors.
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And they also didn't see a rise in risk with increasing doses, which you would expect if there was an issue, right?
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So there is a decent amount of evidence here that there isn't an association either.
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So when it comes to this claim that gabapentin causes dementia, the verdict is rumor.
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So some observational studies show an association, but others don't.
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And the designs don't allow us to say that it's a cause.
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So there isn't evidence that gabapentin causes dementia here.
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Right.
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And importantly, the risks you know I worry about uh aren't dementia decades later.
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You know, they're it's what's in the now, which is sedation, confusion, and the false.
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This is especially true for our, you know, our older patients.
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Uh gabapentin is noted on the beers criteria list for them.
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I think, for example, it mentions high risk in LA patients with kidney dysfunction and also flags that opioid plus gabapentinoid combinations can increase risk for sedation and respiratory depression.
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Good point.
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And I would say those are more clear and present risks than dementia here.
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And we have our potentially harmful drugs, beers criteria chart, is a handy reminder of risky meds to watch out for, including gabapentin.
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Uh, but if a patient tells me, well, I saw on TikTok that gabapentin causes dementia, my response isn't a knee-jerk, well, that could never happen.
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It's we're looking uh for stronger data and we're waiting for that.
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Uh in the meantime, we should use the lowest effective gabapentin dose, adjust routine dysfunction, and obviously reassess those pain benefits.
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All right.
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Of course you're on TikTok, Steve.
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Um getting back to it.
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And if a patient, you know, gets the foggy, gets foggy or unsteady or overly sleepy after starting or increasing gabapentin, you know, maybe in a way decreasing the dose and scan for other meds that could be the culprit.
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These also could include drug interactions with other sedating meds.
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I agree.
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And if the med isn't clearly helping with pain or function, considering tapering it off and switching to another med rather than just letting it ride indefinitely on that med list.
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All right.
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All right, now let's take a ride along to everyone's favorite segment, Fast Facts.
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And this is where we jump into some common bite-sized claims about gabapentin and give them a seal of approval or debunk them quickly.
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So, first up is gabapentin is associated with increased risk of cardiovascular disease.
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And the verdict is true.
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Gabipentinoids have been linked to higher rates of cardiovascular events like heart attacks and stroke in observational studies, but this only shows an association, not proof of cause.
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But still consider baseline cardiovascular risks, potential edema and weight gain, overall medication burden when choosing therapy.
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Right.
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And next up, gabapentin is effective for generalized anxiety disorder.
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And the verdict here is rumor.
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Gabapentin is sometimes used off-label here for anxiety, but we don't have randomized controlled trial evidence around using it for generalized anxiety disorder.
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It shouldn't be a first-line option, so stick with therapies that have stronger evidence.
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Uh, for more on choosing alternatives and managing risk, we've linked to several evidence-based resources in our show notes.
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Well, glad we could take those for a spin.
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Now, this next claim is a serious one.
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Right.
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And before we move on, we want to let listeners know that the next segment will discuss suicide and mental health.
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So if this topic is sensitive for you, please take care of yourself and feel free to skip ahead.
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If you or someone you know is struggling, help is available.
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Call or text 988 or check our show notes for more resources.
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Yeah, thank you, Steve.
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So the next claim is gabapentin is associated with suicidal behavior.
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And when we talk about suicidality, we have to separate three things.
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First one is the underlying condition, you know, things like chronic pain, depression, substance use.
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Second thing is the medication itself, and lastly is what the data can truly prove.
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So I reached out to one of our specially consultants, Dr.
00:19:16.400 --> 00:19:18.640
Adam Kay, to help us explain this.
00:19:18.640 --> 00:19:22.960
He's a clinical pharmacist and pain specialist who's published several papers of gabapentin.
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Let's see what he had to say.
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Hey Adam, welcome to the podcast.
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Glad to have you on.
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I was a little apprehensive on bringing you on since you're a Lakers fan, but I guess we'll look past that and go to the expert here.
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So our claim, this particular claim is gabapentin is associated with suicidal behavior.
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Uh, what are your thoughts on that?
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Well, I would say since 2008, the FDA has made it very clear that their analysis of thousands of patients and 11 anti-convulsants, that there is a strong association between the risk of suicide and antiepileptics, including gabapentin.
00:20:10.400 --> 00:20:25.839
So I think it's absolutely reasonable for there to be a black box warning, which we now just call a boxed warning, and an FDA med guide requirement for each dispensing.
00:20:26.960 --> 00:20:31.279
Uh do you so you said there the boxed warning on there?
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Do you have like numbers or percentages of association with um suicide ideation?
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Yeah.
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Um British Medical Journal and Lancet, they've done a lot of studies where they've identified pre-existing um mood and suicidal ideation risks.
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And we know that people that use gavapentin, for example, they also might have comorbidities, including anxiety, depression, insomnia, chronic pain, and all of those contribute to lots of suicides and lots of self-harm.
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So I think the statistics absolutely show a higher risk in people that use gabapentin.
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And I think that it's absolutely uh necessary for pharmacists and prescribers to suggest to patients that they read these med guides and they think about it.
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Is my mood, you know, getting bad?
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Am I being uh mean to my spouse and my kids and my coworkers?
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So we uh absolutely should keep in our mind that gabapentin is associated with self harm and we should monitor the patient's.
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closely because of this.
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Perfect.
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Okay.
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So that that's what you would, you know, that medical professional talking to that patient, you know, if they bring up that question, hey, is this could I have a worsening mood?
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The answer is you could, you know, basically on this.
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And especially if if you were already, you know, predispositioned to, you know, depression, that kind of stuff, that could potentially make it worse.
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Correct.
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Absolutely.
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As a pharmacist clinician, when I would initiate gabapentin, I would always initiate it with a low dose.
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There's absolutely no rush to start someone on 300 TID, for example.
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But you have to make sure the patients understand that there could be fluid retention, weight gain, respiratory depression, and all of these things are additive.
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And the med guide goes over all of this.
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And there's no reason why a pharmacist can't use the med guide to help them with the patient consultation.
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Patients are in a rush.
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They certainly aren't taking notes.
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No, that they're listening to the best of their ability, but I think the med guide absolutely you could point, you could highlight, and you could let the patient know that there are risks associated.
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I I think uh you know going back to consultations on gabapentin and myself and in the pharmacy is letting that patient know to let their families know too sometimes they don't know themselves that they're worsening condition because they're too they're too in it, right?
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And to let their spouse, children whoever listening know, hey, let me know if my mood is worsening.
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Would you kind of agree with that as well?
00:23:38.480 --> 00:23:39.200
Absolutely.
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It's sort of like with opiates in naloxone right now.
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No one expects a patient to utilize naloxone themselves if they lose consciousness.
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We know right now that the world is pretty opioid phobic.
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So I mean we have to believe that 80% of all the gabapentin or more is being used specifically for chronic pain.
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And these people have lots of comorbidities.
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We know that insomnia is very prevalent with chronic pain depression and anxiety and uh financial problems ED.
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I mean the list goes on and on.
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Yeah it's all additive.
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So I love the uh naloxone analogy thank you for that so anytime so thank you for joining us uh great answers and um talk you next time thanks okay it's been a pleasure thank you so much really good points there.
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I'm glad you got to talk with them Don uh and that's actually a really good reminder that I even needed to counsel patients and caregivers to watch for newer worsening depression agitation or suicidal thoughts and to contact a clinician right away if those occur.
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And I think about alternatives if a patient is unstable or has untreated mental health concerns.
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Yep.
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So going back to that claim which is gabapentin associated with suicidal behavior the verdict is true with conditions.
00:25:10.559 --> 00:25:24.319
Yeah I would treat this label warning like a monitoring prompt, not a guarantee but ask about mood at baseline, recheck after starting or titrating the med, and make sure patients know what symptoms should trigger an urgent call.
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Right.
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And also another point is when dispensing gabapentin ensure patients are receiving that FDA required medication guide with every fill to ensure they're informed about proper use and risks.
00:25:36.559 --> 00:25:42.799
And the bottom line truth here today is that many of the concerning claims around gabapentin don't tell the full story.
00:25:42.799 --> 00:25:50.160
Some are rumors some show associations without proof of cause and none mean the drug should be avoided wholesale.
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Right.
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The takeaway here whether you know here or anywhere else is gabapentin isn't isn't a bad drug.
00:25:57.680 --> 00:26:02.960
You know its proper use depends on what we're using it for, the dose and how we monitor it.
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Yeah so when you prescribe or dispense it think are we actually treating the right type of pain?
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And are we watching for sedation falls appropriate dosing for patient's kidney function and risky combinations?
00:26:15.359 --> 00:26:41.200
I'd say that's how you keep this med from being a risky pain in the neck and we hopefully calmed your nerves about gabapentin claims e credit and access evidence based resources from pharmacist letter, pharmacy technician's letter or prescriber insights and if you're not yet a subscriber or want to upgrade you can save 10% with our exclusive listener code RVT1026 at checkout.
00:26:41.440 --> 00:26:49.440
Easy link is in the show notes if you're already a subscriber tap the claim credit link in the show notes or search or see organizer for this episode.
00:26:49.440 --> 00:27:02.319
And before we go our favorite mailbag time this time we got a listener question about our antibiotic stewardship episode and it was should patients stop antibiotics early if they feel better?
00:27:03.039 --> 00:27:04.000
Good question.
00:27:04.000 --> 00:27:14.000
In fact we tackled a claim in that episode that was true about limiting most outpatient antibiotic courses to five days uh but we didn't want to pull today's episode off topic.
00:27:14.000 --> 00:27:19.200
So we answered it in a separate bonus episode and it's already in your podcast feed.
00:27:19.200 --> 00:27:19.839
Right.
00:27:19.839 --> 00:27:26.400
And if you're curious just scroll your feed for the bonus mailbag and you'll find our full answer there.
00:27:26.400 --> 00:27:26.960
Right.
00:27:26.960 --> 00:27:34.079
And if you have an aching question about gabapentin or neuropathic pain in general and you want that answered next month, send us a message.
00:27:34.480 --> 00:27:44.559
We also use your suggestions to plan our episodes email us at rumor versus truth at trchealthcare dot com or send us fan mail right from the podcast show notes.
00:27:44.559 --> 00:27:50.559
We really love some of the of our listeners to use the audio feature of that so we can actually hear your questions.
00:27:50.960 --> 00:28:00.480
And join us next time where we'll talk about off label claims around ivermectin which some states have made over the counter and we'll see which claims are over-hyped.
00:28:00.960 --> 00:28:08.640
Thank you for joining us on Rumors is truth your trusted source for facts where we dissect the evidence behind risky rumors and reveal clinical truths.
00:28:08.640 --> 00:28:10.160
See you next time