The Devil You Know – Neurontin’s Massive Flop as an Opioid Alternative

The Devil You Know – Neurontin’s Massive Flop as an Opioid Alternative

https://www.acsh.org/news/2022/09/16/devil-you-know-neurontins-massive-flop-opioid-alternative-16551

Wanna hear something sickening? Neurontin, a drug developed for epilepsy and used off-label for neuropathic pain, had its sales grow 350% between 2004 and 2019. Why? We don’t have 350% more epileptics. No, it’s because the drug is being forced down the throats of people who can no longer get sufficient pain relief. The result? Abuse and also more overdose deaths. Just another chapter in our psychotic war against legitimate opioid drugs and the people who need them.

Ask any chronic pain patient about gabapentin (Neurontin) as a replacement for opioids and you’ll probably get one of two reactions: Laughter or tears. Yet, the drug, originally intended to treat seizures, and subsequently found to be useful for controlling nerve pain and restless leg syndrome has been pushed (along with miscellaneous other useless drugs and techniques) as a safe and effective alternative to legitimate opioid analgesics drugs. It is neither. A new JAMA article makes this painfully obvious.

Using a useless drug?

Bridget M. Kuehn, MSJ, writing in JAMA Medical News & Perspectives primarily focuses on how gabapentin is increasingly contributing to the soaring (1) drug overdose death toll but does not ignore the fact that off-label use of the drug to treat non-neuropathic pain is lacking in evidence, perhaps on an unprecedented scale.

In her article, Ms. Kuehn quotes a number of experts. Don’t be surprised if you are surprised. [My emphasis]

“Gabapentin, by some estimates, is more widely prescribed off-label than what it is indicated for…We really don’t have data on what efficacy and dosages look like for this off-label use.”

Matthew Ellis, Ph.D., MPE, Washington University School of Medicine

If this isn’t a red flag I don’t know what is.

“Physicians have been afraid to prescribe opioids for fear that they will be contributing toward opioid misuse and abuse or that the Drug Enforcement Administration will prosecute them for prescribing opioids…There’s been a significant movement to nonopioids and gabapentin because it is believed by most physicians that it is not abused and that it is less harmful.”

 Lynn Webster, MD, Center for US Policy

Isn’t that wonderful? Physicians living under a cloud of fear and terror. From their own government. Let’s give CDC, DOJ, DEA, and PROP our heartfelt thanks for destroying liberties and lives. Nice job, idiots.

“People are trying to use things other than opioids, and there aren’t a lot of options when it comes to medication for pain”

And

“The elephant in the room is the role of the pharmaceutical industry in the growth of gabapentinoid prescribing…We are living in the world created by that push for off-label use.”

Christopher Goodman, MD,  University of South Carolina School of Medicine Columbia (2)  

 

Additionally, Dr. Goodman co-authored an article, “A Clinical Overview of Off-label Use of Gabapentinoid Drugs” in a 2019 JAMA Special Communication in which the authors concluded:

The evidence to support off-label gabapentinoid (3) use for most painful clinical conditions is limited. For some conditions, no well performed controlled trials exist. For others, one or several placebo controlled studies have been published, but results have generally shown the drugs to be either ineffective or only modestly and inconsistently effective.

 

And I wrote a mini-review on the utility (lack thereof, really) of Neurontin in managing pain in 2019. (See Neurontin: The Darling Of The Anti-Opioid Crowd. But Does It Work?)

So, it is safe to say that, aside from certain neuropathic conditions gabapentin fails miserably when used off-label for pain, something any pain patient who has been denied opioid therapy will tell you.

Someone who did just this is Crystal Lindell, a pain patient who wrote of her experiences with the drug (and the doctors who shoved it at her, in a 2021 column on the Pain News Network site:

When gabapentin didn’t help with the pain, I went back to my doctor and told him as much. He increased the dose, while assuring me that that was all that was needed. 

Wash, rinse, repeat, until I was on the highest allowable dose. Still with no relief. 

Crystal Lindell, PNN 12/10/21

That’s some mighty bad medicine, according to Chuck Dinnerstein, our Director of Medicine:

As a result, gabapentin does not follow the more is stronger or better rule of thumb that physicians apply to other drugs. As a result, the dosage of gabapentin is increased and continually oversaturates receptors rather than producing a stronger response.

C. Dinerstein, M.D., Private communication 9/12/22

To digress for a moment, Isn’t it funny that PROP fails to acknowledge the lack of viable options during any of its anti-opioid screeds? The group (falsely) maintains that opioids don’t work for chronic pain, yet offer no useful alternative. Is the following the best they can do?

[Tylenol] is a very weak painkiller. I completely agree with you that it’s, it’s very weak painkiller. It actually has, um, can be extremely effective when it’s combined with a nonsteroidal anti-inflammatory drug. It can actually increase the effect of the NSAIDs. So it’s kind of a magic combination combining Ibuprofen or another NSAID, um, with Tylenol, even though the Tylenol on its own is really quite weak.

PROP member Adriane Fugh-Berman, Transcript from a Debate with Jeffrey Singer, June 7th, 2022

Fugh-Berman’s cutting-edge medical advice involves combining a 67-year-old virtually useless drug (Tylenol) with a 53-year-old drug (Advil) that many people can’t even take. How innovative!

Improper use and abuse: Unintended (but not unforeseen) consequences

if you predicted in 1993, when gabapentin was approved, that it would be used three decades later as a primary pain medication you could have possibly become the founding member of QAnon. Yes, it’s that crazy, But because of the CDC- and DEA-sponsored mad rush away from opioids many doctors adopted an “it probably won’t help but at least it won’t hurt” mindset if only to get pain patients out of the office with something. This is reinforced by prescribing data. Between 2004 and 2019 the number of prescriptions for gabapentin rose from 18 million to 45 million – an increase of 350% – much of which was certainly a result of opioid phobia. This has created its own set of problems: lack of efficacy and abuse. 

It is more than a little ironic that in the thoroughly misguided attempt to get a handle on drug overdose deaths by imposing severe restrictions on opioid prescribing use (down by 60% and counting) gabapentin, the designated substitute, is being thrown at patients. And why not? After all, it is a Schedule V drug, along with other monsters like Lomotil and Robitussin AC. Gabapentin can be refilled up to five times, so it is not surprising that there is plenty of it around. 

Which should be no surprise to anyone who was paying attention six years ago.

Neurontin (gabapentin) came out of nowhere and joined the list of the top 15 drugs involved in overdose deaths in 2016. How did a Parkinson’s drug get there?? Source: National Vital Statistics Reports

Of course, once gabapentin abuse began it was virtually guaranteed to proliferate. It did. Even the CDC figured this out:

Although gabapentin is generally considered safe and is infrequently associated with overdose on its own, when used with other central nervous system depressants such as opioids, there is risk for respiratory depression, potentially resulting in death.

[D]ata indicate gabapentin exposures associated with intentional abuse, misuse, or unknown exposures reported to U.S. poison centers increased by 104% from 2013 to 2017…[A]mong 58,362 deaths with documented toxicology results, a total of 5,687 (9.7%) had gabapentin detected on postmortem toxicology. Gabapentin-involved deaths occurred in 2,975 of 5,687 decedents (52.3%) with a positive gabapentin test result.

CDC, Notes from the Field: Trends in Gabapentin Detection and Involvement in Drug Overdose Deaths — 23 States and the District of Columbia, 2019–2020

Isn’t it obvious that the more we continue to bungle the unwinnable “war on drugs” the result will be more and different abused drugs, more deaths, and more suffering for pain patients, who play no significant part in overdose deaths? (3)

My colleague Dr. Jeffrey Singer emphasizes what he calls “opioid prohibition,” and how (as was the case with alcohol prohibition) when one drug is prohibited people will find something else that is less safe, in this case, fentanyl, heroin, cocaine, methamphetamine, and now gabapentin, which may be abused but also used in separation:

I suspect gabapentin OD deaths are not from recreational use, but from pain patients who are in such agony that they take bigger and bigger doses to try to get relief. I suspect that doctors are increasing the dose when the initial dose is ineffective, that sends some patients the message to patients that it’s safe and OK to increase the dose until you achieve the desired result.

Jeffrey Singer, M.D. Private Communication, 9/14/22

As has been the case since fentanyl hit the US in 2013 there are still lessons to be learned about what really happens when legal and necessary medications are demonized and prohibited. How many more “drugs of abuse” will be futilely added to the DEA’s hit list? How many more pain patients will continue to face a choice between living in agony and trying to quell it with whatever pharmaceutical crumbs are tossed their way?

Such unspeakable cruelty. 

NOTES:

(1) Of course, it is illicit fentanyl that continues to be responsible for the vast majority of OD deaths and will probably maintain first place until something worse comes along.

(2) Isn’t it ironic that the pharmaceutical industry, which has been blamed for causing the opioid crisis, is now blamed for pushing hard for a replacement drug? Just asking. 

(3) The term “gabapentenoid” is used because there are several structurally similar drugs that form a class.. People generally hate all of them.

7 Responses

  1. I was forced onto neurontin about 4 times, long before this idiotic opioid hysteria hit. Neurologists with no experience &/or no imagination hit you with it for migraines. And a string of them ignored the fact that I’d tried it before (I was, of course, just looking for drugs to get high with; that’s all we’re all doing, right? GRRRR.).

    Update several years, I acquired my 1st source of chronic pain in 2001. Now pain docs were forcing me on the garbage, along with Lyrica (not at the same time). lyrica wiped out my short-term memory (it mostly came back in the year after I quit the lyrica). Gabapentin didn’t do a damned thing for pain –something else the doctors refused to believe, claiming they had “lots” of patients who’d gotten great pain relief from it (now who’s lying??). Last time, the doc kept increasing the dosage. One night I went to let the dog out back & I had to crawl back into the house; the higher dose had me seeing double, staggering, & falling over like a drunk, & slurring my words…ironically, it was as if I was high. After that I put my foot down; no more gabapentin!

    Many years ago, when gaba suddenly became the go-to miracle of pain relief they tried to convince us it was, I wrote about the fact that it had been abused as a street drug since about 3 days* after it came out for epilepsy. Several people, including doctors, assured me I was crazy. It was the same deal all ’round with Suboxone; that was on the list of abused drugs long before it became yet another “miracle” drug for pain. We’re trying to fight prejudiced belief with facts. . . always a recipe for failure. Add in monetary greed –does good ole Andrew K still own the chain of addiction treatment centers?– and pain patients are screwed. As we know all too well.

    *at a guess. Doesn’t take those chemists long to come up with abusable versions, if any changes are necessary in the first place.

  2. Oh boy, if only I had room to describe the chaos that was my experience with gabapentin and it’s sister med, Lyrica. I’ll just say that both have had lasting impacts on my overall cognitive function. I wouldn’t have continued taking either of them if I’d had a choice but I was informed that if I did not take one or the other, pain medication would be discontinued as well. Kind of like the injections that I was also told that I had to have or lose pain meds at one point. I’n case it’s not clear, I was not on Lyrica and gabapentin at the same time. First Lyrica and then it is was replaced with gabapentin after I was finally allowed to go off of it. Neither ever touched the nerve pain that I have. Or any other type of pain that I have, for that matter. Neither did anything beneficial for me except for making me sleepy. In fact they both caused me to sleep too deeply, to where I was difficult to wake up, in addition to causing a variety of other neurological symptoms that were overlooked. I can only guess that was due to the fact that my doctor did not seem to believe me when I talked about what kind of symptoms I was having when I took either one, plus the fact that I was getting zero relief from them. The dosages on each just kept going up and up and up, until I maxed out. First with the Lyrica, until I was finally able to get the doc to remove from my med regimen. Unfortunately, 60mg per day of my pain medication went with it. And I haven’t even had the courage to bring up the gabapentin just yet because of that, but I have been forced to alter how much I take in fear for my life. That’s by no means an exaggeration. But I fear losing the meager amount of pain meds that I still get if I say anything. I can’t believe what we have all been reduced to. We either do as we are told without making waves or they threaten to take away the one thing that does actually help. I know not everyone is in that situation but in all honesty, NO ONE should be in that situation. I am also aware that some people do report getting relief from either of those medications. I am happy for them if they do something for them. My problem is only with the fact that they can cause serious issues for certain people and it doesn’t seem to make any difference whatsoever. That’s on top of the fact that they don’t work for many people to reduce pain at all. It just so frustrating.

    • I am planning to speak with my doctor about it, just to be clear on that. I just have to figure out how to do that with the hopes of it not having a bad outcome for me. I just don’t want to end up dead because I have to take it or lose pain meds. Which would pretty effectively end what small amount of life I’ve been able to eke out too. I forgot to mention that I have something going on with me right now that is causing extreme fatigue on top of everything else. I went from not being able to sleep more than about 4-6 hours (if I was lucky) beforehand to sleeping for 10+ hours and taking unplanned naps throughout the day. There’s also some other stuff going on with me physically that I’m not going to go into but it does concern me that I might not wake up one of these times with gabapentin regularly causing me to be difficult to wake up even when not taking the full dose. I have an upcoming appointment and I am going to talk with the doctor about it then. Im hoping that I can explain my concerns in a way that doesn’t end with me being in some kind of trouble. Wish me luck, please!

      • I’d planned on wishing you tons of luck even before I got to the last sentence of your comment! I’ve been forced onto gabapentin several times, & I was on Lyrica for about 18 months. The Lyrica wiped out my short-term memory, almost making me lose my job. The only reason I didn’t was that I had a GREAT boss. Most of the s-t memory came back.

        I got such negative effects from the gaba the last time I was on it, I swore never again. But if my doctor was extorting me as yours is, I truly don’t know what I’d do. Ironically, the intolerable side effect was to make me see double, stagger around, & slur my words…in other words, it was like I was high.

        • I can definitely relate. It’s downright scary. If it weren’t for my family raising issues over the Lyrica, I don’t know what would have happened. My symptoms with the gabapentin are not that far off. They’re not identical, but not that far off. I can’t tolerate the constant cognitive impairment with gaba, even at lower dosages. ST memory is gone, most mornings I woke up wondering if maybe I had an actual stroke in my sleep, then going through all day feeling like my brain is a giant cotton ball, only to lay down and do it all again. It also makes me sleep so deeply that it’s absolutely scary. I’m hoping to be heard out, at least. The sad thing about the Lyrica is that if it had been removed without taking the 60mg pain medication with it, I am absolutely certain that I could have gone to work instead of being stuck at home in pain and with all of those symptoms. The Lyrica was quite literally what was causing all of that dysfunction and increased pain. Shortly after I went off of it, I felt “normal” and had actual pain relief for the first time, since I started the Lyrica and pain meds at the same time. I wish my doc would have seen the value in only doing one thing at a time there. But it was coming anyway given the guidelines, I suppose. Getting a job would have been short lived. I just wish I could have experienced real relief and being as close to normal as I could get, without the added pain and sickness. Would have been nice. As far as the gabapentin goes, I can’t take the full dosage. If the doc tells me to go back on it, I guess I’ll give up the pain medication because I just can’t do it. I am positive of that. I already tried to make it work and all it did was make me feel like I had lost 3/4 of my IQ, a significant portion of physical function due to cognitive dysfunction and as I said, like I’d had a stroke or perhaps was developing Alzheimer’s or something. I can’t reasonably see living that way just to appease someone else.
          Thank you so much for your kind words. I’m sorry to hear that you’ve also had similar “lovely” experiences with Lyrica and gabapentin. It’s shameful that they push those meds so hard as a purported substitutes or adjuncts to actual pain medication, under threat of losing them if you refuse to take the other. I do realize some people get relief from them but to be completely honest, I’ve heard more people say that they have had awful experiences with them than have said they’ve gotten relief from either one.

  3. I was prescribed Neurontin for Fibro when it first came out. I quickly realized after a very brief honeymoon on it that it was of no value AND it made my eyes ross. I was the sole driver in our family. So I quit taking it after less than 6 weeks.
    My doctor’s reaction? “They are looking for patients to be in an ad for it.”
    (No thank you.)

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