A painkiller used in almost every situation

Mary Peart, a 67-year-old retired nurse from Manchester-by-the-Sea, Mass., started taking gabapentin a year and a half ago to relieve pain and fatigue from fibromyalgia. The drug helps her climb stairs, walk her dog and take art classes, she said.

Thanks to this, “I have life,” she said. “If I forget to take a dose, my pain comes right back.”

Jane Dausch has a neurological condition called transverse myelitis and takes gabapentin as needed for pain in her legs and feet. “It seems to be effective for nerve pain,” said Ms. Dausch, a 67-year-old retired physical therapist from North Kingstown, R.I.

Amy Thomas, who owns three bookstores in the San Francisco Bay Area, takes gabapentin for rheumatoid arthritis. In addition to yoga and physical therapy, “that probably helps me move around more easily,” Ms. Thomas, 67, said.

All three are taking a non-opioid painkiller for purposes other than its intended utilize. The only conditions for which gabapentin has been approved for utilize in adults by the Food and Drug Administration are seizures in 1993 and postherpetic neuralgia, a nerve pain that can linger after shingles, in 2002.

But that hasn’t stopped patients and healthcare professionals from reaching for gabapentin (also known as Neurontin) for a range of other conditions, including sciatica, diabetic neuropathy, lower back pain and post-operative pain.

Also: Agitation due to dementia. Insomnia. Migraines. Itching. Bipolar disorder. Alcohol addiction.

Evidence of effectiveness for these conditions is everywhere. The drug seems to bring relief to some patients with diabetic neuropathy but not for some other types of neuropathic pain.

Several tiny studies indicate that gabapentin may reduce itching associated with renal failure. However, data on its efficacy against lower back pain or number mental disorders are narrow and have no significant impact.

“It’s crazy how many indications it’s used for,” said Dr. Michael Steinman, a geriatrician at the University of California, San Francisco, and co-director of American Prescription Withdrawal Research Network“It’s become a drug that we don’t know what else we can do.”

(A related but less commonly used drug, pregabalin — brand name Lyrica — is also FDA-approved to treat several conditions, including fibromyalgia.)

What drove this? universal popularity“The history of gabapentin is really a history of applications outpacing evidence,” said Dr. Joseph Ross, an internist and health policy researcher at Yale School of Medicine.

Initially, Warner-Lambert, the manufacturer of gabapentin, introduced prescriptions for the drug for purposes other than its intended utilize. aggressive marketing methods which the Department of Justice has determined to be illegal and fraudulent; the company settled the government’s case for $430 million in 2004. Despite this, tripling the use of gabapentin between 2002 and 2015.

It got another boost when opioid utilize and abuse reached crisis proportions. “People were looking for alternatives, and this was often the drug they came across,” Dr. Steinman said.

Using Medicare data, he calculated that five million seniors with Part D plans received at least one prescription for gabapentin in 2020—12.2% of that population. The following year, that figure reached 12.8%.

By 2022, the latest year for which data are available, 5.7 million older adults had received a prescription for gabapentin. It has become one of the most prescribed drugs in the country.

It’s also a drug that geriatricians and other researchers have been warning against for years, partly because of its side effects—including drowsiness, dizziness, and confusion—but also because it can interact with other commonly prescribed medications.

Beer criteria, catalog of potentially inappropriate medications Last year, it warned that gabapentin could escalate the risk of falls and fractures when taken with at least two other drugs that act on the central nervous system, such as antidepressants, antipsychotics, benzodiazepines and muscle relaxants.

Combining gabapentin with opioids is particularly risky, which, according to the Beers criteria, can lead to “sedate sedation-related adverse events, including respiratory depression and death.”

Like any medication, gabapentin can also cause “cascade rewriting” in which problematic side effects lead to treatment with another drug. For example, 2 to 16 percent of gabapentin users experience leg swelling, for which a diuretic such as Lasix is ​​sometimes prescribed, said Dr. Matthew Growdon, a geriatrician at UCSF

But diuretics have their own side effects: dizziness, falls, dehydration, abnormal electrolyte levels. The swelling can also lead a healthcare provider who is unaware of the patient’s gabapentin utilize to suspect heart failure.

If so, “you’d need an echocardiogram,” Dr. Growdon said. “And then you’re off to the races.”

Nanci Cartwright learned this lesson firsthand when a nurse suggested she take gabapentin for restless legs syndrome, which caused uncomfortable, involuntary movements that would wake her up and force her out of bed several times a night.

The insomnia was getting worse, said Ms. Cartwright, a 73-year-old retired executive assistant from Santa Fe, N.M. Her nurse thought the drug might also lend a hand ease pain in one leg, possibly caused by a pinched nerve.

Thanks to gabapentin, Ms. Cartwright enjoyed eight hours of uninterrupted sleep. “Unfortunately, I slept in the next day, too,” she recalled.

She became torpid and needed naps. It was “like being underwater,” she said. “I hated that feeling.” She no longer cared about activities she once enjoyed, like crafts and hiking on local trails. Her ankles and calves were swelling.

Unable to find a dose sturdy enough to relieve her symptoms without adverse side effects, she gradually began weaning herself off gabapentin. Within three weeks, she was off the drug.

However, elderly patients often take gabapentin for years or even decades without remembering why they started taking it or what effects it had.

Dr. Steinman called it a “sticky” drug. He was the author 2022 Study of Older Adults Prescribed Gabapentin after surgery, most commonly hip and knee replacements. One in five people had their prescription refilled after more than three months, when “their post-op pain had probably long since subsided,” he said.

Long-term gabapentin users should talk to their doctors, Dr. Growdon said. Why are they taking it? Does it still lend a hand? Could it cause symptoms or interact with other medications they take? Could they lower their dose?

Prescribing medications or renewing prescriptions is quick and uncomplicated, he said, but “stopping something or reducing the dose is a struggle early on,” requiring much more time and discussion.

Patients should not stop taking gabapentin suddenly, he added, because it can lead to withdrawal symptoms such as irritability, anxiety and insomnia. It is safer to gradually discontinue, as Ms. Cartwright did. This can take several weeks or, at higher doses, several months.

As older patients seek relief from chronic pain, “we don’t have a lot of great options,” Dr. Steinman said of health care providers. Prescribers try to avoid opioids, and nonsteroidal anti-inflammatory drugs like ibuprofen are recommended only for short-term utilize.

Some people find relief with medical marijuana, topical medications such as creams and patches, and non-pharmacological methods such as acupuncture, therapeutic massage, and exercise.

“Often the best thing I can do for patients who are in pain is to take them to physical therapy,” Dr. Steinman added.

He says various mind-body interventions, such as meditation and cognitive behavioral therapy, can also make pain more bearable by changing the way the brain responds to it.

That’s where Ms. Cartwright is now. Without gabapentin, her restless legs syndrome and insomnia have returned. “I think I need to focus more on non-drug solutions,” she said. She’s trying an online app that teaches techniques for managing chronic pain.

As for leg pain attributed to a pinched nerve, further diagnosis revealed that she didn’t need medication but hip replacement surgery, which she underwent a year ago. “It was fantastic,” she said. “It completely got rid of the leg pain.”