Gabapentin (Neurontin) is not a medication that would make the FDA proud. Less than 1% of its outpatient use is for an FDA indication, and a good portion of the off-label use takes place in psychiatry. These trends sparked a backlash in the 2000s, when Pfizer paid a $1.3 billion fine for misleading marketing practices. Recent reports of misuse of gabapentin and its GABAergic cousin, pregabalin (Lyrica), have added to those concerns.
What Kinds of Off-Label Usages of Gabapentin Can Treat ?
Gabapentin is frequently prescribed off-label for a variety of conditions outside its primary approvals for epilepsy and nerve pain. Here is a list of some of the common off-label uses:
- Anxiety Disorders: Gabapentin is sometimes used to manage generalized anxiety disorder (GAD) and social anxiety, especially in patients who don’t respond well to traditional anti-anxiety medications.
- Bipolar Disorder: While not a first-line treatment, gabapentin may be used as an adjunct to stabilize mood in patients with bipolar disorder, particularly those who have difficulty tolerating other mood stabilizers.
- Insomnia: Due to its sedative effects, gabapentin is occasionally prescribed to help with sleep disorders, especially for those who struggle with sleep due to chronic pain or anxiety.
- Alcohol Dependence and Withdrawal: Gabapentin is used to help reduce cravings and manage withdrawal symptoms in patients with alcohol use disorder, as it can help alleviate anxiety, tremors, and insomnia associated with withdrawal.
- Migraine Prevention: Gabapentin is sometimes used off-label to prevent migraines, especially in cases where traditional migraine medications are ineffective or not tolerated.
- Hot Flashes: Particularly for postmenopausal women or breast cancer patients, gabapentin can be prescribed to help reduce the frequency and intensity of hot flashes.
- Restless Legs Syndrome (RLS): Gabapentin can help alleviate symptoms of RLS, a condition that causes uncomfortable sensations and an urge to move the legs.
- Pruritus (Chronic Itching): Gabapentin has shown effectiveness in managing severe itching related to conditions like kidney disease, liver disease, or certain types of neuropathy.
- Chronic Cough: Some cases of refractory chronic cough, where traditional treatments are ineffective, have responded to gabapentin.
- Multiple Sclerosis (MS)-Related Symptoms: Gabapentin can help alleviate nerve pain, spasticity, and certain types of tremors associated with MS.
- Temporomandibular Joint (TMJ) Disorders: In cases of chronic TMJ-related pain, gabapentin may be used to reduce discomfort.
- Post-Traumatic Stress Disorder (PTSD): It is sometimes prescribed to help manage PTSD symptoms, particularly anxiety, sleep disturbances, and hyperarousal.
- Vulvodynia: Gabapentin can help reduce pain in patients with vulvodynia, a chronic pain condition affecting the vulvar region.
- Phantom Limb Pain: After amputation, some patients experience pain in the “phantom” limb, and gabapentin may be used to help relieve these sensations.
- Chronic Pelvic Pain: Gabapentin is sometimes prescribed to help manage chronic pelvic pain, especially when associated with nerve involvement.
- Trigeminal Neuralgia: Although more commonly used for postherpetic neuralgia, gabapentin can also help with trigeminal neuralgia, a painful nerve condition affecting the face.
These off-label uses are based on clinical observations, smaller studies, or anecdotal evidence, so efficacy may vary. Always consult with a healthcare provider for guidance on using gabapentin for any off-label purpose.
What Are the Risks of Prescribing Gabapentin?
The rising use of gabapentin in combination with the ongoing opioid crisis has contributed to a surge of negative health outcomes including hospitalizations and death.
In 2019 the FDA issued a warning about the potential risks of respiratory depression in patients taking gabapentin or pregabalin in combination with central nervous system (CNS) depressants such as opioids, antidepressants, and benzodiazepines. The FDA also warned the medication could increase breathing difficulties in patients with underlying lung disorders, such as asthma or COPD, as well as the elderly.
Despite this warning, gabapentin prescribing has continued to increase in the United States.
According to IQVIA National Prescription Audit, total prescriptions dispensed for gabapentin were approximately 68.3 million in 2019, 69.0 million in 2020, and 70.9 million in 2021. At least 40% to 65% of individuals with prescriptions for gabapentin and roughly 20% for individuals who misuse opioids report gabapentin misuse.
Gabapentin misuse may in part be driven by dependence and withdrawal symptoms. Studies have demonstrated that patients who have taken as little as 400 mg daily for three weeks may experience withdrawal symptoms—including anxiety, pain, nausea, fatigue, and restlessness—that can begin within 12 hours of stopping the medication and can last up to 10 days.
Such misuse can quickly turn deadly: The Centers for Disease Control and Prevention (CDC) in 2022 issued a report that found the number of overdose deaths involving gabapentin approximately doubled from 2019 to 2020.
Why is Gabapentin Prescribed Off-Label?
- Versatility: Gabapentin affects the nervous system broadly by calming overactive nerves, making it useful for a wide range of conditions.
- Low Abuse Potential: Unlike opioids, gabapentin has a lower potential for abuse, making it a safer alternative for chronic pain management.
- Safety Profile: Generally, gabapentin is well-tolerated and considered safe when used properly, encouraging doctors to explore its benefits for other conditions.