A case of pregabalin addiction.

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Pregabalin, a gamma-aminobutyric acid analog, is a new-generation anticonvulsant that acts by reducing the release of glutamate, noradrenaline, and substance P. Apart from use as concomitant therapy in partial epilepsy, it is used in the treatment of treat neuropathic pain, fibromyalgia, and generalized anxiety disorder. Experimental studies have claimed its usefulness in the treatment of benzodiazepine dependence and withdrawal, as well as preventing relapse in alcohol-dependence patients.[12] Pregabalin use in primary health care has increased recently. In therapeutic dosage, chances of addiction are unlikely. However, there are few reports of addictive potential of the drug when prescribed in higher amount.[3] A case of pregabalin addiction is presented because of its rarity in India. A 32-year-old married male, an operation theater assistant, reported with the complaints of regular use of tablet pregabalin for the past 7 years. Initially, the patient was prescribed tablet gabapen 300 mg bd for chronic pain following traumatic mandibular subluxation. After taking the medication for 3 months, he perceived improvement in his pain. He also felt energetic. When he stopped taking tablet gabapen, he experienced fatiguability and irritability. Since tablet gabapen was costly and he had easy access to tablet pregabalin, he started consuming pregabalin. However, he was not getting the same effect, so he kept increasing the dosage and eventually was consuming 20 tablet/day. At this dose, he used to feel energetic, elated, had increased work performance, and was appreciated by his seniors. His appetite increased significantly. Over the course of 7 years, he experienced diminishing effect, so he gradually increased the dosage to 40 tablet/day. Finally, he was caught stealing drugs and was removed from the job. To satisfy his craving, he started taking loans and sold household articles, and consequently, his family abandoned him. He then tried stopping tablet pregabalin for a few days, but he experienced low mood, irritability with decreased sleep, and appetite, so he restarted taking the tablets. His friend eventually brought him to the psychiatric center. Past and family history was not significant. No history of other substance use was reported. His physical examination and routine investigations were within normal limits. Electroencephalogram showed right frontocentral abnormality. On mental status examination, he was in contemplation stage of motivation. He was admitted and was started on tablet oxcarbazepine 150 mg bd, tablet clonazepam 0.25 mg tds, and tablet tryptomer 10 mg along with psychotherapy. Gradually, his craving reduced and he has maintained abstinence for 3 months after discharge. A systematic review of 106 studies on PubMed/Scopus did not find credible evidence of a strong addictive power of gabapentinoids, due to their limited rewarding properties, few relapses, and the very few cases with gabapentinoid-related behavioral dependence symptoms in patients without a history of substance abuse/dependence. Further, there were no reports of people seeking treatment for abuse of gabapentinoids.[4] Our patient was strongly addicted, felt euphoric and energetic due to the drug, gave history of relapse, and came for treatment. It is assumed that gabapentinoid pharmacodynamics possibly include brain's drug-reward pathways.[5] Physicians prescribing gabapentins should carefully evaluate any history of substance misuse before starting the drug. Furthermore, they should be able to promptly identify signs of pregabalin/gabapentin misuse, while providing assistance in tapering off the medication.[6] The tendency to downplay the addiction potential of gabapentinoids should cease forthwith. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.