More states make gabapentin a Schedule V Controlled Substance

Abstract

Gabapentin has landed on Schedule V Controlled Substance lists in 7 states over the last 5 years. During that same time period, 12 other states have placed the drug in their prescription drug monitoring programs (PMP). Three others are in the process of adding the prescription medication to Schedule V lists or state PMPs. “We’ve seen a significant increase in gabapentin prescribing over the last 10 to 15 years, but is it actually helping patients? The data suggest that it probably isn’t, and that’s a major concern for me,” said Jordan Covvey, PharmD, PhD, an associate professor in the School of Pharmacy at Duquesne University in Pittsburgh. While gabapentin is not a Federal Schedule V Controlled Substance, these recent actions taken by individual states should alert pharmacists about potential risks related to the drug and highlight the possible need for additional patient counseling in some cases. Gabapentin is the sixth most prescribed drug in the United States, and the vast majority of uses are off-label. Researchers believe that the increase in gabapentin prescribing over the last decade or more may be, in part, a reaction to the opioid epidemic. “It can be used as an opioid-sparing medication,” said Kirk Evoy, PharmD, a clinical assistant professor of pharmacotherapy at the University of Texas–Austin. Prescribers may recommend it in combination with lower doses of opioids. Prescribers also dole it out for numerous other off-label uses, including various types of pain, migraine, restless leg syndrome, hot flashes, insomnia, anxiety, and numerous other mental health conditions. “Many researchers are concerned about the level of prescribing that occurs in the setting where there is no evidence supporting its use,” Covvey said. “Some studies show it’s not effective for lots of indications that people continue to prescribe it for.” Among them, she names low back pain and radiculopathy. Research shows that gabapentin poses some risk for misuse and abuse. Some studies hypothesize that gabapentin releases excitatory neurotransmitters and affects the dopaminergic reward system, which plays a role in addiction. When used in combination with opioids, it can cause euphoria, which may lead to abuse. “Gabapentinoids have been shown to significantly increase the risk of opioid overdose when taken together,” Evoy says. The combination raises risks for central nervous system and respiratory depression, overdose, and death. That risk increases with use of sleep medications, benzodiazepines, antidepressants, or alcohol. The majority of gabapentin overuse, or even misuse, is likely not recreational. “Most of the misuse of gabapentin is likely driven by untreated pain or untreated conditions that may drive individuals, perhaps not having full relief from pain or other symptoms, to self-treatment with gabapentin,” Covvey said. Though some people may misuse gabapentin for recreational purposes, they likely do not represent the majority of misuse or overuse. “It’s very important that we don’t criminalize medication use,” Covvey said. Instead, she recommends, when patients pick up gabapentin, pharmacists should take the opportunity to check in with them to see how well it’s working, given the limited evidence for so many of its off-label uses. Check in every few months. If the medication isn’t helping patients, let prescribers know and make recommendations for alternatives. Pharmacists may need to provide extra counseling to patients who take both gabapentin and opioids or other high-risk combinations. Evoy suggests that pharmacists counsel on the increased risk of overdose and death. He also recommends that pharmacists advise patients to take these medications at home until they understand the way they will affect them. They shouldn’t drive right away, for example, until they are sure it’s safe to do so. “When a patient is prescribed opioids and gabapentinoids, pharmacists should not assume that they were ever counseled on the risks of these medications or the risk of overdose,” Evoy said. “Pharmacists should provide counseling, and we may also need to recommend they pick up a supply of Naloxone.” Gabapentin controlled status and monitoring in select states as of November 20, 2020▪States where gabapentin is classified as a controlled substance (AL, KY, MI, ND, TN, VA, and WV).▪States with mandated gabapentin reporting (CT, DC, IN, KS, MA, MN, NE, NJ, OH, OR, UT, and WY).▪States deliberating mandated reporting of gabapentin to controlled substance (DE, NY, and WI). ▪States where gabapentin is classified as a controlled substance (AL, KY, MI, ND, TN, VA, and WV).▪States with mandated gabapentin reporting (CT, DC, IN, KS, MA, MN, NE, NJ, OH, OR, UT, and WY).▪States deliberating mandated reporting of gabapentin to controlled substance (DE, NY, and WI).