March 4, 2024

expert reaction to media reports and questions about pregabalin

Scientists react to media reports about pregabalin for anxiety.

Prof Glyn Lewis, Professor of Psychiatric Epidemiology, University College London (UCL), said:

Why do you think prescriptions for pregabalin have risen? Is it being prescribed inappropriately?

“We do not fully understand why pregabalin prescriptions are rising but it is used for both pain and anxiety. Both are common and often do not respond fully to other medications.

What should happen now?

“We are carrying out a study funded by the NHS to investigate the effectiveness of pregabalin for anxiety in people who have not responded fully to an antidepressant. It is called PETRA and will also investigate whether there are withdrawal symptoms when pregabalin is stopped.

Should it be banned or should more checks before prescribing be enforced instead? 

“There is a known problem of combining pregabalin with opiate medication. The examples given in the newspapers appear to be people who were not following advice from their doctors and taking large doses of both pregabalin and opiate medication.   Pregabalin could be effective and helpful for many people, but patients should follow the advice of their doctor and report any side effects they experience.”

Dr Franziska Denk, Senior Lecturer, King’s College London (KCL), said:

Why do you think prescriptions for pregabalin have risen? Is it being prescribed inappropriately?

“It appears that the patent has expired, which is perhaps why it is being prescribed more frequently now, both for epilepsy and a specific type of pain, known as neuropathic pain which is particularly horrible. I don’t think I can conclude from the data shown here that it is being prescribed inappropriately.

What should happen now?

“It appears that most deaths related to pregabalin occur in combination with other drugs (usually opioids and usually when taken illegally), see e.g. here: https://www.sciencedirect.com/science/article/pii/S037907382100150X#sec0025 and here: https://www.bbc.co.uk/news/uk-northern-ireland-66579996 – so perhaps it would be worth warning people who might engage in recreational drug use of its potentially dangerous side effects, especially when combined with substances, including alcohol.  

“It might also be good to know how many prescriptions for pregabalin are for anxiety alone. My guess is not too many.

Should it be banned or should more checks before prescribing be enforced instead? 

“I do not think there is much evidence to suggest that it should be banned from being legally prescribed, or indeed that it is being over-prescribed to a dangerous degree. A lot of the additional prescriptions since the patent has expired may be to doctors opting for a now cheaper pregabalin over other, more expensive epilepsy drugs. Epilepsy is a very dangerous, life-threatening condition, for which none of the other existing medications, besides pregabalin, are without the risk of serious side-effects.”

Dr Cathy Stannard, Consultant in Complex Pain/Pain Transformation Programme Clinical Lead, NHS Gloucestershire CCG, said:

“The challenge with scrutiny of prescribing data is that there are three main uses of pregabalin: pain, anxiety and epilepsy and we don’t know which of these is driving the rise in prescribing.  For epilepsy and anxiety, my understanding is that the drugs are third- or fourth-line choices. Most people agree that pain is one of the biggest indications but we would have to look at individual GP records to know for sure.  Pregabalin should be used less for pain since the NICE Guideline for Chronic Pain (2021) and the updated guidance on sciatica in the same year made a ‘do not prescribe’ recommendation for many pain presentations.  I thought initially it may be prescribed increasingly for pain as reluctance to prescribe opioids becomes standard practice. However, when we looked at prescribing in our own system, we examined records of over 800 clinical encounters and no patient who was supported to stop or reduce their opioids was initiated on pregabalin.

“So, I think for this important topic to progress, we need greater insight in what the drug is being prescribed for.”

Dr Xinchun Gu, Researcher in the Nuffield Department of Primary Care Health Sciences, University of Oxford, said:

• Why do you think prescriptions for pregabalin have risen? Is it being prescribed inappropriately?
  • Pregabalin is indicated for epilepsy, anxiety, and neuropathic pain. Studies suggest pregabalin has been increasingly used for chronic pain management in the UK, possibly leading to the rapid rise in prescriptions. The traditional drugs for pain management are opioids, which are known to be addictive, prompting clinicians to be cautious about their prescription. Therefore, pregabalin becomes the “safer” choice for many practitioners. I don’t think pregabalin is prescribed by clinicians inappropriately, as it was classified as a controlled drug in the UK in 2019. The area that needs attention may be the black market, because pregabalin appears to be used as a new recreational drug.
• What should happen now?
  • Studies have been published about the risks of using pregabalin, particularly when combined with opioids. My study suggested a higher risk of suicide, hospitalisation due to fractures, and death associated with pregabalin. Clinicians should be more cautious when prescribing pregabalin to patients with chronic pain, and inform patients about the potential risks. Additionally, actions to curb the sale of pregabalin on the black market and suppress recreational use could help.
• Should it be banned or should more checks before prescribing be enforced instead? 
  • I don’t believe pregabalin should be banned, especially as it’s already a controlled drug in the UK. Perhaps if clinicians took more time to assess each patient before prescribing it, and followed up more regularly afterwards, we could reduce the risks.

All our previous output on this subject can be seen at this weblink:

https://www.sciencemediacentre.org/expert-reaction-to-study-on-gabapentinoids-and-risk-of-suicidal-behaviour/

Declared interests

Prof Lewis: I have funding from NIHR, Wellcome Trust and UKRI. I was given travel and accommodation expenses to attend the ENCP 2024.

Dr Denk: I do some consulting for GSK, and I’m on the Scientific Advisory Board of Cellectricon.

Dr Stannard: Clinical Lead for the NICE Guideline on Chronic Pain and for the NICE Guideline on Safe prescribing and withdrawal of dependence forming medicines. Note Dr Stannard does NOT work for NICE.

Dr Gu: No conflict of interest to declare.