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Gabapentin: The most dangerous drug

in America?
Pharmacist Tom Viola was caught by surprise when he read
online that the prescription drug gabapentin was causing
alarm as a new drug that's being abused. What he learned
may surprise you.
Author — Thomas A. Viola, RPh, CCP
Jun 18th, 2018

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It was early on a Sunday morning this past winter when I first received
several notifications on Facebook about a “new” prescription drug abuse
menace in America that was “killing thousands."

“What?!” I said to myself out loud. My initial shock was for two reasons.
First, as a pharmacist, pharmacology educator, speaker, and author for
more than 30 years, surely I would have heard of an issue with the illicit use
of yet another prescription drug.

Second, after such major strides had recently been made in combatting the
opioid epidemic in America, how was it possible that another prescription
drug had slipped in so easily to replace opioids as the next “menace?”

Nevertheless, the notifications and warnings went viral and I watched them
quickly spread from the web to broadcast media. The new menace was the
prescription drug gabapentin, commonly known by its most popular brand-
name, Neurontin. I must admit that initially these warnings struck me as a
bit alarmist. “Gabapentin?!” I said to myself incredulously. “How can that
be?”

What is gabapentin?
Gabapentin is an anti-seizure drug that is also prescribed for nerve pain. It
has been available in the US since 1993. I was unaware of any widespread
reports concerning any safety issues with it. Indeed, my quick review of the
literature indicated that the first peer-reviewed report of any gabapentin-
linked death was published in 2011 in the Journal of Forensic Sciences, and
that was an intentional suicide by overdose.

Well, many prescription and non-prescription drugs taken in excessive

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 amounts may cause death, even such innocuous drugs as aspirin and
acetaminophen. Further review of the literature revealed yet another report
of fatality by overdose, which was published the International Journal of
Legal Medicine in 2015. However, these two reports hardly constituted
thousands.

“So, what’s really going on here?” I pondered. Was this just social and
broadcast media hysteria or is this based on a real abuse phenomenon? As it
turns out, after my initial scratch of the surface, there was a lot for me to
uncover about the truth behind these gabapentin warnings.

Since its introduction, gabapentin has been very popular and widely used as
an adjuvant, an add-on drug that boosts the effects of other drugs,
especially to help control partial seizures in adults. However, in the quarter
century since its initial approval, off-label uses have exploded. It’s been
prescribed to treat multiple physical conditions with neurological origins,
from restless leg syndrome to nerve pain to acute and post-herpetic pain
associated with shingles. It’s also prescribed for multiple psychiatric
conditions, such as anxiety disorder, bipolar disorder, attention deficit
disorder, and is even prescribed, somewhat ironically, in addiction
treatment to reduce cravings and withdrawal symptoms.

Like almost all FDA-approved medications, when prescribed responsibly

and taken as prescribed, gabapentin can offer great relief to those with
these conditions. However, we all know that we live in a world in which not
every patient takes medications as prescribed.

Why should dental professionals take notice?

We dental professionals must be aware of gabapentin’s rise as a drug of
abuse, both alone and in combination with other substances. Why? Well,
while the dangers of gabapentin to patients may have been somewhat
overstated in the media, that doesn’t mean those dangers are not real
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 Since gabapentin works so well as an adjuvant, it is also frequently used in
combination with drugs of abuse to intensify their effects, especially
opioids. In July 2017, a report in Kaiser Health News detailed the dangers of
recreational drug users taking high doses of gabapentin along with opioids,
a practice called stacking. Interestingly, in this report many users were also
found to be taking gabapentin all by itself, in place of opioids, to get high
and stay high during rehab, thereby escaping detection during mandatory
opioid drug screenings (which doesn’t yet screen for gabapentin).

In 2016, a literature review in the journal Addiction reported that only 1% of

the general population misuses gabapentin. However, among people with
prescriptions for the drug, that number soared to 40% to 65%. In addition,
it was noted that among people who abuse opioids, the percentage that also
abuses gabapentin was estimated to be between 15% and 22%. Also in that
year, the state of Kentucky released data gathered from autopsies
performed on people who died of drug overdoses. The data revealed the
presence of gabapentin alongside deadly opioids such as heroin and
fentanyl. In fact, gabapentin was the most frequently detected substance in
these autopsies.

So, what’s the danger? Well, when used recreationally in this way,
gabapentin is often taken in doses that are much greater than its typical
legitimate therapeutic dose. Some users report taking up to 5,000
milligrams at once, which is nearly 2.5 times the usual prescribed daily dose
of 1,800 mg. At those high doses, gabapentin, like many other anti-seizure
medications, may produce exaggerated adverse effects, including,
counterintuitively, seizures.

In this respect, this issue with gabapentin seems to represent a bit of a

perfect storm. First, gabapentin is prescribed for pain, and since no health
professional wants to see a patient in pain, this may foster a bit of leniency
when it comes to prescribing practices and quantity limits for this drug.
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 Second, gabapentin is often prescribed off-label, so this may foster a bit of
an “anything goes” and “let’s try it and see if it works” feeling among
prescribers and their patients, encouraging experimentation with doses
and dosing frequency.

Third, gabapentin is not a controlled substance, and thus, since the usual
guidelines and restrictions for prescribing and dispensing large quantities
of such substances don’t apply to gabapentin, this may foster less oversight
of its use and fewer warnings for its potential abuse.

Fourth, gabapentin is not an opioid and this may foster a relative, and false,
sense of safety about its use and reduce concerns about its potential for
abuse

Finally, since gabapentin is often prescribed in large quantities and covered

by most prescription plans with a low generic drug copay, it is relatively
inexpensive and widely available for both its prescribed use as well as for
experimentation for abuse.

Recreational gabapentin abuse (with or without a prescription) needs to be

on the radar of dental professionals due to its potential for producing not
only additive adverse effects, but also serious drug-drug interactions with
medications we commonly use during dental procedures, such as for
conscious-sedation or the treatment of post-operative pain. Even when
used for legitimate reasons, gabapentin taken in combination with opioids
increases the risk of respiratory depression and death.

It’s important to ask patients about all prescription and non-prescription

medication use when reviewing their medical histories Keep in mind that
while patients may not be willing to admit to abusing opioids or other
substances, they might be willing to admit gabapentin use. That could make
it easier for us to identify those patients who may be at elevated risk during
and after dental procedures.
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 ALSO BY TOM VIOLA

Vaping: the new gateway drug and what dental professionals can do
‘But why? I feel fine!’

Tom Viola, RPh, CCP, has earned a

reputation as an international
authority on dental pharmacology.
Viola is on the faculty of 10 dental
professional degree programs, and
has instructed students in chemistry,
anatomy and physiology,
pathophysiology, pharmacology, and
local anesthesia. In addition, he’s instructed hundreds of practicing
hygienists in local anesthesia certification courses. He is well known for his
contributions to many dental journals in the areas of pharmacology, pain
management, and local anesthesia. For more information, visit
tomviola.com or contact him at Tom@tomviola.com.

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