The safer alternative? Unexpected drug found in one-fourth of overdoses

Published in The Courier Journal April 2, 2018

Reporter Beth Warren: bwarren@courier-journal.com; 502-582-7164; Twitter @BethWarrenCJ

A popular drug has long been touted as a safe alternative to opioid painkillers, but it popped up in Louisville last year in nearly one-fourth of all overdose deaths.

Gabapentin — developed to prevent epileptic seizures but now used for pain — was found in 93 of Jefferson County’s 407 fatal overdoses, according to an analysis of coroner data.

“It’s becoming too popular,” Dr. James Patrick Murphy said. “Unfortunately, we now need to worry about it because people are abusing it.”

Gabapentin isn’t believed to be the cause of the deaths — since more powerful drugs like heroin, cocaine or fentanyl also were detected — but it could have been a contributor, said Rachel Vickers Smith, assistant professor in the University of Louisville School of Nursing.

U of L issued a release about the drug in February, cautioning: “Amid the opioid epidemic, abuse of a different prescription painkiller has widely gone unnoticed.” The university is lobbying for more awareness and research on the drug, sold under the brand name Neurontin and others.

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The U.S. Food and Drug Administration initially approved gabapentin for epileptic patients but later cleared it to treat nerve pain. As doctors have moved away from opioids, many have shifted to doling out gabapentin for a variety of off-label uses including treatment of migraines, hot flashes and almost any type of pain.

Gabapentin skyrocketed to become the 10th top medication in the U.S. in 2016 — with 64 million prescriptions, according to an Aug. 3 article in the New England Journal of Medicine.

Murphy, an addiction and pain specialist, said he prescribes it for some of his Kentuckiana patients,  especially those with chronic pain from nerve damage. But he monitors them closely.

He said the drug is fairly safe — when used as prescribed.

“Alone, it’s not something that will stop your breathing or your heart,” the doctor said.

“But if you take it along with a drug like heroin or fentanyl, together it might be enough to make you stop breathing and put you over the edge.”

Louisville Mayor Greg Fischer talks about opioids – “our largest and most significant drug epidemic in history” – at Friday’s press conference. March 16, 2018 Marty Pearl/Special to CJ

Gabapentin is listed as an “emerging threat” in a recent national bulletin distributed to narcotics officers.

Across Kentucky, it showed up in about one-third of all drug deaths in 2016, said Van Ingram, executive director of the Kentucky Office of Drug Control Policy.

Kentucky lawmakers responded by classifying the drug as a controlled substance last year —  believed to be a first for the nation.

Doctors can still prescribe it throughout the Bluegrass State, but those prescriptions will now show up on the Kentucky All Schedule Prescription Electronic Reporting (KASPER) site. When doctors check the database, they can see if a patient has tried to get it from more than one doctor.

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But doctors aren’t required to run a KASPER check when prescribing gabapentin because state lawmakers made it a Schedule V drug — on the opposite end of the severity scale than fentanyl and heroin, Schedule I drugs.

The U.S. Drug Enforcement Administration doesn’t track it or enforce it because, federally, it’s not a controlled substance. And some local police officers haven’t even heard of it.

Kristin Bieckert, who has been in recovery for 16 months from a drug addiction, said the drug is easy to get on the streets and in 2016 she paid just 75 cents or $1 per pill.

“I think it’s addicting too,” the 25-year-old said. “I had to have it.”

Bieckert, now a peer mentor at The Healing Place in Louisville, said she would sometimes heat up several gabapentin pills in a spoon and inject it. She also took it with heroin, methadone or other drugs to enhance the intoxicating feeling.

And it wouldn’t show up in some drug screens, she said.

Other users have described a euphoria, marijuana-like high, sense of calm as well as “zombie-like” effects, according to GoodRx’s website.

Bieckert said when she stopped taking it abruptly, she suffered body aches and fatigue. Users should gradually taper off use of the drug, Murphy said.

Tommy Loving, head of the Kentucky Narcotics Officers Association, said some dealers are trafficking the drug by itself or along with other drugs. Loving, also the director of the Bowling Green-Warren County Drug Task Force, said he has seen an increase in gabapentin as a street drug in the past two years.

Gabapentin and pregabalin, both gabapentinoids, were recommended by the Center for Disease Control and Prevention in place of opioids for chronic pain.

And gabapentin lessened patients’ reliance on opioids after surgery, according to a study of 422 patients. Those findings were published online in December by the National Institute on Drug Abuse, which co-sponsored the study.

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Some other states, including Ohio, designated it as a “drug of concern” after noticing its prominence and also are monitoring when it is prescribed.

Opioids were once considered safe and non-addictive. Now, they are blamed for driving up overdose and addiction rates and fueling the heroin crisis. So it’s understandable that more medical professionals are eyeing gabapentin and trying to better understand its potential dangers when abused.

“Gabapentinoids are being prescribed excessively – partly in response to the opioid epidemic,” Drs. Christopher Goodman and Allan Brett, with the University of South Carolina School of Medicine, wrote in an article in the New England Journal of Medicine.

“We believe there are several reasons to be concerned about this trend,” the doctors wrote about the shift from opioid painkillers to gabapentin and pregabalin — known by its brand name Lyrica.

Goodman and Brett cited concerns that physicians are using gabapentin for uses that haven’t been studied in robust clinical trials. They also noted possible side effects and found that “sedation and dizziness are relatively common.”

The pair pointed out that doctors can feel pressure from patients who want a prescription to eliminate pain. The two suggested that more conversations should focus on how to cope with or mitigate pain, not eliminate it.

Gabapentin’s potential for abuse and addiction significantly increases “when the drug is taken with other medications such as muscle relaxants, opioids or various anxiety medications,” according to an article last year on Pharmacy Times’s website questioning whether it should be classified as a controlled substance so its use would be more closely monitored.

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Dr. Scott Gottlieb, FDA commissioner, discussed his concern about the growing use of gabapentinoids — especially beyond the scope of approved uses  — when speaking to the National Press Club in Washington, D.C., in February.

“We’re concerned that the misuse and abuse of these drugs may result in serious adverse events, such as respiratory depression and death,” he said.

“We want to understand changes in how patients are using these medicines. We’ll have more to say about our work on this challenge soon.”