Treating pain remains one of the great challenges in medicine, particularly in primary care and particularly in view of the changing landscape brought on by the opioid crisis. Neuropathic pain, fibromyalgia and low back pain with radicular pain are conditions we are often faced with.
We all feel the pressure to avoid or reduce the use of opioids while providing something to help patients in pain.
The options in medication are varied – analgesics, NSAIDS, tricyclics, SNRI’s such as duloxetine are in common use. So, it is topical to see a recent review published in the CMAJ and replayed in the media:
Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis
(see Quick Links for the full article).
The authors of the review state that “The use of anticonvulsants (e.g., gabapentin, pregabalin) to treat low back pain has increased substantially in recent years despite limited supporting evidence" and that their aim was to "...determine the efficacy and tolerability of anticonvulsants in the treatment of low back pain and lumbar radicular pain compared with placebo.”
Their conclusion: “There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.
The number of prescriptions for gabapentin and pregabalin was 6.5 million in 2013 rising to 10.8 million in 2017!
Many people taking gabapentinoids are also taking opioids, which dramatically increases the risks associated with the drugs.
A study published in PLOS on October 3, 2017 (see our Quick Links section for the article) found that patients taking opioids and gabapentinoids were 50 per cent more likely to die from opioid-related causes.
Evidence also suggests that gabapentinoids, on their own, possess potential for abuse, particularly in individuals with a history of opioid abuse, and reports of such abuse are increasingly being documented.
Prescribers should be aware of high-risk populations and monitor for signs of abuse (you can read more about this by checking out the third article in our Quick Links section).
So maybe it is time to take a closer look at our patients taking gabapentinoids. Next week we discuss how to institute a search and reminder exercise to help in deprescribing.