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. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: J Subst Abuse Treat. 2019 Jul 21;105:1–4. doi: 10.1016/j.jsat.2019.07.011

Gabapentin Prescribed during Substance Abuse Treatment: The Perspective of Treatment Providers

Mance E Buttram a, Steven P Kurtz a, Matthew S Ellis b, Theodore J Cicero b
PMCID: PMC6709710  NIHMSID: NIHMS1536144  PMID: 31443885

Abstract

Background:

Gabapentin, a prescription medication approved for the treatment of seizures and neuralgia, is often prescribed off-label for substance use treatment, mental health problems, and pain. Emerging reports also suggest it is misused for the purpose of getting high. The present study examines substance abuse treatment provider key informants’ experiences with gabapentin prescribed to clients in treatment. The focus of this exploratory study is to ascertain how gabapentin is used in these settings and the benefits and risks for clients.

Methods:

Key informants from South Florida participated in confidential, in-depth interviews (N=12). Data analyses included descriptive and In vivo coding schemes and employed a descriptive qualitative approach.

Results:

All key informants recognized the benefits of prescribing gabapentin to clients in treatment for problems related to withdrawal symptoms, mental distress and pain. At the same time, half of participants described gabapentin misuse among clients and four key informants described such misuse as a first marker of relapse. Key informants also stated that more research must be done about how to use gabapentin effectively in treatment settings.

Conclusions:

These findings illustrate the lack of clarity about the efficacy of administration of gabapentin in treatment settings. Additional research about how to best use gabapentin, for whom it may be beneficial, and the effect of prescribed gabapentin on addiction recovery is needed.

Keywords: Gabapentin, substance abuse treatment, qualitative, misuse

1. Introduction

Gabapentin is a ɣ-aminobutyric acid (GABA)-analogue which received approval from the Food and Drug Administration for the treatment of partial seizures and postherpetic neuralgia (Wallach & Ross, 2018). In addition, gabapentin is prescribed off-label in the treatment of substance dependence and mental health problems, including bipolar disorder, posttraumatic stress disorder, and anxiety (Berlin, Butler, & Perloff, 2005; Wallach & Ross, 2018). The off-label prescribing may in part be due to the perceived safety of the medication; gabapentin’s dose-limited absorption properties are thought to present low addictive liability levels (Brockbrader et al., 2010). Gabapentin requires a prescription, but it is not scheduled under the federal Controlled Substances Act. However, Kentucky and Michigan, in 2017 and in 2019 respectively, reclassified gabapentin as a Schedule-V medication at the state level (Michigan Department of Licensing and Regulatory Affairs, 2019; Peckham, Ananickal, & Sclar, 2018). Several additional states are considering similar legislation or have required gabapentin prescriptions to be reported to state prescription drug monitoring programs (Peckham et al., 2018).

These state-level actions are likely a result of emerging reports of gabapentin misuse. Population estimates of gabapentin misuse in the U.S. are not apparent (Smith, Havens, & Walsh, 2016). However, a recent report from Kentucky noted a nearly 3,000% increase in gabapentin misuse for the purpose of getting high between 2008 and 2014 (Smith, Lofwall, & Havens, 2015) and a qualitative study of gabapentin misuse found that gabapentin is used in combination with other drugs, including opioids and cocaine, to produce desired central nervous system effects (Vickers et al., 2018).

Concurrent to reports of misuse, research documents the therapeutic benefits of administering gabapentin to individuals in substance abuse treatment. A recent randomized clinical trial demonstrated the efficacy of gabapentin for treatment of withdrawal symptoms and improvement of executive function among cannabis-dependent adults (Mason et al., 2012), and a second found that gabapentin was effective in treating alcohol dependence and related symptoms, including mood, sleep, and craving (Mason et al., 2014). Specific to opioids, small clinical studies have shown that individuals receiving gabapentin reported decreased symptoms of withdrawal; gabapentin works well in combination with methadone for opioid detoxification; and patients treated with gabapentin report decreased probability of positive urine tests for opioids over time compared to placebo (Moghadam & Alavinia, 2013; Salehi, Kheirabadi, Maracy, & Ranjkesh, 2011; Sanders et al., 2013).

This varied literature regarding gabapentin, including changes in state-level legislation, emerging reports of misuse, and growing evidence of therapeutic benefits, demonstrate the need for more research into the efficacy of gabapentin administration during substance abuse treatment. Given this context, the present study examines substance abuse treatment providers’ experiences with gabapentin prescribed to clients in treatment. The focus of this exploratory study is to ascertain how gabapentin is used in these settings and the benefits and risks for clients.

2. Methods

2.1. Study design

The data are drawn from interviews with a convenience sample of key informants about the prescribed use and potential for misuse of gabapentin among substance abuse treatment clients (N=12). Key informants are generally considered to be individuals with in-depth, specialized knowledge about a particular topic and they are able to provide relatively complete descriptions of specific phenomenon or patterns of behavior (Tremblay, 1957). Substance abuse treatment providers’ knowledge of treatment practices, client experiences, and substance use, make them uniquely qualified to provide reliable, descriptive data as key informants (Cicero, Ellis, Paradis, & Ortbal, 2011). Thus, eligible key informants in this study were currently working with opioid-dependent clients in the substance abuse treatment and detoxification field in South Florida (Miami-Dade, Broward, and Palm Beach Counties). Three key informants (identified as 2, 3, and 4 in Table 1) all worked for the same company across three distinct treatment centers with differing specializations and foci; the remaining key informants all came from different organizations. Interviews were conducted between August 2018 and January 2019.

Table 1:

Characteristics of key informant participants (N=12)

ID Title Education Years of
experience		 Setting
1 Program Director Master of Social Work 6 Public-pay inpatient treatment center
2 Operations Supervisor Bachelor of Arts 7 Private pay in-patient treatment center, PHP level of care
3 Clinical Director Bachelor of Arts 25 Private pay in-patient treatment center, PHP level of care
4 Primary Therapist Master of Arts, Counseling 10 Private pay in-patient treatment center, PHP level of care
5 Primary Therapist Master of Science, Family Therapy 7 Public-pay mental health facility
6 Primary Therapist Master of Social Work 5 Public- and private-pay treatment center
7 Licensed Clinical Social Worker Master of Social Work 15 Private pay in-patient treatment center
8 Registered Nurse Registered Nurse 2 Detoxification center
9 Clinical Director Master of Science, Psychology 8 Private-pay in-patient treatment center
10 Chief Executive Officer Master of Social Work 10 Intensive outpatient center
11 Therapist Master of Science, Counseling 25 Private practice
12 Therapist Master of Science, Counseling 15 Private practice
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After providing informed consent, key informants completed confidential, individual, in-depth interviews (approximately 45 minutes in length) and were compensated with a $100 stipend for their time. A semi-structured interview protocol guided the interview. Topics included the key informant’s current professional role and type of organization for which they work, organizational practices regarding prescribing or administering gabapentin to clients; therapeutic value; and experiences with misuse. The interviews were digitally audio-recorded and transcribed.

2.2. Data analysis

Two coding schemes were used during data analysis: descriptive coding, in which passages of data are coded using words or short phrases, and In vivo coding, in which direct quotes are used to name specific concepts (Saldaña, 2013). The coding process was conducted by two members of the research team and included the establishment of codes and meanings and the cross-checking of code choices. Discussions between the coders allowed for the refinement of the coding scheme and agreement on code choices (Barbour, 2001). Analysis of codes employed a descriptive qualitative approach (Colorafi & Evans, 2016). Recurrent meanings and patterns in the data were used to generate descriptive themes. Atlas.ti version 7 software was used for data management, coding, and analysis.

3. Results

3.1. Participant characteristics

As seen in Table 1, the key informants included in this study represented a range of substance abuse treatment settings and services, including public- and private-pay inpatient treatment centers, a public-pay mental health treatment facility, a detoxification center, an intensive outpatient center, and private practice counseling. All except three key informants had graduate-level education. Years of experience working in the substance abuse treatment field ranged from two to 25.

3.2. Therapeutic Use

Key informants universally agreed that gabapentin has therapeutic value for substance abuse treatment clients. Based on their experiences, one of the primary benefits of administering gabapentin during treatment is that it can treat a range of physical and mental health symptoms which may interfere with the clients’ participation in the treatment program. It is thought that by addressing and moderating these symptoms, substance abuse treatment clients will be better positioned for success upon completion of the program. In the words of key informant 7, gabapentin may help alleviate, “restless legs… the headaches, the nerve pain, the achiness, all the stuff,” associated with withdrawal.

Similarly, gabapentin was described by key informant 8 as helping clients to mentally cope with withdrawal symptoms. Several additional key informants reported analogous experiences. Gabapentin was described as a mood stabilizer which is administered to clients during treatment. Clients are then given a continuing prescription upon completion of in-patient treatment. In such instances, “They, [the clients], are not having any issues,” stated key informant 9. Another provider agreed and said that clients, “Might need something short-term, because [they’re] coming off of serious drugs, feeling sick, and getting their faculties back,” (key informant 5). In addition, treatment providers may seek to moderate anxiety and mental distress symptoms among clients. As described by one primary therapist, “Gabapentin will indubitably help somebody that’s experiencing anxiety, absolutely. And the vast majority of people that are recently sober are experiencing anxiety, right? So, I mean, when you look at it that way, it makes sense that [the clients] were prescribed,” (key informant 6).

A third key reason for administering gabapentin during substance abuse treatment is to treat pain. A treatment center clinical director described pain management among clients in this way, “There is a lot of therapeutic wellness to [gabapentin] that can be used. And it’s a very touchy subject, when addicts have pain in recovery. What do you give them? The truth is they’re human. They have accidents that happen and pain that happens. I say, why should addicts and alcoholics be miserable?” (key informant 3). Although this provider recognizes the benefit of using gabapentin to treat pain among clients, her comments underscore the difficulty substance abuse treatment providers face when attempting to treat pain while simultaneously trying to avoid administering medications with the potential for abuse.

3.3. Misuse among Treatment Clients

Key informants generally agreed that gabapentin is not a narcotic and that any misuse or abuse would likely not carry the same risks as with opioids or other prescription drugs. In fact, gabapentin is used as an alternative to opioids and other prescription medications which have high potential for abuse. However, several key informants described treatment clients experimenting, taking multiple gabapentin pills, and realizing that misusing the medication may produce a desirable central nervous system effect. Descriptions of this effect varied and included, “ a drowsy effect,” (key informant 1), “not really an opiate high, but it’s a little speedy, a little loopy,” (key informant 2), “a high of sorts… not to the extent or magnitude of heroin or crack… but a floating feeling,” (key informant 6), and “a drunk feeling…. an up feeling where they have more energy and they can do more with their day,” (key informant 7). One key informant noted that 3200 milligrams was needed to produce the desired feeling, while another described treatment clients using four or five pills at one time.

Furthermore, four key informants described gabapentin misuse as a potential first marker of relapse. Gabapentin misuse may occur following substance abuse treatment because the client believes they, “need something chemical to cope with their symptoms,” according to key informant 5. Key informant 4 also noted that clients may also make an impulse decision to begin misusing gabapentin as a result of boredom, influence of friends, and because the drug may not register on a standard urine analysis. The concern these key informants had regarding gabapentin misuse is best summed up by this primary therapist, “Gabapentin misuse will precede a recurrence of heroin or crack or other drugs that they would prefer to use. They will often start with the gabapentin misuse,” (key informant 6). Key informant 7 agreed and stated, “It’s hardly ever a surprise when a client relapses because their behavior shows it and oftentimes, they go from abusing gabapentin and Suboxone and Subutex… They go from that right back to their drug of choice… heroin, crack, alcohol.”

In spite of this, all key informants noted that gabapentin, along with other prescribed medication is typically subject to numerous controls to prevent misuse or abuse. While two key informants mentioned gabapentin misuse occurring inside of substance abuse treatment facilities, key informant 6 disagreed and stated, “[The clients] are monitored and their medication is kept away, so the opportunity to misuse the gabapentin isn’t there.”

3.4. Gabapentin Use in Treatment Settings

Given these universally acknowledged benefits of gabapentin use during treatment and the reports of gabapentin misuse among individuals with substance abuse treatment histories, policies regarding the administration of gabapentin in treatment facilities vary. Most key informants described scenarios in which a client may be allowed to take gabapentin during treatment if they were prescribed it for a legitimate physical or mental health problem. Key informants 5, 8, and 9 stated that at facilities where they work, or have worked, gabapentin is regularly prescribed to clients. One registered nurse (key informant 8) stated that, “There’s really not a hesitancy to prescribe,” and key informant 5 said that at her facility, when clients are discharged, “they’re given that as part of their discharge medication, so they continue to use it.” In addition, key informant 10 noted that gabapentin was prescribed at his facility, but only for physical pain and not for anxiety or other forms of mental distress.

According to the providers, some clients enter their facilities and possess current prescriptions for gabapentin, which were given in a previous detoxification or treatment facility, by a psychiatrist, or by a medical doctor for pain relief. For patients without physical or neurological pain, four key informants stated that in their treatment facilities, clients who possess a prescription for gabapentin will be asked to taper and end their use of the medication. As one treatment center program director said, “There have been a few occasions where we had to tell a client, ‘These are the medications you’re on, and these are the ones we would like you to stop taking.’ One of them being gabapentin,” (key informant 1). The rationale behind this decision was best described by key informant 3, “Everyone’s becoming aware of [gabapentin misuse] now. We always gotta stay ahead of the curve. If we see [gabapentin misuse] starting to develop, we gotta nip it.”

3.5. Lingering Questions and Future Directions

The conflicting perception of gabapentin as an adjunct medication during substance abuse treatment, in which it is generally beneficial for clients and that it may be misused by some clients, led to a lack of clarity and lingering questions for two key informants. Key informant 10 stated that it, “would help people in the centers to know why gabapentin is being prescribed and all the multi-uses of it. I think that would really help people understand it better,” and he continued, “But I do think everybody is aware of what an issue [gabapentin misuse] is.” As to whether gabapentin should be administered to substance abuse treatment clients, key informant 3 simply said, “There’s no clear-cut answer. I’d love to hear somebody say there is. And it’s like, ‘Tell me!’”

4. Discussion

4.1. Conflicting perspectives on gabapentin use

According to this sample of substance abuse treatment providers, gabapentin is a commonly prescribed medication during treatment. The benefits of administering gabapentin to clients during treatment may include moderated withdrawal symptoms and fewer symptoms of mental distress, and physical pain. Gabapentin may be beneficial for treatment uptake and efficacy as well. Such perceptions are supported by small randomized trials documenting the safety and efficacy of gabapentin as a treatment for alcohol use disorder (Mason, 2018; Mason et al., 2014); treatment of cannabis and opioid withdrawal (Mason et al., 2014; Salehi et al., 2011); and as an adjunctive therapy for opioid detoxification (Moghadam & Alavinia, 2013). Thus, these findings should be considered when trying to address client needs during treatment.

While key informants described the therapeutic benefits of gabapentin, there was also acknowledgement that gabapentin has been misused by some treatment clients. In fact, limited reports document gabapentin misuse among other populations of substance users (Smith et al., 2016). Considering the setting and the population, it is not unexpected that substance abuse treatment clients would experiment with their prescribed medications in an attempt to get high or achieve an augmented effect from their pills. And while gabapentin is reported to have low addictive liability levels (Brockbrader et al., 2010), key informants expressed some concern about gabapentin misuse as a first indication of relapse. Limiting access to and controlling the administration of gabapentin and other medications during treatment will likely limit the opportunities for misuse among treatment clients.

Multiple key informants indicated that upon completion of substance abuse treatment, clients may be given a prescription to continue using gabapentin. This may be an additional cause for concern, given emerging reports of gabapentin misuse. Moreover, data suggest that since 2002, the rates of gabapentin diversion – the unlawful channeling of prescription medications from legal sources to the illicit marketplace (Inciardi, Surratt, Kurtz, & Burke, 2006) – have risen significantly, especially among individuals who misuse prescription opioids or use heroin (Buttram, Kurtz, Dart, & Margolin, 2017). More research is needed to better understand gabapentin misuse among individuals with substance use histories and the diversion of gabapentin among individuals who have prescriptions.

The need for more research and education about the efficacy of gabapentin use among substance abuse treatment clients was mentioned during the interviews. While some limited randomized clinical trials have been conducted which demonstrate the therapeutic use of gabapentin among substance users, there is no apparent literature describing the beneficial use of gabapentin in “real world” treatment or post-treatment settings. Calls from substance abuse treatment providers in this study for knowledge about how to use gabapentin effectively are important and highlight the need for continued research. Studies of prescribed gabapentin use among treatment clients and the potential for and prevalence of misuse are warranted.

4.2. Limitations

As with all qualitative research, some limitations must be noted. The potential for recall bias and interviewer effects exists. However, the interviewer’s training, experience, and the use of a semi-structured interview guide likely mitigated these effects. The key informants in this study were drawn from a convenience sample of 12 individuals from South Florida. Although qualitative research does not require large sample sizes and samples with 12 participants are often adequate (Guest, Bunce, & Johnson, 2006), the experiences described here may not be representative of substance abuse treatment providers in other settings or locations. Thus, these results are not generalizable.

4.3. Conclusions and implications for future research

This report has examined the experiences of substance abuse treatment providers regarding the prescribed use of gabapentin during treatment. Among the sample, the discussions surrounding gabapentin included the therapeutic benefits as well as the potential for misuse. These findings illustrate the lack of clarity about the effective administration of gabapentin in treatment settings. Additional research about how to best use gabapentin (or not), for whom it may be beneficial, and the effect of prescribed gabapentin on client recovery is needed.

Highlights.

  • Gabapentin is beneficial in treating withdrawal, mental distress, and pain symptoms

  • Key informants describe instances of gabapentin misuse among clients

  • Treatment providers need data on how to use gabapentin effectively during treatment

Acknowledgements

This research was supported by the National Institute on Drug Abuse (grant number R03 DA043613). The contents are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health or the National Institute on Drug Abuse.

Footnotes

Conflicts of interest

None.

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