Descriptions of Gabapentin Misuse and Associated Behaviors among a Sample of Opioid (Mis)users in South Florida

Abstract

Gabapentin has received increased attention due to a growing number of reports of misuse and diversion. However, significant details about gabapentin misuse are scant. Data are drawn from a mixed-methods study examining gabapentin misuse in South Florida. The sample includes 49 respondents who were age 18 or over and reported past year use of illicit opioids and/or the misuse of prescription opioid medications, as well as, recent (past 90 days) gabapentin misuse. Respondents were female (40.8%), Hispanic (30.6%), Black (16.3%), white (49.0%), and other race/ethnicity (4.1%). Mean age was 37.6. Many respondents (43%) misused gabapentin without ever receiving a prescription and 14% prior to being prescribed. Mean frequency of recent misuse was 25.4 days and included a mean of 51.65 pills/doses. Prevalent routes of administration included swallowing (85.7%) and snorting (10.2%). Gabapentin misuse occurred concomitantly with any opioid (44.9%), benzodiazepines (38.8%), alcohol (24.5%), and powder cocaine (24.5), among others. Respondents’ descriptions indicate that gabapentin produces feelings reminiscent of alcohol intoxication or opioid-induced euphoria, but for some it produces no noticeable effect or only alleviates pain. Greater understanding of gabapentin misuse, especially associated behaviors and concomitant use is needed to inform prevention and intervention efforts, and to guide policy approaches.

INTRODUCTION

Gabapentin is an anti-convulsant drug, which was approved by the U.S. Food and Drug Administration for the treatment of post-herpetic neuralgia and epilepsy (Wallach and Ross 2018). Off-label, gabapentin is also used to treat mental health problems, including anxiety and post-traumatic stress disorder, as well as in substance use treatment settings for managing withdrawal symptoms (Buttram, Kurtz, Ellis, et al. 2019; Berlin, Butler, and Perloff 2005). Recently, the use of gabapentin for treatment of physical pain has been reported, as prescribers seek alternatives to opioids (Goodman and Brett 2017).

Perhaps as a result of off-label prescribing, dispensed prescriptions of gabapentin have grown significantly in recent years. Data from 2016 indicate that gabapentin was the 10^th most prescribed medication, with 64 million prescriptions dispensed, up from 39 million in 2012 (Quintiles 2017). During this same period, diversion – the unlawful channeling of regulated pharmaceuticals from legal sources to the informal marketplace (Inciardi et al. 2006) – also increased by significant levels (Buttram et al., 2017).

Recent studies found that gabapentin is misused to achieve a desired central nervous system effect, moderate opioid withdrawal symptoms, attempt to self-detox from opioids, and to treat physical pain or mental distress symptoms (Buttram, Kurtz, Cicero, et al. 2019; Smith et al. 2018; Stein et al. 2020). Gabapentin may be misused alone, yet it is also not uncommon for it to be misused alongside other prescription drugs, notably benzodiazepines and opioids (Bastiaens, Galus, and Mazur 2016; Smith, Lofwall, and Havens 2015; Wilens et al. 2015). Furthermore, gabapentin and buprenorphine are used together for the purpose of “getting high,” and gabapentin is misused to potentiate the effects of methadone (Baird, Fox, and Colvin 2013; Reeves and Ladner 2014; Embers, Ravishankar, and Roopa 2019).

Although, gabapentin has historically been perceived to have low abuse potential levels because of its dose-limited absorption properties (Brockbrader et al. 2010), emerging reports of misuse and diversion have inspired state-level legislative interventions. Since 2017, several states, including Kentucky, Tennessee, Michigan, North Dakota, West Virginia, Virginia, and Alabama, have reclassified gabapentin as a Schedule-V medication at the state level and several additional states are considering similar legislation or have required gabapentin prescriptions to be reported to state prescription drug monitoring programs (Alabama State Board of Health Health 2019; North Dakota State Board ofPharmacy 2019; King 2020, Mincher 2018, Peckham, Ananickal, and Sclar 2018). Gabapentin remains unscheduled federally.

The context surrounding gabapentin is changing and reports of misuse continue to emerge. However, details about gabapentin misuse are scant, including gabapentin prescription history, route of administration, sources, effects, and street names. The aim of the present study is to contribute to the growing literature on gabapentin misuse and provide additional details about this phenomenon and associated behaviors.

METHODS

Study sample and design

The data were collected as part of a study investigating the initiation and consequences of gabapentin misuse. Eligible respondents were age 18 or over and reported past year use of illicit opioids and/or the misuse of prescription opioid medications. The overall sample (N=91) was stratified so that roughly two-thirds of respondents also reported a history of gabapentin misuse with the remaining one-third reporting no gabapentin misuse. Mixed methods interviews were conducted between January and December 2018 in South Florida (Miami-Dade, Broward, and Palm Beach counties). All individuals who reported gabapentin misuse during the past 90 days (N=49) were asked additional survey questions regarding gabapentin misuse and associated behaviors.

Participants were recruited through flyers and advertisements placed in public spaces and a local weekly publication. Periodic public announcements about the study were also made at a local substance use treatment center. Recruitment materials invited individuals to participate in a confidential, in-person, one-on-one interview. Interested individuals were invited to call the research office to be screened for eligibility and to make an appointment to complete the interview.

At the time of the scheduled interview, respondents provided informed consent and were re-screened for eligibility. Confidential interviews lasted approximately 90 minutes and took place in private offices. All participants received a $50 stipend upon completion of the interview. Study protocols were approved by the university’s Institutional Review Board.

Survey Instrumentation

The interview instrument was primarily based on the Global Appraisal of Individual Needs (GAIN; Global Appraisal of Individual Needs, 2016), and it included abbreviated segments of the core domains: demographics, substance use, physical health, sexual risk behaviors, mental health, and environment. Respondents were instructed that prescription drug misuse entails using a prescription drug not as instructed by a doctor, including to get high, for fun, to relax, or to come down from another drug.

We assessed gender, race/ethnicity, age, and education. Race/ethnicity was assessed by asking participants whether they were Hispanic or Latino/a, followed by asking them what race/ethnicity they consider themselves to be. Years of education was assessed with the question, “What is the last grade or year that you completed in school?”

The survey assessed recency of use of gabapentin and other substances including prescription and illicit drugs. Additional questions related to gabapentin misuse included, “During the past 90 days, on how many days have you used gabapentin for fun, to get high, to relax, or to come down,” “In the past 90 days, about how many gabapentin pills did you use in a typical month,” and “How old were you the first time you used gabapentin for fun, to get high, to relax, or to come down?” To assess gabapentin prescription history, participants were asked, “Have you ever been prescribed gabapentin by a doctor?” Affirmative responses yielded follow-up questions which included, “How old were you the first time you were ever prescribed gabapentin,” and “What was the primary reason you were prescribed gabapentin?”

Route of administration was assessed by asking participants, “In the past 90 days, please tell me all of the ways you have used/taken gabapentin.” Participants were provided with a list of routes to endorse (e.g., swallow whole pill, snort, inject). Participants were also asked, “Have you ever used gabapentin in combination with another drug?” Positive responses prompted a follow-up question in which participants were given a list of substances and asked, “Please select all of the following that you have ever used in combination with gabapentin.” Participants were also asked, “Have you ever had any negative consequences or bad experiences after taking gabapentin?” Participants providing affirmative responses were asked to report their bad experiences.

Source of misused gabapentin was assessed by asking participants, “In the past 90 days, what was the primary way you got gabapentin that you used for fun, to get high, to relax, or to come down? By primary, we mean the one you use most often or to get most of your pills.”

Severe mental distress was assessed by the General Mental Distress Scale which includes DSM-5 symptom counts of somatization, depression, and anxiety. The endorsement of symptoms experienced during the past year were dichotomized into “severe” versus not, with severe scores suggesting possible clinical mental illness and the need for mental health interventions/services (GAIN 2016). Substance Use Disorder was assessed by the Substance Use Disorder Scale which examined DSM-5 symptoms of substance abuse, dependence, and craving (GAIN 2016). The endorsement of symptoms experienced during the past year were dichotomized into “severe” versus not, with severe scores suggesting possible substance use disorder diagnosis and the need for interventions/services (GAIN 2016). Overdose history was assessed by asking participants if they have ever overdosed.

Qualitative Interview Protocol

A semi-structured interview protocol guided the qualitative portion of the interview. Respondents were also asked to give a detailed account of the first time they misused gabapentin. Additional follow-up questions inquired about effects of consuming gabapentin and well as nicknames and slang terminology. The interviews were digitally audio-recorded and transcribed. Transcriptions were independently reviewed by the interviewers for accuracy.

Analysis

For survey measures, all analyses were conducted using IBM SPSS Statistics version 25. Descriptive statistics were calculated for the variables of interest. For qualitative analyses, descriptive coding was utilized (Saldaña 2013) and analysis of codes employed a descriptive qualitative approach (Colorafi and 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.

RESULTS

Quantitative measures

Participants in this study identified as Hispanic (30.6%), African American/Black (16.3%), white (49.0%), and other race/ethnicity (4.1%; Table 1). Less than half of participants were female (40.8%) and the mean age was 37.6 years. In addition to gabapentin, substance use among the sample was varied, with a majority of participants reporting past 90 day (mis)use of prescription opioids (81.6%), benzodiazepines (77.6%), heroin (61.2%), marijuana (61.2%), and binge drinking (55.1%). Health problems were also common with most participants reporting past year severe mental distress (73.5%) and severe substance use disorder (89.8%), as well as overdose history (71.4%).

Table 1:

Demographics and background characteristics (N=49)

	N / mean	% / SD
Demographics
Female	20	40.8%
Race/ethnicity
Hispanic	15	30.6%
African American/Black	8	16.3%
White	24	49.0%
Other race/ethnicity	2	4.1%
Age	37.55	(13.263)
Last grade completed in school	13.00	(2.010)
Substance Usea
Binge drinking	27	55.1%
Marijuana	30	61.2%
Cocaine	22	44.9%
Crack cocaine	19	38.8%
Heroin	30	61.2%
Ecstasy	12	24.5%
Methamphetamine	12	24.5%
Hallucinogens	5	10.2%
GHB	3	6.1%
Prescription opioids	40	81.6%
Benzodiazepines	38	77.6%
Prescription stimulants	12	24.5%
Prescription muscle relaxants	8	16.3%
Prescription antidepressants	3	6.1%
Prescription antipsychotics	4	8.2%
Pregabalin	5	10.2%
Health Problems
Severe mental distressb	36	73.5%
Severe substance use disorderb	44	89.8%
Overdose history	35	71.4%

^apast 90 days;

^bpast year

Among the participants, 28 (57.1%) had received a prescription for gabapentin and of those, 25% reported misusing gabapentin prior to being prescribed (see Table 2). Mean age of first prescription was nearly 33 years. Primary reasons for being prescribed gabapentin included neuropathic pain (43.9%), withdrawal symptoms (25.0%), physical pain (17.9%), mental distress (17.9%), and seizures (3.6%).

Table 2:

Characteristics of prescribed gabapentin use (N=28)

	N / mean	% / SD
Misuse prior to receiving prescription	7	25.0%
Age of first gabapentin prescription	32.75	(12.388)
Primary reason for prescription
Nerve pain	12	42.9%
Withdrawal symptoms	7	25.0%
Physical pain	5	17.9%
Mental distress	5	17.9%
Seizures	1	3.6%

On average, participants misused gabapentin on 25.4 of the past 90 days and consumed nearly 52 pills or doses (Table 3). The mean age of first gabapentin misuse was 31.8 years. Most participants reported misusing gabapentin by swallowing a whole pill (85.7%); additional routes of administration included intranasal (10.2%), chewing a pill (6.10%), intravenous (4.1%), parachuting (2.0%), drinking a liquid (2.0%), and rectal (2.0%).

Table 3:

Characteristics of gabapentin misuse (N=49)

	N / mean	% / SD
Misuse behaviors
Days misused (past 90 days)	25.41	(28.102)
Pills/doses misused per month	51.65	(60.576)
Age of first misuse	31.8	(13.745)
Route of administration
Swallow whole pill	42	85.7%
Snort	5	10.2%
Chew	3	6.1%
Inject	2	4.1%
Parachute	1	2.0%
Drink	1	2.0%
Rectal	1	2.0%
Concomitant use
Any opioid	22	44.9%
Benzodiazepines	19	38.8%
Heroin	13	26.5%
No combination use	13	26.5%
Prescription opioids	12	24.5%
Alcohol	12	24.5%
Powder cocaine	11	22.4%
Marijuana	7	14.3%
Crack cocaine	6	12.2%
Prescription muscle relaxants	3	6.1%
Ecstasy	2	4.1%
Hallucinogens	2	4.1%
Prescription stimulants	2	4.1%
Prescription antipsychotics	2	4.1%
Methamphetamine	1	2.0%
GHB	1	2.0%
Negative consequences
Physical health problems	12	24.5%
Psychological problems	4	8.2%
Withdrawal symptoms	3	6.1%
Source
Sharing/trading with others	24	49.0%
Doctor or prescriber	13	26.5%
Dealer/street buy	10	20.4%
Theft	2	4.1%

Nearly half of participants reported misusing gabapentin in combination with any opioid (44.9%). Specific substances concomitantly (mis)used with gabapentin include benzodiazepines (38.8%), heroin (26.5%), prescription opioids (24.5%), alcohol (24.5%), powder cocaine (22.4%), marijuana (14.3%), crack cocaine (12.2%), prescription muscle relaxants (6.1%), ecstasy (4.1%), hallucinogens (4.1%), prescription stimulants (4.1%), prescription antipsychotics (4.1%), methamphetamine (2.0%), and GHB (2.0%). Negative consequences of gabapentin misuse included physical health problems (24.5%), psychological problems (8.2%), and withdrawal symptoms (6.1%). Sources of misused gabapentin included sharing or trading with others (49%), a doctor or prescriber (26.5%), a dealer or street buy in the illicit market (20.4%), and theft (4.1%).

Qualitative findings

The effects of gabapentin, as described by participants, were varied. Participants’ descriptions were roughly evenly split among the following themes: feelings of intoxication, sedative-type effects, euphoria reminiscent of opioids, pain relief, and unpleasurable or no noticeable effects. Participants also described the effects of gabapentin in terms of potentiating an opioid. Finally, street names and slang terminology for gabapentin were discussed.

Feelings of intoxication.

The description of gabapentin causing the feeling of drunkenness or intoxication was common. A 32-year-old white man said, “I guess it gave me like a drunk, weird, body high. I don’t really compare it to a heroin high, but it’s a high.” Other participants shared similar descriptions, including 24-year-old white man who said, “If you take 2400mg, you almost feel like a little drunk… like you’re wobbly.”

Sedative-type effects.

Another group of participants described gabapentin as a “downer” with sedative-like qualities, with one of the primary effects being that it increased somnolence. In the words of a 35-year-old African American man, “It’s a completely different high (compared to opioids) because it is hard to resist the urge to fall asleep.” Said another participant, “It made you relax, you felt, like, nice and numbly, then you went to sleep,” (46-year-old white man). Another participant (Hispanic man, age 55) agreed and said, “It made you capable to lay down and go to sleep, really relaxed you. It seemed to relax you faster if you snorted it.” In addition, a 27-year-old white woman said gabapentin had a sedative effect and that it makes her “more tired” and “less aware of what’s going on.”

Euphoria reminiscent of opioids.

Although some participants noted that gabapentin can produce feelings of euphoria, all shared similar feelings to that of a 23-year-old African American woman who that the feeling was much milder than opioid-induced euphoria. A 29 year-old Hispanic man said that gabapentin is, “more of a relaxed, kind of euphoric,” feeling. Similarly, a 24 year-old white man described gabapentin in this way, “It did kind of give me somewhat of a euphoric effect, but nothing along the lines of opiates. Nothing like that, but it does give you a little rush.”

Pain relief.

The next group of participants described gabapentin as a pain reliever which alleviated opioid withdrawal symptoms, as well as physical pain. For these participants, the desired effect of gabapentin misuse was therapeutic, rather than feelings of being high. Said a 43-year-old white man, “It just kinda soothes the detoxing. The gabapentin is good for that. There was very little recreational use for it for me.” Another participant (Hispanic man, age 28) agreed and said, “It helps with sleep if you have that restless syndrome… yeah, it calms your nerves. It relaxes you.” Others described the pain-relieving qualities of gabapentin as helping with back strain and nerve pain. A 46-year-old Hispanic man had similar sentiments and went on to say, “It just kinda takes the pain away. Drug addicts don’t go looking for gabapentin. You know, if they don’t have back problems or neck problems, they’re not even bothering with it. There’s no reason to take it.”

Unpleasurable or no noticeable effects.

Multiple participants said that they did not experience any pleasure from gabapentin misuse. Some participants said that gabapentin made them feel “weird,” or “uncomfortable,” and as a 26-year-old Hispanic woman said, “I didn’t like it, though. I didn’t like how it made me feel, and I don’t see why people would want to abuse that.” Another participant (19-year-old white man) agreed and also said, “I’ve heard a lot of people say it’s hit or miss, like some people don’t feel much from it, some people love the effect that it provides. For most people, it’s not their drug of choice. It doesn’t provide the euphoria that they’re looking for.” Others shared this feeling. A 43-year-old Hispanic man said, “See, once you got a tolerance for heroin, the gabapentin… I don’t notice that I feel it, or my receptors are like, ‘that’s not what I want,’ so I don’t really get too much pleasure out of it.” Similarly, a 25-year-old Hispanic man described misusing gabapentin to try to get high as, “insane,” and said, “If you’re gonna get high, go get high! Why not do a shot of heroin?”

Concomitant use.

Finally, some participants’ descriptions of gabapentin’s effects were tied to concomitant use of other substances, primarily opioids. “[It] just kind of increased the [heroin] high” said a 32-year-old white man. A 35-year-old white man elaborated and described his co-use of gabapentin and oxycodone like this, “I’d definitely get more high. When I do the oxycodone by itself, I get more upper but when I do the gabapentin, downer. Sometimes I’m right in the middle where I think I’m awake but I’m dipping out.” Describing his use during his teenage years, a 25-year-old white man said, “It’s like Suboxone is a fire and gabapentin’s oil and you’re throwing oil on that fire. It just, if feels like it enhances the buprenorphine so much. That was one of my favorites at a younger age.” Another participant (Hispanic woman, age 25) said of the combination of alprazolam and gabapentin, “You’re mellow. Nothing really bothers you. You don’t jones that much. You don’t feel like you’re getting high.”

Street names for gabapentin.

Most participants said that gabapentin is known as “Johnnies,” however it is also just as common to say “gabapentin” or use the brand name Neurontin. Although one participant said that the nickname “Johnnies” came from Boston, two participants said it derived from Philadelphia slang in which a “John” or a “Johnny” can refer to any noun. A white male participant, age 19, provided an example, “Can you turn that John on?” is what someone might say if they were talking about a television. Some nicknames were derived from the word “gabapentin” and included, “gabbys,” “gabs,” and “pens.” The brand name Neurontin was also the basis for several nicknames including, “neuros,” “nans,” “Rottweilers, “rotts,” and “rotties.”

DISCUSSION

Gabapentin is receiving increasing attention because of ongoing reports of misuse and diversion. The present study contributes to this literature by describing characteristics and behaviors associated with gabapentin misuse. Many participants (43%) in this sample misused gabapentin without ever receiving a prescription and 14% prior to being prescribed. This finding suggests that gabapentin misuse extends well beyond the number of individuals who have been prescribed.

Multiple routes of administration of gabapentin were reported, with the majority of participants stating that they primarily swallowed a whole pill. However, intranasal, intravenous, and rectal administration were also reported. Alternate routes of administration carry increased risk for HIV and hepatitis C infection if injection or snorting equipment is shared (Aaron et al. 2008; MacDonald, Crofts, and Kaldor 1996). The findings indicate that alternate routes of administration are not common. However, this has the potential to change if gabapentin misuse increases, especially among populations of substance users who already engage in alternate or other risky administration behaviors.

Descriptions of gabapentin misuse in combination with other substances is scant. Recent literature notes that gabapentin is combined and consumed with caffeine to obtain slight psychoactive effect and that gabapentin is combined with opioids to potentiate or induce feelings of euphoria (Smith et al. 2018; Stein et al. 2020; Baird, Fox, and Colvin 2013; Reeves and Ladner 2014; Embers, Ravishankar, and Roopa 2019; Chatterjee et al. 2019). Participants in the present study reported concomitant use with prescription and illicit opioids, benzodiazepines, alcohol, powder and crack cocaine, and marijuana. Moreover, a range of other prescription (e.g., muscle relaxants) and illicit substances (e.g., methamphetamine) were also used concomitantly with gabapentin. The diversity of concomitant use reported here indicates that a combination of in-depth and systematic epidemiologic research is needed to elucidate motivations and behaviors and to monitor trends related to concomitant use.

Such investigations are especially warranted given the potential negative consequences of gabapentin misuse, which can include seizures, as well as dependence and withdrawal symptoms. When used in combination with other substances, negative consequences can be especially dangerous. Gabapentin misuse occurring in conjunction with opioids is associated with hospitalization and overdose (Peckham, Fairman, and Sclar 2018; Evoy, Morrison, and Saklad 2017; Gomes et al. 2017). Prescribers, substance use treatment providers, and health and social service providers may be good candidates to educate patients about gabapentin misuse, as well as the potential dangers of polydrug use involving gabapentin.

Findings from this study document a wide range of sources for gabapentin among misusers, with nearly half of participants reporting sharing or trading with others and more than 20% stating that they purchased gabapentin through dealer or sellers in the informal market. Given that dispensed prescriptions of gabapentin, as well as diversion, have escalated in recent years (Quintiles 2017; Buttram et al. 2017), prescription drug monitoring programs may have the potential to monitor and manage gabapentin prescription. In addition, greater attention must be paid to informal distribution. Legislative interventions designed to curb diversion and informal sharing and trading, including scheduling gabapentin at the state level, are occurring (Peckham, Ananickal, and Sclar 2018). In time, analyses of these state-level interventions will demonstrate their effectiveness in curbing gabapentin misuse and diversion. In-depth research into sources of gabapentin and ongoing surveillance of diversion will also inform policy approaches.

Qualitative descriptions of the effects of gabapentin were varied and represent a range of feelings reminiscent of alcohol intoxication, stimulants, depressants, or no feelings at all. Importantly, many participants described effects of gabapentin in terms of pain relief and the alleviation of opioid withdrawal symptoms. The effects of gabapentin misuse may be influenced by other substances one has consumed, route of administration, or physical pain. Thus, the variability in participants descriptions can be expected. However, the pain-relieving qualities of gabapentin described by participants is important to highlight, especially considering that pain relief is one of the main motivations for deciding to initiate gabapentin misuse (Buttram, Kurtz, Cicero, et al. 2019). With the increasing controls being placed on gabapentin (Peckham, Ananickal, and Sclar 2018), the need to provide access to medication for individuals who need it, including substance users, must be balanced with interventions designed to limit diversion and misuse.

This study has some limitations which must be noted. Participants were drawn from a convenience sample in South Florida and the findings may not be generalizable to other locations or populations; still, the present findings are similar to those reported elsewhere (Applewhite et al. 2020; Chatterjee et al. 2019). All data are based on self-report; drug use biomarkers were not included in assessments. However, the high levels of substance use and other risk behaviors suggest that underreporting of these behaviors appears to be minimal. Furthermore, diagnostic measures of severe mental distress and substance use disorder were not clinician-administered. Thus, caution is warranted when comparing these measures to other studies. In addition, qualitative research involves the potential for interviewer effects and the underreporting of socially undesirable behaviors. The interviewers’ training, experience, and the use of a semi-structured interview guide likely mitigated these effects.

Reports of gabapentin misuse continue to emerge. Findings presented here describe misuse among a sample of prescription and/or illicit opioid (mis)users and demonstrate that gabapentin misuse is common among those without a gabapentin prescription, includes alternate routes of administration, occurs concomitantly with use of other substances, and is obtained through multiple sources in informal markets. Gabapentin produces feelings reminiscent of alcohol intoxication or opioid-induced euphoria, but for some it produces no noticeable effect or only alleviates pain. The need to better understand gabapentin misuse, especially associated behaviors and concomitant use is needed to inform prevention and intervention efforts, and to guide policy approaches.