A Qualitative Examination of Gabapentin Misuse Inside of Treatment and Recovery Settings

Abstract

Objective:

Gabapentin, an anti-convulsant medication used to treat seizures and neuralgia, is also prescribed off-label for the treatment of substance use disorders and withdrawal symptoms in treatment settings. Yet, reports of gabapentin misuse are increasing in the United States. The present study examines the misuse of gabapentin in treatment and transitional living facility settings.

Method:

Data are drawn from a study examining gabapentin misuse in South Florida. The sample includes 34 adult participants who reported past-year use of illicit opioids and/or the misuse of prescription opioid medications, as well as histories of gabapentin misuse and treatment for substance use disorder. Data analyses included descriptive and in vivo coding schemes and used a descriptive qualitative approach.

Results:

Participants were female (26.5%), White (67.6%), African American/Black (5.9%), Hispanic (20.6%), Asian (2.9%), and other race/ethnicity (2.9%). Mean age was 31.6 years. Findings indicate that inside of treatment and recovery settings, gabapentin misuse occurs as individuals attempt to get high or cope with withdrawal or mental distress symptoms, and one quarter of participants perceived no benefit in misusing gabapentin. Participants also described the concept of “freelapse” (i.e., justifying the misuse of prescribed gabapentin and still considering oneself to be sober). Gabapentin misuse inside of transitional living facilities is common because of limited supervision and screening.

Conclusions:

Continued research is needed to understand the risk factors for gabapentin misuse and any potential benefits for continued gabapentin administration among treatment patients. Efforts to mitigate gabapentin misuse, including increased supervision and screening in treatment facilities, appear warranted.

Gabapentin is an anti-convulsant drug that is used to treat post-herpetic neuralgia and epilepsy (Wallach & Ross, 2018). Reports indicate that gabapentin is prescribed off-label to treat mental health problems, including anxiety and posttraumatic stress disorder, as well as in treatment settings for managing withdrawal symptoms (Berlin et al., 2015; Buttram et al., 2019b). Recently, the use of gabapentin for treatment of physical pain has been reported, as prescribers seek alternatives to opioids (Goodman & Brett, 2017).

Although gabapentin has historically been perceived to have low abuse potential levels because of its dose-limited absorption properties (Bockbrader 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, 2020; King, 2020; Mincher, 2018; North Dakota State Board of Pharmacy, 2019; Peckham et al., 2018). Gabapentin remains unscheduled federally.

Recent studies and case reports document that gabapentin is misused; of note, one study of adults reporting current nonmedical use of diverted prescription opioids in Kentucky documented a 2,950% increase in gabapentin misuse for the purpose of getting high between 2008 and 2014 (Smith et al., 2015). Gabapentin, when used in combination with methadone and other prescription opioids, potentiates central nervous system effects (Baird et al., 2014; Reeves & Ladner, 2014; Smith et al., 2015). In addition to getting users high, gabapentin is misused to moderate opioid withdrawal symptoms, attempt to self-detox from opioids, and treat physical pain or mental distress symptoms, according to a recent ethnographic study (Buttram et al., 2019a). Gabapentin diversion—the unlawful channeling of regulated pharmaceuticals from legal sources to the informal marketplace (Inciardi et al., 2006)—is also growing, and diverted gabapentin is combined and used in conjunction with heroin (Buttram et al., 2017).

In contrast to these findings, research documents the therapeutic benefits of administering gabapentin to individuals in treatment for substance use disorder. Two recent randomized clinical trials showed that gabapentin decreases withdrawal symptoms and improves executive function among cannabis-dependent adults (Mason et al., 2012) and improves rates of alcohol abstinence; days without heavy drinking; and measures of mood, sleep, and craving among individuals with alcohol dependence (Mason et al., 2014). These studies suggest that gabapentin may be efficacious in reducing withdrawal symptoms, cravings, and substance use among patients in treatment for substance use disorder.

At the same time, treatment providers have questions about the appropriateness of administering gabapentin to their patients. One recent study found that the administration of gabapentin during treatment varies by provider, with some requiring patients to desist from using prescribed gabapentin during treatment and others allowing it (Buttram et al., 2019b). Moreover, providers described both the therapeutic benefits of gabapentin use during treatment, as well as the potential for misuse (Buttram et al., 2019b). Additional literature has noted gabapentin misuse among patients in detoxification or medication-assisted treatment programs, people in prison or jail, and those in community samples in the United States (Embers et al., 2019; Reccoppa et al., 2004; Stein et al., 2020; Vickers Smith et al., 2018; Wilens et al., 2015), as well as among samples of individuals in treatment for substance use disorder in Europe (Baird et al., 2014; Wagner et al., 2018).

However, in-depth qualitative examinations of gabapentin misuse inside of treatment and recovery settings, including treatment and transitional living facilities, are scant. “Real-world” experiences of treatment patients receiving prescribed gabapentin remain unstudied. Given the literature describing gabapentin misuse and potential benefits to treatment patients and misuse, as well as differing opinions among treatment providers, the present study attempts to address this void in the literature and examine the motivations and settings in which gabapentin is misused in an effort to inform treatment practices for substance use disorder.

Method

Study sample and design

The data were collected as part of a larger study investigating the initiation and consequences of gabapentin misuse (N = 91); eligible respondents were age 18 years or older and reported past-year use of illicit opioids and/or the misuse of prescription opioid medications, in addition to histories of gabapentin misuse. Individuals who reported experiences of gabapentin misuse while they were inside of a treatment and/or recovery setting (i.e., detoxification, treatment for substance use disorder, transitional living facility) were asked additional follow-up questions included in these analyses (n = 34). The sample included 9 women; respondents identified as White (n = 23), African American/Black (n = 2), Hispanic (n = 7), Asian (n = 1), and other race/ethnicity (n = 1). Mean age was 31.56 years, and mean years of education was 12.97. Participants reported being admitted to treatment or detox for use of alcohol or drugs an average of 7.71 times and reported a drug overdose or drug-related emergency an average of 8.09 times. Three respondents were recruited through direct outreach and were not in treatment at the time of the interview; however, of those who were recruited while in treatment (n = 31), the primary substances that participants were receiving treatment for included heroin (n = 21), prescription opioids (n = 3), methamphetamine (n = 3), benzodiazepines (n = 2), and alcohol (n = 2).

Participants were recruited through a variety of strategies, including outreach at local treatment centers, and flyers and advertisements were placed in public spaces and a local weekly publication. 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 on completion of the interview. Interviews were conducted between January and December 2018 in South Florida (Miami-Dade, Broward, and Palm Beach counties). Study protocols were approved by the university’s Institutional Review Board.

Qualitative interview protocol and analysis

The interview was guided by a semi-structured protocol. Respondents provided information about demographic characteristics, and they were also asked to give a detailed account of the initiation of gabapentin misuse. The semi-structured interview guide included prompts to elicit more information, including, “Was gabapentin prescribed to you?” “Where were you the first time you used it?” “Did you use it when you were by yourself or with someone else?” and “How did you discover that it could be misused?” Additional follow-up questions inquired about additional instances of gabapentin misuse, besides the first time they misused; respondents were asked, “Have you ever used or seen gabapentin misused in a treatment center, halfway house, or other recovery setting?” Mentions of treatment and recovery settings elicited additional follow-up prompts that asked participants to describe their gabapentin misuse in these settings, explain how common gabapentin misuse is among individuals in treatment and recovery, and describe motivations for use in these settings.

The interviews were digitally audio-recorded and transcribed. The Principal Investigator reviewed the transcripts for accuracy. ATLAS.ti Version 7 (Scientific Software Development GmbH, Berlin, Germany) software was used for data management, coding, and analysis.

Interviews were coded using descriptive (words or short phrases to summarize passages of data) and in vivo (actual language from participants to name concepts and themes) coding schemes (Saldaña, 2013). Memos were written after each participant was interviewed and after each interview was coded to reflect code choices, emergent themes and patterns, and conceptual models (Saldaña, 2013). Two members of the research team participated in the coding process, which included establishing codes and meanings and cross-checking code choices. Regular discussions were held between the coders that yielded insights to help refine the coding scheme and facilitate agreement on code choices (Barbour, 2001). Using a descriptive qualitative approach to analysis (Colorafi & Evans, 2016), the data were themed and the final set of codes and their meanings were transformed into longer and more descriptive themes in order to organize recurrent meanings and patterns. Themes and definitions of themes were constantly compared across interviews to ensure consistency and reliability; external validity was ensured through the use of thick, rich descriptions of data, which allowed for the identification of patterns and relationships and evaluation of the extent to which such descriptions reflected the lived experience of the participants (Creswell, 2013; Lincoln & Guba, 1985).

Results

Demographic and background characteristics

Table 1 displays demographic characteristics corresponding to each theme that emerged during analysis. Numbers of women and mean age are similar across each theme. Although non-White participants are represented in each theme, “Self-treatment of withdrawal or other symptoms” appears to include the most racial/ethnic diversity.

Table 1.

Themes related to respondents’ experiences of misuse in treatment and recovery settings according to respondent demographic characteristics (n = 34)

	Attempting to “get high” during treatment		A “fruitless” activity		Self-treatment of withdrawal and other symptoms		Misuse inside of transitional living facilities		“Freelapse”
Variable	N	%	n	%	n	%	n	%	n	%
Total respondents	11	100%	8	100%	7	100%	13	100%	4	100%
Female	4	36.4%	3	37.5%	2	28.6%	2	15.4%	2	50.0%
Race/ethnicity
White	9	81.8%	6	75.0%	1	14.3%	11	84.6%	2	50.0%
African American/Black	0		0		1	14.3%	1	7.7%	1	25.0%
Hispanic	2	18.2%	2	25.0%	3	42.9%	1	7.7%	1	25.0%
Asian	0		0		1	14.3%	0		0
Other race/ethnicity	0		0		1	14.3%	0		0
Age, M (SD)	32.73	(9.819)	28.75	(7.246)	35.00	(8.505)	29.00	(6.096)	31.25	(8.421)

Attempting to “get high” treatment for substance use disorder

Gabapentin misuse while in treatment primarily occurred with the intention of feeling a desired psychoactive effect, described by respondents as, “a buzz,” “a speedy feeling,” or “loopy, drowsy.” At detox and treatment centers, a common practice was to “cheek” the medication. This involves hiding the gabapentin pill inside one’s cheek or under the tongue rather than swallowing the pill when it was administered by treatment staff. One White woman, age 30, described being given three doses per day, which she would save and take all at once before bed. Similarly, a 24-year-old White man said, “You know, like a lot in rehab, like, you’ll cheek it, and then go back [to your room] and you’ll sniff it,” while another said, “people would hide it . . . like they hoard them so you could have five, six, seven, so they could use it for a buzz. I’ve done it before” (Hispanic man, age 43).

In some instances, gabapentin was “a hot commodity,” said a 24-year-old White man. He went on to explain, “If you can get it, you’re like the king of rehab. Like, if [other treatment patients] are only getting 300s, they’ll be like, ‘Come on man, let me get one of your 600s.’ Shit like that. It’s kinda sad really. It’s just a prescription pill and people are thinking it’s like crack.” Another method of acquiring gabapentin was to feign symptoms for which it could be prescribed. As one Hispanic man, age 43, said, “I was in rehab and of course we talk. This guy tells me, ‘Well, just say that you got a sciatica pain and the doctor will give you gabapentin.’” It was through this method that he was able to obtain a prescription. A White woman, age 45, also described gabapentin as being very valuable during treatment. Previously, she had been in a treatment center that also had a detox facility in which all incoming patients were administered gabapentin for opioid withdrawal symptoms. She said, “I remember that there was a guy who left and he was trying to buy people’s gabapentin. And then there was another girl that left and she was kind of freaking out because they didn’t give her a prescription for gabapentin to leave with. She was saying she was sick and trying to get her prescription filled and she was having a whole, big panic attack over it.”

A fruitless activity

Other respondents did not understand why gabapentin was a sought-after substance. About a quarter of respondents believed that misusing gabapentin during treatment was a fruitless activity. For some, this perception was based on their prior experience of misusing gabapentin. As one respondent said, “The more you hear about it, the more it got put in [my head]. Some nights, I’d take five [gabapentin pills]. Even though there was no reward from it, I still did it” (White man, age 33). Similar experiences were described by others, including one 25-year-old Hispanic man, “I went to my first rehab when I was, like 20 and they had prescribed me gabapentin, but I think I misused it, like a couple of times, but it was just so stupid to me. I think people that do gabapentin, that misuse it, are retarded.” Another respondent said, “It’s more like dumb people in halfway houses trying to get high” (White woman, age 28).

Part of the frustration expressed by these respondents was because any potential psychoactive effect achieved from misusing gabapentin would not compare to drugs they used before entering treatment. According to a 24-year-old White male respondent who said, “I hear it a lot in rehab . . . people just think that they can abuse it . . . ’cuz you kinda feel a little something, but that little something is nothing compared to the drugs that we can get. And I think it’s just being desperate, you know? Having nothing else . . .” Another respondent agreed, but he was not tempted to misuse gabapentin during treatment. In his words, “If I’m gonna relapse, I’m gonna relapse on what I wanna use, you know? I’m not gonna use [gabapentin]” (White man, age 24).

Self-treatment of withdrawal and other symptoms

A 41-year-old Asian man said that he has heard talk of gabapentin misuse and the ability to “get a nice buzz off it,” especially among opioid addicts. However, he says most of this misuse is likely because “you can detox with its effect. That’s, like, the important point instead of getting high. I think that’s more important.” Another respondent (African American man, age 35) described gabapentin misuse in his treatment center, in which incoming patients with current gabapentin prescriptions shared their medication with others. As he said, “Guys are . . . trying to take the edge off the withdrawal.” For some, knowledge of the therapeutic benefits of gabapentin was attained while misusing before treatment. As a 46-year-old White man said, “I tried to get [treatment staff] to prescribe [gabapentin] to me but they wouldn’t. I mean, I’m still trying to get it . . . because it made me go to sleep faster.”

Describing his withdrawal from buprenorphine, a 25-year-old Hispanic man said that in his current treatment center, he was given gabapentin by another patient. “He gave me one to sniff and it made my anxiety go away a little bit. I mean, it didn’t really do much, but I was so sick I didn’t care. I was just so sick, dope sick, dude. Maybe it was a mental thing. I don’t know if it helped or not. I still did it because I was willing to do anything.” His feeling of desperation to feel better was echoed by another respondent who said he experienced depression while in a halfway house because he did not want to be there. He said, “I was very depressed. I was so depressed that I just took, like, five or six [gabapentin pills] every single day. And I would be taking them because I wanted to go to sleep because they helped me sleep” (Hispanic man, age 43).

Misuse inside of transitional living facilities

Specific to transitional living facilities, including halfway houses and recovery houses, respondents described the prevalence of gabapentin misuse. This was in part because many residents in the houses had prescriptions for gabapentin. One 32-year-old White man said he learned about gabapentin when he moved into a halfway house following treatment. He said, “But like literally, each person would get a prescription, and they would just split it with the house. And then the next person would get a prescription and they would split it with the house. So it just became like a party thing.” “A free-for-all” is how a 24-year-old White man described it. Another 32-year-old White man described having been to several halfway houses and that in his experience, “It seems like that’s what people abuse the most because they can kind of get away with it and try to feel some sort of way.” In fact, the desire to misuse gabapentin in these settings prompted some to seek prescriptions, even when it was not medically necessary. Said one 23-year-old African American woman, “People will sit there and lie and say that that have extremely bad anxiety so that way they can get prescribed . . . Like everybody who does drugs knows that gabapentin can get you high.”

A 25-year-old White man noted that the lack of adequate drug testing, combined with the ease of getting a prescription, is why it is abused in halfway houses. His comments were echoed by several others. “Gabapentin’s not really gonna pop up on a 12-panel test unless they send it out, so [people in halfway houses] will get away with it,” said a 32-year-old White man.

“Freelapse”

For respondents who described gabapentin misuse inside of treatment settings, their rationale for doing so was best described by a 23-year-old African American woman who told about the concept of “freelapse.” Because she suffers from anxiety, she was prescribed gabapentin during treatment and her thinking was, “Okay, well, you know, let me try [misusing] it because they say it gets you high without actually getting high.” Within this context, she was able to rationalize that her behavior was permitted, rather than adversely affecting her sobriety. Others, although not using the term freelapse, described the same concept. A 29-year-old White man said, “I was trying to remain sober and justify taking [gabapentin] because of my ankle and my pain level at the time. So, I was conscious of trying not to get too messed up on them, but at the same time, yeah, that was the desired effect.” Respondents also said, “Once I started to try to get clean . . . I would take handfuls of [gabapentin]” (White woman, age 30) and, “Gabapentin now . . . is like a thing you do when you’re sober” (Hispanic man, age 43).

Discussion

As described by respondents, the misuse of gabapentin inside of treatment and recovery settings appears to be common. Although many individuals were attempting to achieve a desired psychoactive effect, misuse also occurred as a result of mental distress and in an effort to alleviate opioid withdrawal symptoms. Still, others say there is no reason to misuse gabapentin whatsoever. When gabapentin was misused to achieve a desired psychoactive effect, transitional living facilities were common settings; avoiding urine analysis testing and maintaining one’s sobriety through a “freelapse” were some of the primary motivations for gabapentin misuse in these settings.

Misuse of gabapentin carries risks, including nausea, hypotension, sedation, ataxia, toxicity, and symptoms of dependence and withdrawal (Evoy et al., 2017). In addition, gabapentenoid drugs can contribute to polysubstance-related fatalities, with the most significant risk being respiratory depression and overdose when these drugs are used in combination with opioids (Evoy et al., 2019). According to treatment providers, gabapentin misuse may also be a first indicator of a relapse; individuals may begin misusing gabapentin because of its availability and then progress to their drugs of choice, including heroin, crack cocaine, and alcohol (Buttram et al., 2019b). Participants in the sample who wished to get high and who described freelapse behaviors would seem to fit this profile.

Gabapentin and other medications may be kept in a secure location in treatment facilities and only administered to patients on a dose-by-dose basis. However, participants in the study described leaving treatment with a supply of gabapentin and little supervision in transitional living facilities. Such scenarios provide opportunities for gabapentin misuse. Additional safety measures appear to be warranted and may include limiting prescriptions for patients leaving treatment and supervised gabapentin administration in transitional living facilities. Furthermore, the inclusion of gabapentin in routine urine analysis testing of residents in halfway or recovery houses would likely limit gabapentin misuse as well.

At the same time, additional research has demonstrated the therapeutic benefit of administering gabapentin to patients in substance use treatment. In small trials, gabapentin use is associated with improved outcomes, including reduced withdrawal symptoms, substance use reduction and abstinence, and improved executive functioning (Mason et al., 2012, 2014). Among the sample, descriptions of misuse for self-treatment of mental distress and opioid withdrawal symptoms support the findings from these trials that gabapentin may be beneficial for treatment patients. Yet, practicing treatment providers lack knowledge related to the best practices for the use of gabapentin among their patients and in treatment settings (Buttram et al., 2019b). Thus, the “real-world” experiences of patients receiving gabapentin as an adjunct to opioid use disorder treatment remain unstudied.

Findings from this study suggest that more research is needed to elucidate risk factors for gabapentin misuse among individuals in treatment for substance use disorder. Although limited studies have documented gabapentin misuse among medical detoxification and treatment patients (Embers et al., 2019; Stein et al., 2020; Wilens et al., 2015), additional studies examining gabapentin administration and misuse within the context of medication-assisted treatment are also needed. Furthermore, the development of screening and diagnostic tools that may aid treatment providers in identifying patients most at risk for misusing gabapentin will likely be necessary if gabapentin continues to be administered in treatment settings. Until more complete data are available, caution in administering gabapentin to treatment patients appears warranted.

Limitations

Like all research, this study has some limitations that must be noted. The potential for recall bias and interviewer effects exists. However, the interviewers’ training, experience, and the use of a semi-structured interview guide likely mitigated these effects. Eligibility was determined based on self-reported data from the respondents; however, a separate re-screening process before the interview likely mitigated any false reports from potentially eligible respondents. Participants were drawn from a convenience sample from South Florida, and these findings are not generalizable to other locations or populations. Moreover, given the histories of treatment and overdose, it is likely that respondents in this sample have had greater substance use involvement and related problems than other populations, which also limits generalizability.

Conclusions

To our knowledge, this is the first study to examine gabapentin misuse inside of treatment and recovery settings, including transitional living facilities. As with gabapentin misuse reported in other populations and in other contexts, participants report multiple motivations for engaging in this behavior. However, continued research is needed to understand the risk factors for gabapentin misuse and any potential benefits for continued gabapentin administration among treatment patients. In addition, efforts to mitigate gabapentin misuse, including increased supervision and screening, appear warranted.