Gabapentin for Musculoskeletal Pain?

At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin.  One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding.  He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever.  The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago.  The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).

Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections.  These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics).  Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives. 

The problem is that prescribing gabapentin for musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.

JAMA recently published a review article entitled “A Clinical Overview of Off-label Use of Gabapentinoid Drugs.”  The article reviewed the published evidence for the use of gabapentin and pregabalin (Lyrica) for various pain syndromes and reported the following:

  1. Low back pain. “The evidence does not support gabapentinoid therapy for low back pan or radiculopathy.”  The authors also note that “nonspecific lower body pain is (often falsely) labeled as neuropathic to justify gabapentinoid prescribing.”  However, since there is no evidence that gabapentin is effective for low back pain even with radiculopathy, this should not matter!
  2. Other pain syndromes (such as the broken hand patient above). The few studies that have been done on the use of gabapentin for pain show no benefit or benefit of “no clinical importance.” 
  3. Non-diabetic neuropathy. The authors point out that there is much confusion about exactly what “neuropathy” means when deciding to prescribe gabapentin for “neuropathic” pain.  Does my gunshot wound patient above have neuropathy?  Probably not, though you can find that diagnosis in his medical record.  Nevertheless,  according to JAMA, there is no credible evidence that supports using gabapentin for non-diabetic neuropathy—however defined.
  4. Gabapentin has a euphoric effect which results in “growing diversion activity and street value for gabapentinoids.” We correctional practitioners know this very well! The benefits of any drug must outweigh the potential liabilities to justify the prescription. If using gabapentin for pain has no value but does carry formidable risks, it should not be prescribed.

Besides this JAMA article, other gabapentin review articles have been published recently. One excellent example was published last January in the Therapeutics Initiative last year, entitled “Gabapentin and Pregabalin:  Are High Doses Justified?” Their conclusions:

  1. Most patients will not benefit from gabapentin or pregabalin for pain.”
  2. Do not expect better pain relief from higher doses.”

The Prescriber’s Letter agrees, stating “There isn’t good evidence for (the use of gabapentin) for chronic back pain.  And don’t use gabapentinoids for sciatica—they aren’t better than placebo.”

I could keep going.  For those who want more evidence of the ineffectiveness of gabapentin for chronic pain, please see the following (they say the same thing):

Essential Evidence Plus, Back Pain (Low, Chronic)

Uptodate, Subacute and chronic low back pain: nonpharmacologic and pharmacologic treatment.

In summary:

  1. Gabapentin has been found in multiple trials to be ineffective for musculoskeletal pain.
  2. Many practitioners “manufacture” a clinically inappropriate diagnosis of “neuropathy” to justify prescribing gabapentin for musculoskeletal pain.
  3. However, gabapentin has also been found in multiple trials to be ineffective for non-diabetic neuropathy. For example, it does not matter whether a chronic back pain patient has radiation of their pain or not–gabapentin should not be used.

I understand that treating patients with chronic pain is an arduous process. But gabapentin is not the answer.

As always, what I have written here is my opinion, based on my training, experience and research.  I could be wrong!  If you think I am wrong, please say why in comments . . .

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6 thoughts on “Gabapentin for Musculoskeletal Pain?

  1. Avatardolph a druckman, MD

    The reason gabapentin is asked for is because folks feel better… Look at the dopaminergic pathway and understand that it’s “feel good” actions are not dissimilar from a cocktail and or a cigarette.
    Good luck.

    Reply
  2. AvatarRishona Corson MD FACEP

    I agree with you completely. At Montana State prison, we have done away with gabapentin for musculoskeletal pain or for radicular pain. Currently, we are using trileptal for radicular pain. I’m relatively new to the prison system, and I have made it clear to all of my new inmate patients that I will not prescribe narcotics nor will I prescribed medication such as gabapentin for their musculoskeletal pain. I’m giving them options to go to physical therapy as well as the usual nonsteroidal anti-inflammatories. Once I’ve explained this to them, most have been receptive. I guess I should consider myself lucky up to this point.????

    Reply
  3. AvatarBertram Moshier

    I agree with you on Gabapentin for various pain issues. My doctor feels it is the end all to curing my non-diabetic neuropathy pain. He has me on 600 mg 3 times daily. I’ve been on Gabapentin for 2 months (including the introduction phase) and I don’t feel any decrease in pain.

    I’ve had non-diabetic neuropathy pain since 2005 in my left foot and have a Son with diabetic neuropathy. I know and understand the difference. Gabapentin isn’t a solution to non-diabetic neuropathy pain.

    I don’t like opioids and try to stop them for a week once a month. While the pain returns, it is worth it knowing the opioids are working. During this week, I don’t stop the Gabapentin and thus far the pain without opioids but on Gabapentin is just as bad as before going on the opioids.

    I can only say, with the opioids I’m able to get out of bed, walk, do PT, and even go outside from time to time. Without them (and yes with Gabapentin), in time, all I want to do is stay off my feet, cry, and wonder if life is nothing but pain is it worth it. Yes, life it worth it, but only when one can do stuff.

    Thank you for your continued great insights into medicine and corrections.

    Reply
  4. AvatarKatherine M Fontaine

    Having worked in corrections as a Psych APRN, for the past 20 yrs, it has long been a drug of abuse & most DOC’s no longer Rx it due to that. Unfortunately I often see folks coming in who are on suboxone & gabapentin up to 3600mg daily is given for “anxiety” .

    Reply
  5. AvatarDarin L Haugland

    I am a Physical Therapist with 20 years experience in the Minnesota Dept of Corrections. I am quite immersed in the pain discussion at my sites. I am completely against Gabapentin for Orthopedic pain. Virtually no patient ever tells me it “works” – they just need the dose to be increased. The abuse level of this medication is very high – it has put some patients “at risk” as they become targets to cheek this medication for others. I fully realize that my doctors feel pressure from patients and feel like they have minimal options. I would suggest to providers they are actually on higher standing denying Gabapentin for off label use. I try to emphasize to them to use research like Dr. Keller presented here. Avoid making it personal discussion about THEIR pain-talk studies and how you are uncomfortable with off label use of the medication.

    Reply

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