Is it acceptable to prescribe pregabalin (lyrica) to a patient with a history of non-adherence to a controlled substance agreement, as evidenced by a positive urine drug test?

From the Guidelines

Prescribing pregabalin after a patient has broken a controlled substance agreement with a positive urine drug test is generally not recommended. Pregabalin (Lyrica) is a controlled substance with potential for misuse, and continuing to prescribe it to someone who has demonstrated non-adherence to treatment agreements raises significant concerns about patient safety and appropriate medication use 1. The positive drug test indicates the patient may be using substances not prescribed to them or using medications in ways not directed by their healthcare provider. In this situation, the provider should reassess the treatment plan, consider non-controlled substance alternatives for pain or anxiety management, and address the underlying substance use concerns. This might include referral to addiction specialists, pain management specialists, or mental health providers. The decision ultimately depends on the specific clinical context, the nature of the agreement violation, the patient's medical needs, and the provider-patient relationship. A transparent discussion with the patient about the breach of trust and development of a new treatment plan that prioritizes safety is essential before considering whether controlled substances like pregabalin can be safely prescribed in the future. Some key considerations in this scenario include:

• The potential for substance use disorder, as indicated by the positive urine drug test, which should be addressed through referral to appropriate specialists and development of a treatment plan that prioritizes safety and adherence to controlled substance agreements 1.
• The importance of using urine drug testing as a tool for monitoring adherence to controlled substance agreements and identifying potential substance use concerns, while also being aware of the limitations and potential for false positives or negatives 1.
• The need for clinicians to review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put them at high risk for overdose 1.
• The importance of not dismissing patients from care based on a urine drug test result or PDMP information, as this could constitute patient abandonment and have adverse consequences for patient safety 1.

From the FDA Drug Label

1. Drug Abuse and Dpendence 9.1 Controlled Substance Pregabalin is a Schedule V controlled substance. Pregabalin is not known to be active at receptor sites associated with drugs of abuse. As with any CNS active drug, carefully evaluate patients for history of drug abuse and observe them for signs of pregabalin misuse or abuse (e.g., development of tolerance, dose escalation, drug-seeking behavior).
2. 2 Abuse In a study of recreational users (N=15) of sedative/hypnotic drugs, including alcohol, pregabalin (450 mg, single dose) received subjective ratings of "good drug effect," "high" and "liking" to a degree that was similar to diazepam (30 mg, single dose)
3. 3 Dependence In clinical studies, following abrupt or rapid discontinuation of pregabalin, some patients reported symptoms including insomnia, nausea, headache or diarrhea [see WARNINGS AND PRECAUTIONS (5.6)], consistent with physical dependence.

The patient has broken the controlled substance agreement with a positive urine drug test. Prescribing pregabalin in this scenario may not be appropriate due to the patient's history of drug abuse. The drug label recommends carefully evaluating patients for history of drug abuse and observing them for signs of pregabalin misuse or abuse. Given the patient's positive urine drug test, it is likely that they are at a higher risk for pregabalin misuse or abuse. Therefore, alternative treatment options should be considered. 2

From the Research

Prescribing Pregabalin with a Broken Controlled Substance Agreement

• Pregabalin is a Schedule V controlled substance, which means it has a potential for abuse and dependence 3, 4.
• The decision to prescribe pregabalin to a patient who has broken a controlled substance agreement and has a positive urine drug test should be made with caution.
• According to the available evidence, there is no clear guidance on how to proceed in this situation, but it is essential to carefully monitor the patient's use of pregabalin and assess their risk of abuse or dependence 3, 4.

Considerations for Prescribing Pregabalin

• Pregabalin has been shown to be effective in managing neuropathic pain, but its use should be carefully considered in patients with a history of substance abuse 3, 4, 5.
• The patient's urine drug test results should be interpreted in the context of their medical history and the potential for false-positive or false-negative results 6.
• The clinician should weigh the potential benefits of pregabalin against the risks of abuse or dependence and consider alternative treatment options if necessary.

Clinical Implications

• Clinicians should be aware of the potential for abuse and dependence associated with pregabalin and monitor patients closely for signs of misuse 3, 4, 5.
• Patients with a history of substance abuse or a positive urine drug test should be carefully evaluated before being prescribed pregabalin, and alternative treatment options should be considered if necessary.
• The use of pregabalin should be part of a comprehensive treatment plan that includes regular monitoring and follow-up to minimize the risk of abuse or dependence.