Is gabapentin (Neurontin) effective for treating alcohol use disorder?

Gabapentin for Alcohol Use Disorder

Gabapentin has shown some effectiveness for alcohol use disorder but is not a first-line treatment and should be considered only after FDA-approved medications have been tried or are contraindicated.

Evidence on Gabapentin for AUD

Current clinical guidelines recognize gabapentin as a potential option for alcohol use disorder (AUD), but with important limitations:

• The French Association for the Study of the Liver and French Alcohol Society (2022) mentions gabapentin as one of the medications available without marketing authorization that has "shown some effectiveness in the treatment of alcohol use disorder" 1

• The European Association for the Study of the Liver (2012) notes gabapentin as one of several medications being researched for alcohol withdrawal syndrome, but states that "sufficient evidence in favor of their use is lacking" 1

Treatment Algorithm for Alcohol Use Disorder

1. First-line FDA-approved medications:

   • Acamprosate (safe in patients with liver disease) 1
   • Naltrexone (contraindicated in severe liver disease due to hepatotoxicity) 1
   • Disulfiram (contraindicated in severe liver disease) 1

2. Second-line options (off-label):

   • Baclofen (safer in advanced liver disease) 1
   • Topiramate 1
   • Gabapentin (consider only after other options)

Gabapentin Safety Considerations

When considering gabapentin for AUD, several safety concerns must be addressed:

• Risk of falls and altered mental status: A large study of 571,718 veterans found gabapentin was associated with increased risk of falls/fractures (RR 1.35) and altered mental status (RR 1.12), with a clear dose-response relationship 2

• Potential for misuse: While gabapentin is "not especially harmful or lethal" compared to other psychotropic drugs, there is concern about its potential for abuse 3, 4

• Ineffectiveness for withdrawal: A 2019 study found gabapentin did not reduce benzodiazepine requirements during alcohol withdrawal and was actually associated with higher benzodiazepine use 5

Clinical Application

If considering gabapentin for AUD:

• Dosing: Efficacy for AUD starts at doses of 900 mg/day 2

• Monitoring: Implement heightened monitoring, especially at doses ≥600 mg/day 2

• Patient selection: Screen for opioid or other prescription drug abuse before prescribing 4

• Specific benefits: May have unique benefits for alcohol-related insomnia and negative affect compared to other available treatments 6

Cautions and Pitfalls

• Gabapentin should not be used as first-line therapy for AUD when FDA-approved options are available and not contraindicated
• The dose-response relationship for adverse effects means higher doses (needed for AUD efficacy) carry greater risks
• Patients with liver disease may require more careful monitoring, though they didn't show excess risk compared to those without liver disease in safety studies 2
• Gabapentin is not effective for alcohol withdrawal and should not be used as a substitute for benzodiazepines in this context 5

In conclusion, while gabapentin shows some promise for AUD treatment, particularly for addressing sleep and mood issues during early abstinence, it should be reserved as a second-line option after standard therapies have been tried or are contraindicated.