Why is gabapentin preferred for treating anxiety in individuals with alcohol (ETOH) abuse who are trying to stop drinking?

Gabapentin for Anxiety in Alcohol Use Disorder

Gabapentin is preferred for treating anxiety in individuals with alcohol use disorder who are attempting to stop drinking because it effectively manages both anxiety symptoms and alcohol withdrawal while having a lower abuse potential compared to benzodiazepines, which are contraindicated in this population due to their high risk of dependence and cross-addiction.

Rationale for Gabapentin Use in Alcohol Use Disorder with Anxiety

Benzodiazepine Limitations

• Benzodiazepines are considered the gold standard for alcohol withdrawal syndrome (AWS) treatment 1, but they carry significant risks:
  • High potential for abuse and dependence
  • Cross-addiction risk in patients with alcohol use disorder
  • Should be avoided beyond the initial 10-14 days of treatment 1
  • Patients with alcohol use disorder are at higher risk for benzodiazepine abuse 1

Gabapentin Advantages

• Effectively manages both anxiety and alcohol withdrawal symptoms 2, 3
• Lower abuse potential compared to benzodiazepines (though not zero) 2
• Can simultaneously address multiple symptoms:
  • Anxiety
  • Insomnia
  • Headaches
  • Pain
  • Alcohol withdrawal symptoms 2, 3
• Demonstrated efficacy for mild alcohol withdrawal and early abstinence 4
• Well-tolerated safety profile 2, 4

Evidence for Efficacy

• Gabapentin has shown effectiveness in treating alcohol dependence 2
• Case reports demonstrate efficacy in managing alcohol withdrawal symptoms with dosing of 400 mg TID for 3 days, then tapered over 2 days 3
• Helps address anxiety, insomnia, and other symptoms that often trigger relapse 2, 4

Important Cautions and Monitoring

• Despite advantages, gabapentin is not risk-free:

  • Cases of gabapentin abuse have been documented, particularly in patients with history of substance abuse 5
  • Average doses in abuse cases exceeded 3000 mg/day (range 600-8000 mg/day) 5
  • Misuse rates: 1.1% in general population, 22% in drug abuse treatment centers 5
  • Dependence and withdrawal can occur 5
  • Deaths involving pregabalin (related gabapentinoid) have been rising 6

• Recommended approach:

  • Screen for history of opioid or prescription drug abuse to determine if heightened monitoring is warranted 4
  • Consider gabapentin as a second-line alternative to standard therapies 4
  • Monitor for drug-seeking behaviors 5
  • Be vigilant for signs of abuse, dependence, and withdrawal 5

Alternative Medications for Alcohol Use Disorder

If gabapentin is not appropriate, consider:

• Naltrexone (50 mg daily oral or 380 mg monthly injectable) - recommended by American Academy of Family Physicians, combined with CBT 7

  • Requires liver function monitoring every 3-6 months 7
  • Reduces alcohol cravings and consumption
  • Associated with reduced dropouts compared to placebo (OR 0.70,95% CI 0.50 to 0.98) 1

• Acamprosate (666 mg three times daily) 7

  • Best evidence for maintaining abstinence (OR 1.86,95% CI 1.49 to 2.33) 1
  • Associated with reduced dropouts compared to placebo (OR 0.73,95% CI 0.62 to 0.86) 1
  • Safe in patients with liver disease 7

• Baclofen (30-60 mg daily) 7

  • Shown benefit in patients with alcohol-related liver disease 7
  • GABA-B receptor agonist that may increase abstinence rate and prevent relapse 1

Conclusion

While gabapentin is a valuable option for treating anxiety in patients with alcohol use disorder who are attempting to stop drinking, clinicians should:

• Be aware of its potential for abuse, especially in patients with prior substance abuse history
• Use appropriate monitoring
• Consider the full range of available medications based on patient-specific factors
• Combine pharmacotherapy with behavioral interventions like CBT for optimal outcomes