Does Gabapentin (Neurontin) have a potential for abuse?

Gabapentin Abuse Potential: Clinical Reality

Yes, gabapentin is increasingly recognized as a medication with significant abuse potential, particularly among individuals with histories of substance abuse, opioid use disorders, or psychiatric conditions, and the FDA acknowledges postmarketing reports of misuse and abuse despite gabapentin not being a federally scheduled controlled substance. 1

Prevalence of Gabapentin Abuse

The epidemiological data reveals concerning patterns:

• General population abuse prevalence is approximately 1%, which may seem low but represents substantial numbers given widespread prescribing 2
• Among patients with gabapentin prescriptions, abuse rates range from 40-65%, indicating that a significant proportion of prescribed patients misuse their medication 2
• In opioid-abusing populations, gabapentin misuse occurs in 15-22% to as high as 68% depending on the study population, making this the highest-risk group 2, 3
• International adverse event databases identified 11,940 reports of gabapentinoid abuse from 2004-2015, with over 75% reported since 2012, demonstrating rapidly escalating abuse patterns 3

FDA Recognition and Regulatory Status

The FDA drug label explicitly addresses abuse potential:

• Gabapentin is not a federally scheduled controlled substance, which has contributed to its widespread off-label prescribing 1, 4
• The FDA acknowledges postmarketing cases of gabapentin misuse and abuse, noting that individuals take higher-than-recommended doses for unapproved uses 1
• Most individuals in FDA reports had histories of polysubstance abuse or used gabapentin to relieve withdrawal symptoms from other substances 1
• Some U.S. states have independently reclassified gabapentin as a Schedule V controlled substance to enable prescription monitoring 4

High-Risk Populations

Specific patient populations demonstrate elevated abuse risk:

• Individuals with opioid use disorders represent the highest-risk population, with gabapentin frequently used to potentiate opioid effects or manage withdrawal 2, 3, 5
• Patients with psychiatric comorbidities show increased misuse rates, particularly those with anxiety or mood disorders 3, 6
• Those with previous prescription drug abuse history are at substantially elevated risk 6, 4
• Polysubstance abusers commonly incorporate gabapentin into their drug-seeking repertoire 1, 5

Patterns and Motivations for Abuse

Gabapentin is misused through distinct patterns:

• Recreational purposes dominate, with users reporting euphoric effects reminiscent of opioids, benzodiazepines, and psychedelics 2
• Dosages used for abuse are typically 3-20 times higher than clinically recommended doses, with some case reports documenting extremely high doses 6
• Gabapentin is frequently combined with opioids, benzodiazepines, or alcohol to enhance intoxication effects 2, 3
• Self-medication for anxiety, insomnia, or withdrawal symptoms represents another common misuse pattern 2
• Users report cocaine-like highs, alcohol craving reduction, and sedative effects as motivations 4

Clinical Guidelines Recognition

Professional guidelines acknowledge abuse concerns:

• The American College of Cardiology notes gabapentin carries Schedule V controlled substance designation in its 2023 cardiac amyloidosis guidelines, listing euphoria as an adverse effect alongside sedation and confusion 7
• The 2007 American College of Physicians/American Pain Society guidelines note that gabapentin is not FDA-approved for low back pain and carries risks for abuse 7
• The Lancet Psychiatry emphasizes dangerous respiratory depression when gabapentin is combined with opioids, highlighting serious safety concerns 8, 9

Physical Dependence and Withdrawal

Evidence demonstrates physiological dependence:

• Rare postmarketing reports document withdrawal symptoms (agitation, disorientation, confusion) after abrupt discontinuation of higher-than-recommended doses 1
• Physical dependence develops through neuroadaptive changes requiring continuous administration, typically more than 5 days 9
• Approximately 50% of patients prescribed gabapentinoids in England had continuous treatment for at least 12 months, raising concerns about long-term dependence 9
• Withdrawal symptoms resolve after restarting gabapentin, confirming physiological dependence 1

Dangerous Drug Interactions

Gabapentin abuse creates life-threatening combinations:

• When combined with opioids, benzodiazepines, or CNS depressants, gabapentin causes dangerous synergistic respiratory depression 8, 9
• The 2019 AGS Beers Criteria recommends caution when combining gabapentinoids with other CNS-active drugs due to increased fall risk and cognitive impairment 9
• Gabapentin is increasingly identified in postmortem toxicology analyses, though effects of high doses alone are generally non-lethal 3

Clinical Prescribing Implications

Physicians must implement specific safeguards:

• Carefully evaluate patients for history of drug abuse before prescribing gabapentin 1, 6
• Observe for signs of misuse including tolerance development, self-dose escalation, and drug-seeking behavior 1
• Avoid prescribing to patients with opioid use disorders, psychiatric disorders, or substance abuse history when possible 5
• If prescribing to high-risk patients is necessary, implement close monitoring for signs of misuse 5
• Consider that gabapentin is recommended only as second-line therapy for neuropathic pain after tricyclic antidepressants 9
• Reassess risk-benefit ratio when treatment exceeds 12 months, as approximately half of long-term prescriptions may be of doubtful efficacy 9

International Scope

Gabapentin abuse is a global phenomenon:

• Published abuse reports originate from the United States, United Kingdom, Germany, Finland, India, South Africa, and France, indicating worldwide distribution 2
• An anecdotally growing black market for gabapentin has been reported across multiple countries 6
• International adverse event databases show exponentially increasing reports since 2012 3