Can a patient with a history of substance abuse and Alcohol Use Disorder (AUD) be prescribed Lyrica (pregabalin) instead of gabapentin during an Ativan (lorazepam) taper?

Pregabalin Should NOT Be Prescribed Instead of Gabapentin During Ativan Taper in AUD

Pregabalin (Lyrica) is contraindicated in patients with alcohol use disorder and substance abuse history during benzodiazepine taper due to significant abuse potential, and gabapentin is the safer alternative despite its own modest misuse risk. 1, 2, 3

Critical Safety Concerns with Pregabalin in This Population

Abuse and Dependence Risk

• The FDA label explicitly warns that pregabalin causes CNS depression and has additive effects with benzodiazepines and alcohol, increasing risks of respiratory depression, somnolence, and dizziness 1
• All documented cases of pregabalin addiction occurred in patients with previous history of alcohol, cocaine, or opioid abuse, with patients typically escalating to doses exceeding 3000 mg/day (range 600-8000 mg/day) 2, 4
• A case report documented severe withdrawal symptoms when pregabalin was discontinued in a patient with underlying alcohol and polysubstance dependence, emphasizing that pregabalin should be used carefully in patients with a history of substance dependence 2
• Misuse rates for pregabalin reach 22% in drug abuse treatment centers 4

Dangerous Drug Interactions During Benzodiazepine Taper

• The FDA specifically warns that patients requiring concomitant treatment with benzodiazepines may experience additive CNS side effects including respiratory depression, somnolence, and dizziness 1
• This additive CNS depression is particularly dangerous during an Ativan taper when the patient is already at risk for withdrawal complications 1

Why Gabapentin is the Preferred Alternative

Relative Safety Profile

• Gabapentin is considered safe and appropriate for use in patients with all types of substance use disorders, including those taking opioid drugs 5
• Compared to other psychotropic drugs, gabapentin is not especially harmful or lethal 5
• Gabapentin is effective for treating comorbid anxiety, insomnia, and pain in patients with substance use disorders without the same level of abuse liability as pregabalin 5

Documented Abuse Risk is Lower

• While gabapentin misuse is possible, all documented cases of gabapentin addiction occurred in patients with previous history of alcohol, cocaine, or opioid abuse (similar to pregabalin but with lower frequency) 4
• Misuse of gabapentin in the general population is only 1.1% compared to pregabalin's 22% in treatment centers 4
• Average doses in gabapentin abuse cases were over 3000 mg/day (600-8000 mg/day range), suggesting therapeutic dosing carries lower risk 4

Appropriate Management During Ativan Taper

First-Line Treatment Remains Benzodiazepines

• Benzodiazepines are the only proven treatment to prevent seizures and reduce mortality from delirium tremens during alcohol withdrawal 6
• For patients with hepatic dysfunction or elderly patients, lorazepam 6-12 mg/day is the preferred benzodiazepine due to its shorter half-life 7, 6
• Benzodiazepines should not be continued beyond 10-14 days due to abuse potential 6

Essential Adjunctive Treatment

• Thiamine 100-300 mg/day must be administered BEFORE any glucose-containing fluids to prevent Wernicke encephalopathy 7, 8, 6, 9
• Continue thiamine for 2-3 months following resolution of withdrawal symptoms 7, 6
• Fluid and electrolyte replacement with careful attention to magnesium levels is essential 8, 6

Post-Acute Relapse Prevention

• Psychiatric consultation is mandatory after stabilization for evaluation, ongoing treatment planning, and long-term abstinence strategies 7, 8, 6
• Baclofen has demonstrated efficacy in maintaining abstinence specifically in patients with liver cirrhosis, making it valuable where other agents are contraindicated 7, 6
• Acamprosate 1,998 mg/day can be initiated 3-7 days after the last drink for patients ≥60 kg 7, 6
• Naltrexone is effective but contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk 6, 9

Common Pitfalls to Avoid

• Never prescribe pregabalin to patients with active substance use disorders or history of polysubstance abuse during benzodiazepine taper 1, 2
• Do not administer glucose-containing IV fluids before thiamine, as this can precipitate acute Wernicke encephalopathy 8, 6, 9
• Avoid continuing benzodiazepines beyond the acute withdrawal period (5-10 days maximum) to prevent iatrogenic dependence 6
• Monitor for signs of gabapentin misuse if it must be used, particularly in patients with polysubstance abuse history 4, 5