What is the best course of action for a patient who has been taking high doses of pregabalin recreationally and now wants to stop?

Management of Recreational Pregabalin Use and Abrupt Discontinuation

For a patient who has taken escalating high doses of pregabalin recreationally over 5 days (450-1350mg daily) and now wants to stop, immediate cessation is appropriate without a taper, but close monitoring for withdrawal symptoms is essential, with supportive care and psychiatric evaluation to address underlying substance use patterns.

Immediate Clinical Assessment

Evaluate the patient urgently for signs of pregabalin toxicity and withdrawal risk:

• Assess current mental status, including presence of visual or auditory hallucinations, confusion, agitation, or suicidal ideation, as pregabalin at high doses can cause psychotic symptoms that may persist for weeks 1, 2
• Check vital signs, particularly respiratory rate and oxygen saturation, as pregabalin combined with other CNS depressants poses respiratory depression risk 3
• Obtain comprehensive drug screen and history of all substances used concurrently, as nearly 50% of pregabalin abusers use it alongside multiple other psychoactive drugs (mean of 4 concomitant drugs) 4
• Assess for rhabdomyolysis with creatine kinase, basic metabolic panel, and urinalysis, as severe pregabalin intoxication can cause muscle breakdown and acute kidney injury 5
• Screen for suicidal ideation, as pregabalin carries FDA warnings about increased suicide risk 3

Withdrawal Management Strategy

Abrupt discontinuation is medically appropriate for this short-duration recreational use pattern:

• No taper is required after only 5 days of use, even at supratherapeutic doses, as physical dependence requiring gradual dose reduction typically develops with chronic therapeutic use over weeks to months 3
• Monitor for withdrawal symptoms including insomnia, nausea, headache, anxiety, hyperhidrosis, and diarrhea, which are the expected withdrawal syndrome from pregabalin 3
• Increased seizure frequency is a risk with abrupt discontinuation in patients with seizure disorders, but this patient's recreational use pattern does not suggest underlying epilepsy 3
• Withdrawal symptoms from pregabalin typically resolve within 48 hours in cases of short-term high-dose abuse 1

The evidence from benzodiazepine and opioid withdrawal guidelines does not directly apply to pregabalin:

• Unlike benzodiazepines, pregabalin withdrawal does not carry risk of seizures, delirium, or death in otherwise healthy patients 6
• Unlike opioids, pregabalin withdrawal is not associated with severe physical symptoms requiring medication-assisted treatment 6
• The gabapentinoid class (pregabalin, gabapentin) has a distinct withdrawal profile that is generally milder than benzodiazepines or opioids 6

Supportive Care During Withdrawal

Provide symptomatic management without introducing additional dependency risk:

• Offer non-benzodiazepine anxiolytics or sleep aids if insomnia or anxiety are severe, avoiding agents with abuse potential given this patient's drug-seeking behavior 7
• Ensure adequate hydration and electrolyte monitoring, particularly if nausea or diarrhea are present 3
• Monitor mental status daily for the first week, as psychotic symptoms (hallucinations, delusions) may persist for 1-2 weeks after discontinuation 1, 2
• Suicidal ideation should be assessed at every encounter, as pregabalin carries FDA black box warnings about suicide risk that may persist during early withdrawal 3

Addressing Underlying Substance Use Disorder

This pattern of escalating recreational use over 5 days indicates high-risk drug-seeking behavior:

• The rapid dose escalation from 450mg to 1350mg over 5 days, with 80% taken as a "startup dose," demonstrates classic abuse pattern rather than therapeutic misuse 4, 7
• Pregabalin abuse typically occurs as part of polydrug use, with abusers taking it alongside opioids, benzodiazepines, and other psychoactive substances 4
• Refer immediately to addiction medicine or substance use disorder treatment program, as this patient qualifies as a probable drug abuser based on the use pattern 4
• Screen for co-occurring psychiatric disorders (depression, anxiety, bipolar disorder) that may drive substance-seeking behavior 1

Implement harm reduction strategies:

• Educate about the dangers of combining pregabalin with opioids, benzodiazepines, or alcohol, as this combination dramatically increases respiratory depression risk 3
• Warn that pregabalin has caused lethal outcomes when combined with other recreational drugs, particularly ketamine and opioids 5
• Explain that high doses of pregabalin (up to 111.6mg/L serum concentration) are tolerated with surprisingly few immediate toxicological consequences, which may falsely reassure users about safety 4, 1
• Clarify that pregabalin can cause dependency and addiction despite being Schedule V (lowest abuse potential) in the US 1, 7

Critical Pitfalls to Avoid

Do not prescribe pregabalin or similar gabapentinoids to this patient in the future:

• This patient has demonstrated clear abuse potential and drug-seeking behavior, obtaining pregabalin from multiple sources 7
• Patients with history of opioid or other substance abuse are at highest risk for pregabalin abuse and diversion 7
• If pain management is needed, avoid all controlled substances and gabapentinoids; consider non-pharmacological approaches and non-addictive analgesics 7

Do not underestimate the psychiatric risks:

• Visual and auditory hallucinations can occur with high-dose pregabalin use and may persist for weeks after discontinuation 1, 2
• Suicidal ideation is a recognized adverse effect that requires immediate psychiatric evaluation 3
• Psychotic symptoms may worsen before improving during the first 48 hours of withdrawal 1

Do not attempt outpatient management if the patient is unstable:

• Admit for inpatient psychiatric care if suicidal ideation, psychotic symptoms, or severe agitation are present 1, 5
• Consider admission if concurrent use of other CNS depressants creates respiratory depression risk 3, 5
• Hospitalization may be necessary if rhabdomyolysis or acute kidney injury are present 5

Follow-Up and Long-Term Management

Schedule close follow-up within 48-72 hours of discontinuation:

• Reassess for resolution of withdrawal symptoms, which should improve significantly by 48 hours 1
• Monitor for persistent psychotic symptoms or mood disturbances that may require psychiatric treatment 1, 2
• Verify engagement with substance use disorder treatment program 4, 7

Long-term addiction treatment is essential:

• Cognitive-behavioral therapy targeting substance use patterns and triggers should be implemented 6
• Address any underlying psychiatric conditions (depression, anxiety, chronic pain) that may have motivated the recreational use 1
• Establish a treatment contract prohibiting controlled substances and requiring regular drug screening if ongoing medical care is provided 7