Gabapentin Abuse in Seniors - An Emerging Concern for Senior Care Providers
by Don Drake, Connelly Law Offices, Ltd. 8.2.24
"Gabapentin is a prescription medication approved by the FDA and is used as an anticonvulsant to manage specific types of seizures," stated professional fiduciary and certified elder law Attorney RJ Connelly III. "It is also prescribed for nerve pain stemming from various conditions, such as diabetes and shingles."
"While gabapentin is not currently classified as a federally controlled substance, it is available under brand names including Neurontin," he continued. "Gabapentin has been associated with widespread diversion, non-medical misuse, potential dependence, and withdrawal when misused in conjunction with other substances."
In tandem with the rise in gabapentin prescriptions, its misuse has markedly increased over the past decade. Misusers often combine it with opioids to intensify euphoric effects, and some misuse gabapentin for self-treatment of conditions such as insomnia, anxiety, pain, and substance withdrawal.
According to the website GoodRx, current data ranks this medication in the top ten of the most prescribed drugs in the United States, attributable to its increasing use as an alternative to opioids in pain management amid the ongoing focus on the opioid epidemic. Referred to as "Johnny Rottens," "Johnnies," "Morontin," or "Gabbies" on the street, this medication has been subject to abuse by addicts for many years. Notably, this medication is likely to be found in the medicine cabinets of many seniors.
The Increasing Abuse
During the 2015-16 period, toxicology screenings of individuals who experienced drug overdoses in Kentucky indicated that gabapentin was present in more than one-third of cases. This discovery raised concerns among healthcare professionals and legislators regarding the potential abuse and diversion of gabapentin, leading to its reclassification as a Schedule 5 controlled substance in Kentucky in July 2017.
Other states have since classified gabapentin as a Schedule V controlled substance including Alabama, Michigan, North Dakota, Tennessee, Virginia, and West Virginia. Additionally, gabapentin is subject to prescription reporting requirements as part of their prescription drug monitoring program (PDMP) in Connecticut, Indiana, Kansas, Massachusetts, Minnesota, Nebraska, New Jersey, Ohio, Oregon, Utah, Washington D.C., Wisconsin, and Wyoming.
It is also important to note that gabapentin shares structural and pharmacological similarities with pregabalin (Lyrica, Lyrica CR), a Schedule V controlled substance, which is federally regulated in all states. While not classified as a narcotic, the Drug Enforcement Administration (DEA) has observed a growing trend of gabapentin being illicitly abused. This has been well-documented by law enforcement, reflected in crime reports, and noted by U.S. poison control centers.
According to Psychiatry Online, the FDA issued a warning about the potential risks of respiratory depression in patients taking gabapentin in combination with central nervous system (CNS) depressants such as opioids, antidepressants, and benzodiazepines. The FDA also cautioned that the medication could exacerbate breathing difficulties in patients with underlying lung conditions like asthma or COPD, as well as in the elderly.
According to the IQVIA National Prescription Audit, the total number of gabapentin prescriptions dispensed was around 68.3 million in 2019, 69.0 million in 2020, and 70.9 million in 2021. Between 40% to 65% of individuals with gabapentin prescriptions and approximately 20% of individuals misusing opioids have reported gabapentin misuse.
In a recent national bulletin distributed to law enforcement and narcotics officers, the High Intensity Drug Trafficking Areas identified gabapentin as an "emerging threat." Considering these concerns, it is crucial to contemplate the ramifications for seniors.
Russell's Story
Russell, a 68-year-old baby boomer, had developed a habit of using gabapentin. He not only obtained the drug through prescriptions but also purchased it from other seniors at a senior center just outside of New Bedford, Massachusetts.
With a history of marijuana use and a stint in rehab for narcotics abuse, Russell was no stranger to illicit drug use. He took advantage of other seniors' financial struggles at the end of the month, purchasing gabapentin and other drugs from them at a significantly reduced price, and in some situations, obtaining them free as others shared their leftover medications with him.
Upon entering treatment, Russell admitted to mixing gabapentin with quetiapine (Seroquel and Seroquel XR) to achieve a sedating and euphoric high. He also confessed to combining gabapentin with methadone, which intensified the opioid effects of the drug. Despite undergoing treatment under court orders, Russell boasted about remaining high throughout without getting caught, as the urine screens did not test for gabapentin. Unfortunately, his behaviors continued in his subsidized housing program and created significant problems for both his neighbors and staff
Baby Boomers and Abuse
It's surprising that today's seniors, mostly baby boomers, are not the same as the seniors from previous generations. Their upbringing in the sixties and seventies has given them a different perspective on drug use and other behaviors, which is evident in senior programs.
This shift in attitudes has led to higher rates of addiction and alcoholism among today's seniors. Disturbingly, statistics show that baby boomers are getting arrested for possession of substances at higher rates than teens and young adults.
The American Addiction Centers have documented numerous cases of middle-aged and elderly patients with a history of alcohol abuse being prescribed gabapentin, only to end up abusing it and experiencing severe withdrawal symptoms, which can be life-threatening. Other treatment programs also report concerns of gabapentin abuse in seniors given its availability and the decline in prescriptions for opioids to treat chronic pain.
The Prevalence of Gabapentin Today
As noted earlier, the prescription of gabapentin has notably increased, largely due to its off-label usage in treating conditions such as pain and substance use disorder. Despite initial marketing portraying gabapentin as a medication with low abuse potential and high safety and effectiveness, there is a growing body of evidence emphasizing the hazards associated with overprescribing the drug.
A study published in JAMA Internal Medicine revealed that while gabapentin prescriptions in the United States escalated between 2006 and 2018, opioid prescriptions initially stabilized and then declined, which seems to indicate that providers were substituting gabapentin for opioids to treat chronic pain.
Within the prison system, medical professionals have identified gabapentin as one of the most abused and diverted drugs. These insights shed light on the potential for abuse and misuse of gabapentin, despite it being positioned as a safer alternative to opioids. Such information is crucial for understanding the evolving landscape of drug misuse and abuse trends, as well as for proactively addressing the associated challenges.
It is vital to acknowledge the concerns raised regarding the utilization of gabapentin as a precautionary narrative, particularly due to its presence in the medicine cabinets of numerous seniors or its potential future prescription for them.
It is important for individuals who provide services to seniors to consider the implications of this information. While those working in nursing homes may have minimal cause for concern at this time, staff in senior centers and those working with seniors in the community should be mindful of the potential for misuse and abuse of gabapentin. They need to be prepared to intervene if necessary and to refer individuals for treatment when appropriate. Being proactive in addressing these issues can make a significant difference in the well-being of seniors.
Medication Sharing
Instances of medication misuse among seniors are not always attributed to abuse but to seniors' well-intentioned efforts to assist others in avoiding the expenses associated with doctor visits and medication co-pays. Often unaware of the potential risks, seniors readily share leftover antibiotics, asthma inhalers, antidepressants, insulin, and medications such as gabapentin with family, friends, or colleagues who may be suffering. The reluctance to discard excess, expired, or ineffective medication due to its cost further perpetuates this practice.
Some individuals may engage in the sharing of medications over prolonged periods out of financial necessity, as the rising costs of drugs, medical care, and living expenses, such as groceries and gas, pose challenges in affording prescriptions and necessary doctor visits. Research indicates that those most likely to share prescription drugs are individuals of low socioeconomic status, the elderly, and family members sharing common chronic illnesses like diabetes.
Considering varying individual needs and potential adverse reactions, sharing medications, particularly among individuals with diabetes and other chronic conditions, can have serious consequences. The improper use of diabetic drugs can lead to insulin shock or liver damage, while sharing antidepressants runs the risk of exacerbating undiagnosed conditions.
Additionally, the lack of awareness regarding potential drug interactions further complicates this issue. Seniors' misuse of gabapentin, for example, can present symptoms resembling other disorders, potentially leading to misdiagnosis and the prescribing of additional and unneeded medications that have long-term negative implications.
The Look of Gabapentin Abuse
Gabapentin abuse may lead to potentially serious consequences, as indicated by the Food and Drug Administration (FDA). Those who misuse gabapentin may experience a range of concerning signs such as agitation, restlessness, irritability, panic attacks, insomnia, mania, new or worsening anxiety and/or depression, and changes in mood or behavior, including aggressive or violent tendencies.
Withdrawal symptoms can manifest in individuals who have used gabapentin for as little as 3 weeks and may emerge within 12 hours to 2 days after cessation. Gabapentin withdrawal effects mirror those of benzodiazepine withdrawal and can be especially perilous for older individuals.
A Final Note
"The abrupt cessation of gabapentin can lead to severe adverse effects, so it is advisable to consider enrolling in a medical detoxification program to safely discontinue gabapentin usage and effectively manage any associated withdrawal symptoms linked to Neurontin," stated Attorney Connelly. "This approach can be particularly beneficial if there is concurrent use of other substances, such as opioids, benzodiazepines, or alcohol. Individuals struggling with gabapentin misuse or other substances may also benefit from exploring structured treatment options, including inpatient or outpatient rehabilitation programs."
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