Chronic Pain Is an Impossible Problem

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Gabapentin was supposed to be the answer. Chronic pain afflicts about a fifth of American adults, and for years, doctors thought it could be treated with prescription painkillers like Oxycontin. But as the drugs began killing the equivalent of three planeloads of Americans every week, opioid prescriptions fell off precipitously. Many doctors embraced gabapentin, an anticonvulsant drug traditionally used to prevent seizures, as a way to treat neuropathic pain while avoiding triggering life-threatening addiction.

From 2012 to 2016, prescriptions for gabapentin increased 64 percent. It’s now the 10th-most-commonly-prescribed medication in the United States. Baclofen, a muscle relaxant, has become another popular opioid replacement. Though gabapentin and baclofen can cause a boozelike “high” for some people, they’re far less addictive and less likely to be fatal when taken in large quantities than opioids are.

But now their own pitfalls are becoming clear. Though gabapentin and baclofen are much safer alternatives to opioids, recent research suggests that they’re not as safe as some doctors might have hoped, especially in combination with other sedating medications. The findings are a frustrating turn that suggests there’s still no silver bullet for chronic pain.

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By examining the National Poison Data System, which collects reports of poisonings around the United States, Kimberly Reynolds, a researcher at the University of Pittsburgh, and her co-authors recently found that people are increasingly using both gabapentin and baclofen to either get high or attempt suicide. From 2013 to 2017, people tried to commit suicide using gabapentin nearly 42,000 times, and thousands more abused or misused the substance. In most cases—nearly 70 percent—the poisoned individuals took a combination of gabapentin and other drugs. Meanwhile, the majority of the poison cases involving baclofen were suicide attempts. “It’s rare, but overdose from large quantities of gabapentin or baclofen can be fatal,” Reynolds told me via email.

In isolation, gabapentin isn’t necessarily dangerous. Many chronic-pain patients rely on it to maintain functionality. But when used in high doses, or in combination with opioids or benzodiazepines, it can be risky. “People who take high-dose gabapentin for months or years on end often do develop tolerance”—that is, the need to take more and more of the drug to achieve the same effect, says Arthur Robin Williams, an assistant professor at Columbia University who was not involved in Reynolds’s study. When patients stop taking these drugs abruptly, they can experience withdrawal symptoms. They often start taking them again in order to feel “better,” when in reality their improved feeling is simply the withdrawal symptoms abating.

Reynolds’s study and others suggest that doctors’ long struggle to find a safe, reliable treatment for chronic pain is far from over. Just as opioids were used to get recreationally high and potentially cause overdose, it appears that their replacements sometimes are as well. In fact, Reynolds and her co-authors write that people often take gabapentin and baclofen in combination with benzodiazepines, such as Xanax, or with opioids, in order to increase their intoxicating effect.

Gabapentin is often prescribed in combination with opioids, in order to enhance their pain-relieving potential, and this combo can be especially dangerous. Gabapentin is sedating, and it increases the risk of overdose death by compounding opioids’ sedating effect. In a 2017 study, David Juurlink, a scientist at the Sunnybrook Research Institute, in Toronto, and his co-authors found that among patients who take prescription opioids, those who die of overdose are more likely to have also been prescribed gabapentin or a version of it, pregabalin, than those who don’t die.

Reynolds and others say patients who are prescribed drugs like gabapentin and baclofen should be screened for substance-abuse disorders, mood disorders, and suicidal ideation. And patients who are taking gabapentin should avoid mixing it with other drugs, especially depressants such as alcohol and opioids. Some states have started treating gabapentin as a serious drug, rather than the chronic-pain equivalent of gummy vitamins. Kentucky, Tennessee, and Michigan have reclassified gabapentin as a Schedule 5 controlled substance. Several other states have mandated the reporting of gabapentin prescriptions to prescription-drug-monitoring databases. (Baclofen, however, remains unscheduled.)

Not only does gabapentin appear to exacerbate or create overdose risk, it also doesn’t work that well for chronic pain. A review published last year found that gabapentin is ineffective for treating back pain. This study “is one more reason to think twice before starting a patient on this drug,” Juurlink told me.

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But that still leaves unresolved the devilish problem of lower-back and neck pain, a major cause of disability in Western nations. Now that narcotics, non-narcotics, and so many other treatments have been tried and failed, many doctors are left scratching their head. There’s not much else they can prescribe instead. “We have very limited drug options for pain,” Juurlink says. In the old days, he prescribed his pain patients opioids, but he has cut back on them after seeing how deadly and addictive they can be. Cannabinoids, the compounds derived from marijuana, can work for some people, but not everyone.

Williams says the medical community should take a closer look at non-pill remedies such as physical therapy and psychotherapy. These treatments are often not covered by insurance, take longer to work, and take more of providers’ time. But for many, they might be a better option than yet another pill that has yet another pathway to abuse. “The reality is, a lot of the pills that change how you feel in the next 10 to 30 minutes,” Williams says, “carry addictive liability.”