The misuse, abuse & addictive potential of gabapentinoids

Simon Curtis - Wednesday, August 02, 2017

Rob comes to see you. Life is hard for him. He is 40, lives alone, has chronic pain from multiple previous fractures and associated nerve damage. He has a past history of drug and alcohol misuse, but he says this is now under control. He is requesting a repeat prescription of pregabalin for his chronic pain. He is also on long-term tramadol. So, how do you manage this request? This is an example of a seemingly simple prescription request which in reality is incredibly complex and difficult to manage, especially within the confines of a 10 minute GP appointment. And yet it is a scenario that most GPs face on a daily basis. How you manage it of course depends on the time of day, how late you are running and how 'resilient' you feel but one thing we should all consider now is the undoubted misuse potential of these drugs and the potential danger to the patient especially if they are also taking opioids. 

I must say I was very suspicious of pregabalin when it first came along. A drug claimed to help chronic pain AND anxiety just seems too good to be true, and too seductive to prescribe to unhappy patients with seemingly insoluble problems. In my experience it is an example of a drug that has hugely over promised and under delivered (as has duloxetine...who wouldn't want a treatment for chronic pain, depression and urinary incontinence??) and side effects seem common. Yet, in the last 5 years the prescribing of pregabalin and gabapentin has increased by 350% and 150% respectively.

A recent report from the Advisory Council on the Misuse of Drugs has highlighted the increasing concerns over the abuse, misuse and addictive potential of gabapentinoids and recommended that their status is changed to that of controlled drugs. They are described as having a significant risk of addiction and high misuse potential. This is particularly a problem in patients with polydrug use, especially opioids, and has for some time to be known to be a major problem in prisons. Gabapentoids increase the risk of respiratory depression and fatal overdose and recent research Addiction 2017 reveals that the number of deaths associated with gabapentoids in the UK has increased from 1 in 2009 to 137 in 2015 (which is likely to be an under estimate) and 80% of deaths also involve opioids. Heroin users report that they potentiate the effect of heroin and that they are easy to obtain.

So, what do we do with Rob's prescription request? As always yes is easy, and no is hard....sometimes we just have to take the path of least resistance to get through the day and often this can be justified 'for the greater good'. After all, we have a lot of people to try to help every day. But one of the beauties of General Practice is that it is not static, it is not limited to a 10 minute snapshot. It is highly dynamic, we offer continuity and over time relationships, management plans, values and attitudes evolve. 10 minutes doesn't sound very long, but we probably see Rob 12 times a year. That gives us a couple of hours to try to change things over the next year, starting today with 'planting the seed' ('Do you know Rob about the risks of this drug?', 'It doesn't seem to be helping your pain Rob?' etc). From this seed a tree may grow and over the year maybe we could wean him off and introduce a more holistic, rehabilitative approach to his pain management. Or, at least a safer prescription. Who knows,  it may even save Rob's (or someone else's) life...

Medical Skills Courses by Dr Mike Smith

Linda Scott - Tuesday, June 06, 2017

I was a late convert to General Practice.

Until 2007, I had done many years as a Plastic Surgery Trainee, but a series of epiphanies and a few hospital jobs later, I found myself in my registrar year at a wonderful practice in Hertfordshire. It was genuinely wonderful.

I got to have meaningful conversations with patients, staff and my family. I felt like I was part of a team rather than part of a large, overbearing organisation. I loved it.

However, I did miss the practical hands on tasks of surgery itself. I was told I was quite good at it.

So, imagine my delight when I was asked to do a ‘minor ops list’ by my practice. A list of my own, with my own room, my own assistant and more importantly my own patients. This was a chance to be a surgeon again.

I went through my checklist:

  • Tottenham Hotspur Scrub hat – check 
  • Personalised surgical scrub top – check
  • Surgical Marker Pen – check
  • Personalised consent form – check
  • Cheesy 80’s music to play in the background (Electric Dreams by Phil Oakley being a personal favourite) – check
On the day of the list, I was excited. I had the minor ops room set up in my style. I was going to show these GPs how minor surgery was really done. I was going to add a touch of Hollywood glamour to Welwyn Garden City.

I strutted into the room.

Within seconds the wind was taken out of my sails. It was then that I realised that the world of General Practice minor surgery was very different environment, and I was going to have to learn, relearn and adapt very quickly.

The first thing that struck me was the patient. She was in her 70’s and was having a premalignant lesion removed from her trunk. She was fully dressed and wasn’t even close to being ready for an operation. There was no hospital gown and she wasn’t quite sure why she was here. I spent a further 10 minutes explaining the procedure, 10 minutes helping her undress, and then 10 minutes talking about how lovely Dr B (the senior partner was) and how he was the one who usually saw her.

After 30 minute I hadn’t even put knife to skin. It was at this point, the lady decided she didn’t want the procedure.

At least the next patient went better. I managed to get to the point of operating on him. Admittedly, there was no operating table, very little surgical equipment and questionable lighting, but at least I had managed to cut an ellipse of skin from him.

At this point I glanced over to my assistant, the lovely nurse Lynne, and made a waving gesture with my hand. Now anyone who has done any amount of surgical training knows what this gesture means (for those of you in doubt, it means ‘Please pass the diathermy’). However, Lynne just smiled back at me. I waved again for the diathermy. She smiled and waved back.

At this point I decided to ask her outright “please pass the diathermy.”

The dia-what?”

“The thing you use to stop the bleeding,’ I helpfully explained.

“Oh! I know what you mean”, and she quickly trotted off to the store room and came back with an old wooden box. She then proceeded to take out an even older wooden box with a lead coming from it with a red-hot attachment at the end. She gave it to me. I used it.

The smell of burnt flesh was only beaten by the chunk of skin that was ripped away by this attachment. This certainly wasn’t a diathermy (I later found out it was an electrocautery machine.) It bled like stink. I grabbed some wet gauze and applied pressure, the whole time trying to look in control of the whole procedure.

As I stood there, applying pressure to the wound, looking at Lynne cleaning the tip by burning off the excess flesh, I realised that Primary Care Minor Surgery was different. It wasn’t more dangerous, it wasn’t worse, it was just different.

So, what did I want to do about it?

I decided over the next year that I would, with the help of the RCGP and my professional colleagues, try and learn as much about Minor Surgery in General Practice as possible, whilst weaving in the techniques, skills and evidence from my surgical training. With this information, we would write a handbook, write a course, get it CPD accredited and approved by the professional bodies. We would take pride in delivering the courses ourselves, knowing that we were driving up the standards of minor surgery for patients and practices alike, whilst having fun in the process. And so MEDICAL SKILLS COURSES was born……..

A decade later, thousands of delegates later, and many wonderful moments later, we find ourselves partnered with NB MEDICAL, the most reputed and largest General Practice educator in the country, educating GPs in exactly what they need to know to deliver high quality and evidence based practice……..a philosophy we wholeheartedly agree with!

And as for my practice nurse in 2007?

Thanks Lynne. For teaching me a valuable lesson about the beauty of General Practice, and thanks for showing me how GPs can be amazing at minor surgery.

For more information on our Minor Surgery and Joint Injection courses for GPs please click the link below……..its easier than you think……

Medical Skills Courses

Dr Mike Smith MBBS MRCS(Eng) MRCGP

 

Locum Organiser