No one has time to deal with low back pain and, with it being one of the leading causes of missed work days, taking medication to make it go away as quickly as possible can seem like the only option sometimes. You might be someone who is lucky enough to take a couple of Aleve pills and the pain stays at bay for most of the day. Unfortunately, the effects of certain medications can vary greatly from person to person, as can their side effects.
So when a newer medication comes along with the promise of relieving pain and not having a lot of side effects, it is quite natural that people are excited to learn more about it and to try it out themselves.
US Opioid War
The US is currently fighting a battle against opioid prescriptions, with many being denied their prescriptions and being forced to find their own solutions to pain. This has led many people to try alternative treatments on the market that are not as addictive in nature. Welcome, gabapentin.
According to Statista, in 2004 there were 18 million prescriptions written for gabapentin. In 2015 an estimated 4% of US adults received a prescription for gabapentin at least once. And in 2017 those numbers had increased by over 46 million. The New England Journal of Medicine reported that gabapentin was the 10th top prescribed medication in the US, with a whopping 64 million prescriptions!
What Is Gabapentin?
So what is gabapentin? Although it isn’t exactly a new medication (it has actually been available in the US since 1993), Gabapentin has rapidly been gaining popularity amongst many as a new pain reliever and as an alternative to opioids, specifically. Gabapentin (also known by the brand name Neurontin) is a prescribed anti-seizure drug that is also prescribed for nerve pain. Gabapentin belongs to its own drug class, Gabapentinoids. It is an anticonvulsant that is most often used in the treatment of epilepsy, hot flashes, neuropathic pain, and restless leg syndrome.
How Does Gabapentin Work?
How gabapentin works is by altering the electrical activity in your brain, which influences the activities of the neurotransmitters between your nerve cells. Basically this means that it changes the way your nerves send messages to your brain. Sometimes your nerves can send false messages to your brain about pain that is supposedly happening in your body. For example, if something is pressing on a nerve, or a nerve isn’t working properly, that nerve might send your brain the message that there is pain, when there actually isn’t any. By changing how your nerves work, gabapentin has the ability to reduce perceived pain.
What is Gabapentin Used For?
Because of its effectiveness in treating nerve pain, gabapentin is also used in the treatment of chronic nerve pain in the spine. This pain is often described as a shooting or burning pain, a weakness or tingling throughout your back and neck. This pain can also radiate through the arms and legs, like with sciatica. This is making it a popular consideration for those with back pain, especially for those who don’t know how or where their pain originally started.
Since its introduction to the market, gabapentin has become very popular, especially as an add-on drug that doctors sometimes use to boost the effects of other drugs. During its almost 30 years on the market, gabapentin has also seen a huge increase in off-label uses. Gabapentin is now used to treat all sorts of issues from the post-herpetic neuralgia associated with shingles to psychiatric conditions like anxiety disorder, ADHD and bipolar disorder. These uses have provided enormous relief to many who struggle with these conditions and who have not found relief with other medications.
Misuse Of Gabapentin
Unfortunately, there is always someone who will try and use medication in a way for which they were not intended. Because gabapentin works so well as an add-on drug to improve the effects of another drug, it is becoming increasingly popular amongst those who abuse substances. In July 2017, Kaiser Health News reported on the dangers of a thing called opioid stacking. Opioid stacking is the practice of using multiple opioid products at the same time to produce a stronger analgesic response. This process of stacking can dramatically increase the risk of overdose and death amongst users.
While gabapentin is generally considered to have low addiction potential, people who take it can develop dependence over time. After some time of regular use, the body adapts to the drug and starts to depend on it for normal functioning. Tolerance build up can also occur and patients can end up needing higher doses in order to feel the same effects. Patients who are using it recreationally, for non prescribed purposes, can experience some severe withdrawal symptoms when they stop taking it. These can be both physical and psychological withdrawal symptoms and are similar to the effects of alcohol withdrawal.
How Safe Is Gabapentin?
Despite the concerns around its potential for abuse, gabapentin is considered to be a fairly safe medication and has even been approved for use in children as young as 3 years of age. According to a 2017 review the side effects of gabapentin are very few and were often the same as those who took placebo. The review stated that the most common side effects (which occurred in 10 percent of the participants) were:
Water retention (swelling in the arms, hands, legs and feet)
Problems walking (balance issues)
Other research, however, has shown slightly different side effects to be considered. Researchers have reported effects such as memory loss, tremors and weight gain. More severe side effects that have been reported include depression, anxiety, panic attacks, suicidal thoughts and violent behavior.
Because of its effects on nerve pain, gabapentin is frequently prescribed for chronic back pain syndromes, especially when there is a neuropathic or ‘radicular’ component to the pain - if it radiates into the upper or lower legs. Unfortunately, when we look at the data, there seems to be little evidence to support its benefits for this condition.
In the July 2016 edition of the journal Pain, a study was published that looked at the effectiveness of gabapentin for pain relief in patients with chronic low back pain. The study followed 108 patients at the VA in San Diego and found that gabapentin was not effective for analgesia in chronic low back pain. This was the same whether there was a radiating component to back pain or not (a neuropathic cause). They also found that the side effects were higher than expected, since gabapentin is supposed to have very few side effects.
Another study that looked at the use of gabapentin for low back pain relief was the PROSPERO study. This study actually reviewed almost 100 different studies and articles about using anticonvulsant medicines in patients with low back pain.
Again, for chronic low back pain, with out without the radicular component, there was high quality evidence to show that gabapentinoids did not help with low back pain, either long term or medium term. There was some small evidence that it might help for short term pain relief but it had no effect on disability or patients being able to function at their usual capacity. They also found strong evidence to show that again, gabapentinoids did not have the low risk side effect that they are supposed to have.
Low back pain is such a big problem for patients around the world, and many patients do not find the pain relief that they are looking for. While it is tempting to try “new” medications to help relieve pain and get back to “normal life”, there is very little evidence to support the use of gabapentin for chronic low back pain. Instead, international clinical guidelines still recommend using nonpharmacologic interventions - using methods other than medication. Using medications such as NSAIDs and aspirin are still favored over stronger medicines like anticonvulsants and opioids.
It would be wonderful to have another option for low back pain sufferers, but it seems as if the increase side effects, such as increased risk of suicidality and the potential for misuse outweigh the potential pain relieving benefits that many people are looking for. These recommendations are in line with the US, UK, Australian and European guidelines for low back pain, none of which recommend using anticonvulsants like gabapentin to treat the condition. One area that gabapentinoids might be helpful for is in the area of sciatica, but this still needs further research and review. In the meantime, it seems as if following the international clinical guidelines of exercise and NSAIDs as a first line treatment for low back pain is still the best way to go.