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Gabapentin as a substitute for opioids: Is the solution creating new problems?

Bongiovanni T, Gan S, Finlayson E, et al. Prolonged use of newly prescribed gabapentin after surgery [published online ahead of print, 2022 Aug 24]. J Am Geriatr Soc. 2022;10.1111/jgs.18005. doi:10.1111/jgs.18005

Postoperative pain management has changed significantly in the last decade. Surgeons have attempted to decrease opioid prescribing by using non-opioid “multimodal” pain regimens, such as gabapentinoids (gabapentin and pregablin). While gabapentinoids are associated with reduced postoperative pain and opioid consumption, they are still included in the AGS Beers Criteria list as potentially inappropriate medications (PIMs) for older adults in certain contexts. In addition, closer attention must be paid to the proper discontinuation of gabapentinoids when they are no longer needed for post-operative pain control. Prolonged use of gabapentinoids carries its own unique risks, from altered mental status to other adverse events and hospitalizations. Researchers from UCSF and Yale investigated the predictors of prolonged gabapentin use through a retrospective cohort study of Medicare patients undergoing major surgeries. From a sample of 604,356 older adults undergoing surgeries, 17,970 (3%) had a new prescription for gabapentin after surgery. Nearly two-thirds of these new prescriptions went to people receiving knee or hip arthroplasty, and 73% of people who received a new gabapentin prescription also received opioids, a dangerous combination. Overall, among people newly receiving gabapentin after surgery, 22% were still using it 90 or more days after the surgery. Prolonged use was more common in people with higher levels of comorbidity and in those concurrently receiving long-term opioid therapy –groups which are at especially high risk of gabapentin-associated adverse events. Although gabapentin can be part of an approach to non-opioid pain management, once started, continuation and concomitant opioid use are both common. Researchers are hoping to understand the causes of prolonged gabapentin use and potential opportunities for intervention. 

We asked primary author and USDeN JII member Tasce Bongiovanni whether she would recommend allocating more resources to improving communication between PCPs and surgeons, or to improving the clarity of prescriptions for patients…

“Both! More work needs to be done to better understand how prolonged use is happening – whether it is part of the inertia of medication lists for older adults we already know about it, or whether it’s a problem starting at discharge if it’s not made clear which medications are meant for short-term versus long-term use. We also want to understand how caregivers could play a role during this care transition, and how to improve communication between all of those involved.”

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