All Wales gabapentinoid resources for chronic pain - Overview

Development of resource packs

These resources have been developed with input from the All Wales Gabapentinoid Taskforce, a multidisciplinary group of pain specialists, pharmacists, clinicians, GPs, physiotherapists, and substance misuse specialists, with representation from Welsh health boards. Members of the task force include Dr Faye Graver, Christina Birkby, Dr Emma Davies, Robert Bevan, Bethan Thain, Rhian Owen, Dr Rhian Hills, Rhodri Parfitt, Tammie Ng, Dr Sunil Dasari, Dr Gemma Rogers, Simon Gill, and Ceri Clatworthy. Materials have been adapted from resources created within health boards, including collaborative work between Aneurin Bevan University Health Board (UHB) and Cwm Taf Morgannwg UHB, as well as resources from Swansea Bay UHB, Hywel Dda UHB and Betsi Cadwaladr UHB. Several of these resources were piloted in health boards prior to their inclusion. The patient pain medication review questionnaire has been adapted from the Living Well with Pain author’s resource.

Rationale

Prescribing of gabapentinoids (gabapentin and pregabalin) has continued to increase despite the introduction of a National Prescribing Indicator (NPI) in 2017 and their reclassification as Schedule 3 controlled drugs in 2019. They are widely prescribed for a range of pain conditions, although there is very limited evidence to support their use outside neuropathic pain.

Concerns about safety and harm have also grown. In Wales, there has been a rise in deaths in which pregabalin has been recorded on the death certificate, alongside a substantial increase in gabapentinoid-related enquiries to the Welsh National Poisons Unit. Misuse and dependency have also been reported.

This growing body of evidence, together with variation in prescribing practice across Wales, highlights the need for practical resources to support the safe and appropriate use of gabapentinoids in chronic pain.

Purpose

The purpose of this resource pack is to support healthcare professionals and patients in making informed, shared decisions about the use of gabapentin and pregabalin, known as gabapentinoids, for chronic pain. These medicines should be prescribed only after a thorough clinical assessment and evaluation of potential risks, including misuse, diversion, and dependence. If treatment is started it should be reviewed regularly to ensure it remains appropriate and continues to provide benefit.

The resource materials aim to support safe and effective prescribing by providing guidance on appropriate use, balancing the potential benefits against harms, and encouraging a holistic approach to pain management. They are split into five packs providing practical tools to support prescribers in evidence-based decision making across the treatment pathway, covering background information and supporting prescribers from consideration and initiation to monitoring and deprescribing:

• Resource pack 1: Background for prescribing gabapentinoids in chronic pain
• Resource pack 2: Initiating a gabapentinoid
• Resource pack 3: Reviewing gabapentinoid use
• Resource pack 4: Reducing and stopping a gabapentinoid
• Resource pack 5: Auditing gabapentinoid prescribing and supporting tools

These resource packs can be read and used as standalone documents. While together they form a complete prescribing pathway, users may access the pack most relevant to their prescribing decision or stage of care, with Resource pack 1 providing helpful background context and Resource packs 2–5 providing practical guidance and resources through the prescribing journey. To aid navigation and readability, key messages and tools in the resource packs have been colour-coded:

Blue: Summarised information

Green: Resources and questions for patients

Red: Risks and safety points

Orange: Practical checklists

Information is also summarised in a Prescriber quick reference guide and Clinical pathway for prescribers.

Scope

These resource materials are intended for all healthcare professionals involved in the care of people with chronic pain, across both primary and secondary care settings. They are particularly relevant for those working in general practice, including GPs and pharmacists delivering structured medication reviews. They may also serve as valuable references for clinicians in specialist areas such as pain medicine, neurology, neurosurgery, rheumatology, orthopaedics, substance misuse services, and physiotherapy.

These materials apply to the prescribing, review and deprescribing of gabapentinoids for people with chronic pain that has persisted or recurred for longer than three months. This could include people receiving palliative care whose anticipated survival and clinical complexity mean that prescribing decisions should follow the same principles as for anyone else with chronic pain.

The guidance includes specific considerations for people at higher risk, including older or frail individuals, those with respiratory disease or renal impairment, a history of substance use or dependence, significant mental illness, and concurrent use of opioids, Z-drugs, benzodiazepines or other central nervous system (CNS) depressants.

These materials do not apply to people thought to be in the last months of life where the primary focus of care is comfort rather than long-term risk reduction, and do not address short-term treatment of acute or peri-operative pain. They apply only to use in chronic pain and should not be used to guide prescribing for other indications.

Document history