Resource pack 1: Background for prescribing a gabapentinoid in chronic pain

This background section provides an overview of the evidence, clinical context and key considerations relevant to the use of gabapentin and pregabalin (gabapentinoids) in the management of chronic pain. It provides a foundation for the practical guidance set out in subsequent resource packs.

On this page:

1.1 Patient population
    1.1.1 Palliative care patients
1.2 Place in therapy
    1.2.1 Licensed indications
    1.2.2 Off-label use
1.3 Risks
    1.3.1 Adverse effects
    1.3.2 Populations at increased risk
    1.3.3 Mortality risk
    1.3.4 Dependence
    1.3.5 Misuse
    1.3.6 Legal status
1.4 Principles of treatment
Appendix 1a: Information poster for prescribers – Gabapentin and pregabalin

1.1 Patient population

This guidance is applicable to adults who are receiving or considering gabapentinoids, with the exception of those prescribed gabapentinoids for epilepsy or generalised anxiety disorder. Where people are receiving palliative care, some aspects of the guidance may require tailoring to their individual needs (see section 1.1.1 People receiving palliative care).

1.2 Place in therapy

Gabapentinoids are licensed in the UK for the management of epilepsy and neuropathic pain, with pregabalin also approved for the treatment of generalised anxiety disorder.^1-5 When used in pain management, gabapentinoids should be prescribed only where there is a clear clinical rationale and where the potential for benefit outweighs the known risks.

1.3 Risks

Gabapentinoids are associated with a range of risks that must be considered before initiation and throughout treatment. These include common adverse effects that may affect day-to-day functioning, as well as more serious harms such as respiratory depression, dependence and misuse. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued multiple Drug Safety Updates highlighting reports of severe respiratory depression, in some cases without concomitant opioids use.^14-17

1.4 Principles of treatment

The decision to prescribe a gabapentinoid should be made in accordance with the principles of treatment outlined here and addressed in more detail in the relevant sections. 

Principles of treatment comprise:
•    Appropriate indication: Prescribe only when there is a clear clinical rationale, such as confirmed neuropathic pain (see section 2.1). 
•    Non-pharmacological approaches: Explore non-pharmacological options before considering gabapentinoids, as these do not carry the risks associated with medicines (see section 2.2.1). 
•    Alternative pharmacological options: Consider alternative medicines, particularly those with safer profiles or stronger evidence base for the person’s condition (see section 2.2.3). 
•    Shared decision making: Prescribing should follow a shared decision-making process, ensuring the person understands the potential benefits, limitations and risks of treatment (see section 2.3).
•    Setting goals: Agree realistic, measurable treatment goals prior to initiation, focusing on improvement in function rather than complete pain relief (see section 2.4).
•    Safe prescribing considerations: Apply safe prescribing principles, including assessment of risk factors for harm, dependence and misuse (see section 2.5).
•    Choice of gabapentinoid: Gabapentin is generally preferred because pregabalin is considered to have greater misuse potential, related to its faster onset of action and recognised euphoric effects. Both medicines carry risks of dependence, withdrawal and respiratory depression (see section 2.6).
•    Therapeutic trial: Initiate as a therapeutic trial with a clear plan for dose titration, an agreed period for assessing benefit, and a scheduled review to determine whether continuation is appropriate (see section 2.7).
•    Reviews: Review treatment regularly to assess effectiveness, safety and adherence. Early review should assess pain, function and tolerability. Longer-term reviews should occur every six to twelve months (see Resource pack 3).
•    Discontinuation: Discontinue treatment if treatment goals are not met or harms outweigh benefits. Dose reduction should be gradual, with appropriate support and continuation of non-pharmacological strategies (see Resource pack 4).
•    Documentation: Document all decisions in person’s clinical record, including at initiation (see section 2.8), during review (see section 3.7) and when discontinuing (see section 4.10). 

Appendix 1a: Information poster for prescribers provides a summary of these principles for display.