Off-label gabapentinoid use growing for work-related injuries
Gabapentinoids are the third-highest therapeutic group of drugs in terms of prescription payments among workers’ comp claims.
Gabapentinoids are increasingly being prescribed off-label or unapproved use of an approved drug, as part of pain management regimens following work-related injuries, according to a study by the Workers Compensation Research Institute (WCRI).
The group of drugs, which includes gabapentin and pregabalin (brand name Neurontin and Lyrica, respectively), accounted for the third-highest prescription payments among workers’ comp claims, trailing dermatological and nonsteroidal anti-inflammatory drugs, WCRI reported. During the first quarter of 2020, about 10% of prescription payments were for gabapentinoids in the 28 states covered by the study.
An extreme majority (99%) of workers prescribed gabapentin and 96% of workers given pregabalin didn’t have a documented diagnosis for one of the FDA-approved uses, according to the study.
Given the green light by the Federal Drug Administration (FDA) in the 1990s to treat seizures, the class of drug is also approved for a finite number of pain conditions, according to Dr. Vennela Thumula, one of the report’s authors and a WCRI policy analyst. These other uses include treatment of nerve pain associated with shingle, while pregabalin is also approved to treat nerve pain from diabetes, spinal cord injuries and fibromyalgia.
“Both drugs are widely prescribed off-label for a variety of other pain conditions and syndromes to workers with injuries, including radicular pain syndromes, complex regional pain syndrome and postoperative pain,” Thumula tells PropertyCasualty360.com.
Why the uptick?
The growing use of gabapentinoids, in part, can be attributed to illegal off-label marketing in the first few years following the approval of Neurontin and Lyrica. Warner-Lambert was fined $430 million for illegally promoting off-label gabapentin use for various pain disorders, migraines, bipolar disorder and other ailments, according to WCRI’s report.
However, that’s just part of the story. Thumula explains gabapentinoids might be seeing more off-label use as they can be an alternative to opioids when treating selective conditions.
“In the context of the ongoing opioid epidemic, some prescribers may have increased prescribing of gabapentinoids for various off-label indications due to their relatively favorable safety profile compared with opioids,” she says. “Several guidelines, including the Centers for Disease Control (CDC) chronic pain guidelines (2016), recommend considering gabapentinoids for neuropathic pain, although gabapentinoids are only recommended for FDA-approved neuropathic pain indications such as postherpetic neuralgia and diabetic neuropathy by the CDC guidelines.”
While the intention might be to stem opioid utilization, WCRI’s study found gabapentinoids are often prescribed along with the aforementioned drug class.
“We find that gabapentinoids are being prescribed alongside opioids and simultaneous use is tied to adverse events,” she says. “Also, we see that gabapentin is being prescribed at lower doses than recommended, which raises questions about whether gabapentin at these doses can provide sufficient pain relief so that opioids can be completely weaned off.”
Regarding the prescribing of lower-than-recommended doses, the study does note some patients might be receiving pain relief from these medication levels. This leads care providers to maintain the prescription despite falling below recommended levels for pain relief.
Ultimately, the answer as to why the simultaneous prescribing occurred during the study period is left unsolved, according to Thumula, noting future studies should examine this.
However, Thuluma does offer some potential reasons, explaining: “In some cases, gabapentinoids may be prescribed because opioids are not sufficient to manage pain. In other cases, it is possible that gabapentinoids are added with an intention to wean off opioids.”
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