What are Gabapentin and Pregabalin?

Gabapentin is a drug used to treat certain forms of pain. It is also used to treat epilepsy, a disease which causes seizures. It works by travelling into our nerves and brain, and causing them to slow down nerve or brain activity.

For this reason, it is a very effective pain killer for nerve pain, or neuropathy (neuro = nerve, pathy = pain). Nerve pain arises when nerves are damaged. This can be due to viruses such as the herpes virus, which invade and damage nerves. Nerves are also damaged by diseases like diabetes, where blood-flow to nerves is reduced. Finally, nerves can be damaged through trauma, where they are either damaged directly, or the healing process affecting their proper function.

First licenced for use in 1993, many have had debilitating pain all but eradicated with this drug. It was a significant step forwards in the pain relief field.

Pregabalin is a similar drug, and works in the same way. First prescribed in 2004, it is, for some, a more effective pain killer than Gabapentin.

Like all drugs, there are side effects. Most notably, these drugs are seen to be addictive. And if misused, can lead to the user stopping breathing, and suffocating.

To ensure their safe usage, and to help GPs in their prescribing decisions, the prescribing of drugs is regulated. The aim of this regulation is to reduce harms to patients.

A Brief History of Regulation

The potential for misuse of Gabapentin, and later Pregabalin, has long been known. Their prescribing in other countries was starting to be curbed as early as 2010.

In the UK, prescription drugs are regulated by a body called NICE (National Institute for Health and Care Excellence). Despite evidence of the addictive potential of these drugs, NICE continually recommended their use for nerve pain in three separate reviews, in 2013, 2017, and 2019. It was felt that the benefits of these drugs outweighed the harms arising from addiction.

During this period, some people were prescribed these drugs for non-neuropathic pain, i.e. pain which isn’t due to nerve damage. This is what is known as off-label prescribing, and is within the gift of a prescribing clinician, if they judge that the patient will benefit.

The last date, 2019, is particularly interesting, as this was the year that Gabapentin, and Pregabalin, were reclassified by the Home Office as Class-C drugs.

The reclassification was based on the potential harms that these drugs cause. In 2017, 170 people in England and Wales died due to Gabapentin or Pregabalin use. For comparison, 6262 people died that year from alcohol related illnesses. But reframed as deaths per active user of the drug, 1 in every 10,000 users of Gabapentin or Pregabalin died, versus 1 in every 7000 for alcohol.

Tragically, some of these deaths will have occurred within prisons. And over the 2010’s, the problematic misuse of Gabapentin and Pregabalin within prisons was becoming obvious to many GPs and clinicians working in prisons.

Prescribing Gabapentin and Pregabalin in Prisons

Concerns about Gabapentin and Pregabalin within prisons were first raised by a body of GPs working within prisons, in 2013. They were concerned that people being prescribed Gabapentin and Pregabalin in the community, for non-neuropathic pain, were then becoming problematic users within prisons. They urged community GPs to restrict prescribing of these drugs.

But data shows a year-on-year increase in Gabapentin and Pregabalin prescriptions, which continued through 2013 and up to the current day. Given the pressures community GPs are under, the thought that these drugs might be problematic within prisons, was unlikely to affect prescribing. Especially when NICE guidelines continually rubber stamped their use.

So, many, many more patients were prescribed these drugs. I often prescribed them myself, as a hospital doctor between 2015 and 2017. I didn’t give much thought to the addictive potential of these drugs. I certainly did not think about the consequences of their use within prisons.

And whilst the reclassification of the drugs in 2019 didn’t directly change a doctor’s ability to prescribe them, it changed the landscape of prescribing within prisons. There is now a concerted effort to reduce the illicit use of these drugs within prisons. This is hoped to be achieved through very restrictive prescribing of these drugs.

The outcome of this, is prisoners with legitimate claim to use of Gabapentin or Pregabalin, to control nerve pain, being denied an effective treatment which they might otherwise receive in the community. It is yet another example of the non-equivalence of healthcare between prisons and the community.

The problem is compounded by the nature of pain. Pain is a difficult problem to treat. It isn’t constant. It fluctuates, and changes in response to things like your environment, or your state of mental health. Prison is detrimental to pain management, for exactly these reasons.

An unsympathetic report from Public Health England in 2014, states that pregabalin is prescribed in prisons at double the rate of the general public. It suggests that this increased rate must be due to illicit use.

But to me, it belies the ignorance of this regulator. It makes no account for the disadvantages this population faces in life. That because of these disadvantages, they are more likely to suffer complex, treatment resistant pain. That because of the tortuous prison environment, this pain is likely to exacerbate. To me, it is more surprising that it is prescribed at only twice the rate. The aforementioned prescribing restrictions likely curtailing its legitimate use in controlling pain.

Restrictions on prescribing are no free lunch either. NICE themselves admit that a consequence of restrictive prescribing is an increase in the illicit trade of these drugs. And illicitly acquired drugs tend to increase the harms associated with their use.

What you can do if you suffer Neuropathic Pain in Prison

It is easy to restrict the supply of prescribed drugs from the pharmacy hatch. It is much harder to put in place measures to replace their use.

Be aware, that Pregabalin and Gabapentin can still be prescribed within prisons, though will almost always be supplied via the medications hatch, and not to be in possession. (There is some limited scope for in possession prescribing in open prisons). There is no automatic bar to being prescribed these drugs, just because you are inside.

However, they are not recommended as the first line treatment for nerve pain within prisons. There are alternative, similar medications which can be tried first, which are felt not to have the abuse potential of Pregabalin or Gabapentin.

Likewise, you could ask the prison GP for a referral to a pain clinic. This is a specialist service, delivered in hospital, where pain can be explored, and alternative treatments found. These clinic visits can be done remotely, via telemedicine.

You should also be offered physiotherapy and psychological support. These tackle some of the root causes of pain, and may reduce the need for medication. Again, this is contained within NICE guidelines, and should be offered despite the fact you are in prison.

Keep in mind, the objective is to reduce or eradicate your pain. Work with your GP to achieve this goal, which may take time, trial and error, and patience.

But if you have exhausted all avenues, a complaint may be in order. Ask to see the guidelines they are following, regarding the treatment of neuropathic pain. Look through them, compare the treatment you have received, to the treatment specified in the guidelines. Any deviation in your treatment from the guidelines can be the subject of your complaint, and may facilitate them re-examining your treatment plan.