As prescription drugs pregabalin and gabapentin are liberally given out by GPs — and putting drug users at risk on the black market — the government is taking action.
Illustrations: Joe Watson-Price
“This drug leaves you stuck between a rock and a hard place, we need it to keep us going, but I do have the side effects.”
Jill Marriner, who has multiple sclerosis (MS), has been taking prescription drugs pregabalin and gabapentin since 2010. After accidentally going cold turkey for just a day, she vowed never to do it again. “It was hell,” she says.
Pregabalin and gabapentin are prescribed for anxiety, nerve pain and epilepsy, but their addictive potential as well as a growing black market have prompted the government to propose reclassifying them as class C drugs — like ketamine or other tranquilizers.
They are also under the remit of a wider government investigation launched last week into addiction to prescription drugs. The Advisory Council for the Misuse of Drugs (ACMD) and the British Medical Association (BMA) have both called for the control of the substances.
This move to ban pregabalin and gabapentin follows a sharp rise in related deaths over the last five years. In 2016, there were 111 deaths linked to pregabalin and 59 linked to gabapentin, compared with four each in 2011.
The drugs are increasingly being taken recreationally alongside other substances, and there are fears they have been prescribed too liberally by GPs.
Data provided by NHS Digital shows that prescriptions for pregabalin have shot up more than 11-fold in the last decade, from almost 500,000 in 2006 to more than 5.5 million in 2016.
Over the same period, prescriptions for gabapentin went from 1.3 million to 6.5 million — an increase of more than 500%.
Prescriptions in Bristol have almost doubled in the last three years — reaching a total of 59,095 for pregabalin in 2016/17 and a further 49,500 for gabapentin.
A “growing and emerging” problem
Dr Tim Williams, clinical director for drug and alcohol services at Avon and Wiltshire Mental Health Partnership, tells the Cable: “The misuse of pregabalin and gabapentin is a growing and emerging problem in Bristol.”
“We’ve got an exponential rise in the legitimate use of pregabalin and gabapentin with prescriptions given by legitimate prescribers,” he says.
“What we know anecdotally is that there are a lot more people using pregabalin and gabapentin illicitly but who are also obtaining scripts from legitimate sources.”
A study by researchers at Bristol University found that a recent substantial increase in prescriptions of pregabalin and gabapentin is closely correlated with a rise in the number of drug-related deaths, including heroin overdoses.
Interviews with heroin users found the substances were easy to access and that taking them was associated with a feeling of loss of control and an enhanced effect of heroin.
“There is more and more evidence now that these drugs have an effect when taken with opioid drugs to mean that people are more at risk of overdose,” Williams says.
He says one of the causes of the opioid crisis in the US, which is killing tens of thousands of Americans every year, was their “permissive prescribing culture”.
Although this culture is different in the UK, “there are real warning signs that we are following in the same mould,” he says.
“We are much tighter in the UK with opioid prescriptions, but with pregabalin we are medicating people with lower level symptoms such as low mood and low level anxiety.”
He attributes the overprescribing to the “enormous pressure” on GPs who don’t have time to have a more nuanced discussion about the mental health of pregabalin users.
Reducing prescriptions is the way to tackle the problem, Williams argues. “Certainly, I would not recommend prescribing either of these medications, especially to those with a history of substance dependence.”
He says that if prescriptions are to be restricted, there needs to be effective drug and alcohol services for users who are typically “the socially vulnerable on the margins of society”, in order to provide a safety net to stop them falling into other more harmful drugs, such as heroin or alcohol.
Although the UK’s drug abuse treatment system is far superior to that in the US, cuts to funding for drug treatment, which are “the most underfunded service in the NHS”, are having “enormous consequences on the population we serve,” he says.
Big Pharma, big profits
There has also been controversy around the cost to the NHS of pregabalin, which until recently was produced under patent by US pharmaceutical giant Pfizer.
Pfizer’s patent for branded pregabalin (Lyrica) when prescribed for epilepsy and anxiety expired in 2014, but the company claimed that it held a ‘secondary medical use’ patent when prescribed for neuropathic pain.
In 2015, GPs were asked to change thousands of prescriptions so that Pfizer’s branded Lyrica was prescribed for neuropathic pain, and generic pregabalin produced by other companies was only given out for epilepsy and anxiety.
This secondary patent expired in July 2017, but previously having to prescribe the more expensive Lyrica for pain, and switching back and forth has cost the NHS tens of millions of pounds. Bristol CCG alone has spent £8.6 million on branded and generic pregabalin, according to openprescribing.net.
Tim Williams says that pharmaceutical companies have marketed pregabalin and gabapentin as a catch-all medication for various disorders and downplayed their addiction potential in order to “maximise their profits”.
Calls for criminalisation
The government has consulted on proposals to make pregabalin and gabapentin class C drugs under the Misuse of Drugs Act, again reigniting debate about whether drugs should be decriminalised or cracked down on.
Lead clinical pharmacist Rachel Britton of drug, alcohol and mental health charity Addaction said: “The reclassification reduces the availability of the drugs on the black market, because prescribers are advised not to issue prescriptions longer than 30 days. It also makes people more careful about whom to prescribe them to, recognising the abuse potential.”
Some argue that this worked recently with tramadol, as deaths linked to the drug fell after it was reclassified as class C in 2014.
However, it remains unclear how criminalisation and the restriction of prescriptions would affect those who are prescribed it and have seen the benefits.
Zoe Katherine, a student at Bristol University, has been taking pregabalin since July 2016 for general anxiety disorder (GAD).
“As a medication, it was extremely helpful and really turned my life around. It chilled me out, helped regulate sleep and also helped with chronic pain and migraines,” she tells the Cable.
She is now in the process of gradually coming off it, and apart from a few minor side effects, she says “it’s not been at all problematic or unbearable for me.”
“It would be easier to get addicted if you’re a chronic pain sufferer. I’m very lucky in that I have other meds I can take that help ease that. I’ve always been careful with prescription meds, so I think my addiction risk to any medication is quite low.
“I can see why people would take it recreationally because it makes you feel so chilled out and amazing. The first three months I was on it, I felt like a calm, placid lake.
“I think it would be a great shame for epilepsy sufferers and people with chronic pain and mental health problems, if the number of prescriptions were to be reduced.”
In the world of prescription drugs where the term addiction is far from concrete, the government has a task on its hands to tackle the problem without harming the people using the drugs as intended.