September 22, 2021

WCRI Publishes Report on Off-Label Gabapentinoid Use

The Workers’ Compensation Research Institute (WCRI) published a new study that examines the growing use of off-label gabapentinoids for work-related injuries.

Off-label prescribing – which can be an acceptable practice – is when doctors prescribe a drug to treat a condition, even though that drug has not been FDA-approved to treat that specific condition. Gabapentinoids are drugs indicated to treat epilepsy, as well as specific types of pain, such as nerve pain resulting from shingles or diabetes, or fibromyalgia. However, they are commonly prescribed off-label in workers’ comp to treat other types of pain beyond these indications.

As opioid utilization has decreased due to various pieces of opioid legislation, many have predicted that alternative medications for pain may see greater utilization. Like any drug group, gabapentinoids come with their own potential risks, and therefore it is important to note any significant increases in utilization.

This report examines the use of gabapentin (Neurotonin) and pregabalin (Lyrica) in over 482,000 work-related injuries and illnesses across 28 states from January 1, 2018 to March 31, 2019. Both gabapentin and pregabalin were among the top three drugs in terms of prescription drug spending nationally in 2016.

Only 0.9% of gabapentin prescriptions were prescribed for an FDA-approved diagnosis, while approximately 4% of pregabalin prescriptions were prescribed for an FDA-approved diagnosis.

In terms of prescription payments among workers’ comp claims, gabapentinoids are the third highest therapeutic group of drugs, behind dermatologicals and NSAIDs. In Q1 of 2020, 10% of prescription payments were for gabapentinoids in the median of the 28 study states.

Wide interstate variation in the dispensing of gabapentinoids was also observed. In Louisiana, Massachusetts, and New York, 10% of injured workers who received medication received gabapentinoids, but in California, Kansas, Missouri, and New Jersey, that number only reached 3%.

Concomitant prescribing of opioids and gabapentinoids – a dangerous combination that can cause serious breathing problems and other concerns – was seen. Nearly half of workers with gabapentinoid prescriptions received an opioid prescription in Iowa, Kansas, Louisiana, and Texas. This concomitant use rate was 20% lower in California and Nevada. This potent drug combination is concerning as the FDA published a warning in 2019 that serious breathing difficulties can occur in patients with respiratory risk factors taking gabapentin or pregabalin. Risk factors include the use of CNS depressants (opioids), respiratory conditions (COPD, sleep apnea), and advanced age.

In the past, Healthe has noted the shift from opioids to other medications for the treatment of pain, and in regards to gabapentinoids – as with any medication – there are inherent risks to consider.

Gabapentinoids can lead to mood alterations, suicidal thoughts, the potential for abuse, overdose, and breathing difficulties, which are more severe for older populations.

While recommended by some pain management guidelines as an appropriate treatment option in certain injured worker patient populations, gabapentinoids can have serious side effects including mood alterations, suicidal thoughts, the potential for abuse, overdose, and breathing difficulties, which are more severe for older populations.

Gabapentinoid users were found to be at:

  • 26% higher risk for suicidal behavior or suicide
  • 24% higher risk for overdose
  • 22% higher risk for head or body injuries

In 2017, the state of Ohio alone saw 426 million solid oral doses of gabapentinoids dispensed to patients.

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