Written by Ketan Patel
Spoon Feed
Gabapentinoids are often prescribed for off-label indications with minimal or no clinically significant benefit, while exposing patients to harmful side effects, especially vulnerable elderly patients.
Less ‘Neurotin,’ more neurotoxin? Rethinking gabapentinoids for pain
Gabapentin’s label as an “opioid-sparing” analgesic has resulted in a significant uptake into multimodal pain regimens, despite research showing a very narrow therapeutic efficacy in select conditions, specifically neuropathic pain.
This narrative review asks whether gabapentin and pregabalin meaningfully improve pain outcomes for off‑label pain conditions compared with their harms. Using focused review of RCTs, Cochrane analyses, and large observational cohorts, there was small or clinically insignificant pain reduction (often <1/10 scale; diabetic neuropathy NNT ~6.6 with NNH ~7.5), no benefit in low back pain/sciatica, substantial toxicity (dizziness up to 40%), 7‑fold higher opioid overdose risk, an increase in COPD exacerbations (HR 1.39), fractures, and hospitalizations.
This article is by design a narrative, non-systematic review of heterogeneous trials and observational studies, which subjects the estimates of efficacy and harm to bias. Thus, conclusions may not be generalizable to all ED or inpatient populations.
How does this change my practice?
Opioid prescribing has drastically swung from the early days of my training when “pain score is the fifth vital sign” fueled countless prescriptions. This article makes me pause and consider the opioid alternatives I use, especially for back pain. As a physician, you feel the need to prescribe or do something despite the lack of efficacy, but abuse potential and adverse effects are real. I will incorporate this when counseling patients about pain management regimens.
Source
Things We Do for No Reason™: Prescribing gabapentinoids for pain. J Hosp Med. 2026 Feb 15. doi: 10.1002/jhm.70286. Epub ahead of print. PMID: 41693218.
