The opioid epidemic in this country has left prescribers looking for pain treatment alternatives, and one emerging option has been anticonvulsants known as gabapentinoids (e.g. gabapentin and Lyrica®, also known as pregabalin). With a need for options, and CDC guidelines recommending gabapentinoids as first-line agents for neuropathic pain,1 many now believe gabapentinoids are being overprescribed.2 Prescription volumes have increased substantially in recent years, and gabapentin is now the 11th most prescribed medication in the United States according to ClinCalc.3
Let's compare the alternatives. Although a much safer alternative to opioids, there are still reasons to be cautious and careful in prescribing gabapentinoids. Both gabapentin and Lyrica can be used recreationally to produce a high. The risks of abuse are higher and of greatest concern in prior opioid users.4 Lyrica is classified under federal law as a Schedule V drug. Gabapentin is not a controlled substance under federal law; however, Virginia, Kentucky, Tennessee, West Virginia and Michigan currently list gabapentin as a Schedule V controlled substance due to its potential for abuse.
When it comes to neuropathic pain, it should be noted that the gabapentinoids are still only recommended on a limited trial basis, and not as the first option for treatment. Official Disability Guidelines (ODG) recommends the tricyclic antidepressants (TCAs) such as nortriptyline and amitriptyline, or serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine as initial therapies for neuropathic pain.5 A trial of these agents is recommended before switching an injured worker to either of the gabapentinoids.
If a gabapentinoid is indicated for treating neuropathic pain, however, gabapentin is often considered the first-line choice over Lyrica, due to its lower cost and similar efficacy. A limited trial of gabapentin is recommended per the ODG for several other conditions, including complex regional pain syndrome (CRPS), radiculopathy, neurogenic claudication and more.5 Lyrica is indicated for the same conditions, but is a much newer drug and includes FDA approval for neuropathic pain associated with spinal cord injury. As many of Sedgwick's injured workers suffer from spinal cord injuries, we have seen Lyrica claims triple since 2010. Lyrica is associated with fewer sedating side effects than gabapentin, making it easier for injured workers to tolerate. However, in all cases, injured workers should complete a trial of gabapentin first. If gabapentin is not tolerated, a trial of Lyrica may be appropriate.
Both gabapentin and Lyrica are available as generic medications. Gabapentin is an older drug, with multiple generics available at a much lower cost than Lyrica. The generic version of Lyrica, pregabalin, was recently made available in July 2019. Even though generic versions of Lyrica are new, costs are lower than expected as multiple manufacturers were approved by the FDA to provide the drug. However, generic gabapentin remains the more cost-effective medication compared to pregabalin and remains the preferred first-line agent for neuropathic pain treatment within this class.
Employers with a high level of Lyrica claims should take steps to ensure that prescribers are dosing the pregabalin appropriately to limit their exposure. To focus on safety and mitigate cost, it is important that prescribers should follow evidence-based guidelines and dosing instructions laid out in the package insert.
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