Managing Pregabalin Misuse in Clinical Practice: A Growing Concern in Pain, Palliative and Anaesthesia Care

INTRODUCTION

Pregabalin is an important medication widely used in the management of neuropathic pain, perioperative pain and as part of multimodal analgesia in anaesthesia and palliative care. Its use has significantly improved pain control, both for acute and chronic conditions, when helping to reduce the need for opioids, especially in surgical patients.^[1,2] However, the increasing misuse of pregabalin, particularly in North India, has raised concerns among healthcare professionals working in these fields.^[3]

THE PIVOTAL ROLE OF PREGABALIN IN THE PRACTICE OF MEDICINE

Pregabalin is effective in treating neuropathic and postoperative pain by inhibiting voltage-gated calcium channels, which reduces the release of pain-related neurotransmitters such as glutamate, norepinephrine and substance P.^[1,2] It plays a critical role in multimodal analgesia, helping to lower opioid use and improve overall pain management after surgery. In addition, pregabalin is used in pre-emptive analgesia to prevent pain sensitivity and reduce the likelihood of developing chronic post-operative pain and in palliative care settings.^[1,2] In anaesthesia, pregabalin is often used to manage the stress response to laryngoscopy and intubation, helping to stabilise patients during surgery when reducing post-operative opioid needs.^[4]

THE RISING MISUSE OF PREGABALIN - CURRENT SCENARIO

Despite these benefits, the misuse of pregabalin has become a serious issue. During the COVID-19 pandemic, the disruption in opioid availability led to increased misuse of pregabalin, particularly in North India. A 1-year study involving 3,766 patients from an addiction treatment centre at an academic institution in North India found a prevalence of pregabalin dependence at 3.58/100 registered patients, compared to 5.11/100 registered patients for opioid dependence. The reasons cited by patients for pregabalin use included reduced opioid cravings, sedation, euphoria, relief from opioid withdrawal symptoms and anxiety relief.^[5] We opine that the calming and euphoric effects of pregabalin have made it an attractive substitute for opioids. At the same time, the drug’s easy availability, due to the lack of regulatory control under the Narcotic Drugs and Psychotropic Substances (NDPS) Act, has worsened this problem.^[6]

One case from Punjab illustrates the growing issue. A 30-year-old male, who had previously used poppy husk and tramadol, began using pregabalin to manage withdrawal symptoms. Over 2 years, his dosage escalated to 6,000 mg/day, leading to seizures and other serious complications.^[6] Unfortunately, this is not an isolated case, with reports showing individuals consuming up to 12,000 mg daily. This misuse is particularly common among people with a history of opioid dependence, who seek pregabalin for its euphoric effects.^[6]

At the All India Institute of Medical Sciences in Bathinda, nearly half of the psychiatric beds for drug overdose cases are occupied by individuals abusing pregabalin. The drug’s affordability, easy access and lack of regulation have all contributed to this growing problem, underscoring the need for urgent regulatory measures and increased awareness among healthcare providers.^[6]

STEPS TO MITIGATE MISUSE IN CLINICAL SETTINGS

Several steps should be taken to address the misuse of pregabalin when ensuring that it remains a useful therapeutic tool:

1. Stricter regulation: Pregabalin should be brought under the NDPS Act to regulate its sale and prevent over-the-counter availability. This would help limit misuse by controlling access to the drug.^[6]

2. Prescribing guidelines: Developing clear guidelines for prescribing pregabalin is essential, particularly for patients with a history of substance abuse. Screening high-risk patients before surgery can help reduce misuse

3. Patient education: Healthcare providers must educate patients on the risks of pregabalin misuse. Clear communication about the safe use of pregabalin and adherence to prescribed doses is key to preventing addiction.^[7]

4. Monitoring programs: Prescription monitoring programs should be implemented to track pregabalin prescriptions and detect early signs of misuse. This can help prevent overdose and reduce the risk of addiction.^[6]

5. Research and data collection: Research into the patterns of pregabalin misuse can help guide policy decisions. Gathering data on misuse rates and identifying high-risk populations can help target interventions effectively

6. Multimodal and pre-emptive analgesia: Pregabalin should continue to be used as part of multimodal analgesia strategies to reduce opioid consumption in perioperative settings. Careful use in pre-emptive analgesia can prevent central sensitisation and help manage post-operative pain.^[1,2]

7. Interdisciplinary collaboration: Anaesthesiologists and pain specialists should collaborate with addiction experts to create comprehensive care plans for patients at risk of misuse. This approach will ensure that pain is effectively managed while minimising the potential for addiction.^[7]