Due to its dissociative and euphoric effects, Gabapentin is a major drug of abuse, especially within correctional settings. So why not ban it completely? Great questions and one we’ll only be able to answer after a discussion about the management of Gabapentin within county jails.
Since Gabapentin is well-known as a drug of abuse, its use within county jails opens the door to misuse and diversion. Once Gabapentin’s presence is known by the inmate patient population, the number of sick calls may increase followed by attempts to pressure providers into prescribing it. If prescribed, inmate patients may attempt to “cheek” the medication (hide it between teeth and cheek) to divert it or stockpile it. All these problems would be solved if its use were banned from our jails. So why don’t we?
Despite its notorious reputation, Gabapentin is not all bad. It is FDA approved for both focal onset seizures as well as post-herpetic neuralgia. There is also literature to support its use for neuropathic pain, although considered off-label. Thus, there are certain medical conditions our inmate patients might have for which we’d like this medication to be available. Frustratingly, Gabapentin, despite very few comprehensive studies displaying true effectiveness, has a bountiful list of off-label uses including alcohol use disorder, alcohol withdrawal, chronic refractory cough, fibromyalgia, generalized anxiety disorder, hiccups, chronic pruritus, restless leg syndrome, social anxiety disorder, and vasomotor symptoms of menopause. Inmate patients entering our county jails with a verified, active prescription for Gabapentin have an outside provider deeming this medication medically necessary. Thus, any cessation of this mediation will likely be met with anger, grievances, letters to the state medical board, and even tort claims. So, we must be evidence-based, detailed, and responsible in our decision making.
Additionally, Gabapentin should not be stopped suddenly. Those taking it chronically develop a physical dependence and rapid cessation results in up to 10 days of withdrawal symptoms. Therefore, allowing Gabapentin in our jails gives us access to at least taper the medication if the provider does not deem its use medically necessary.
So, what do we do?
With county jails often being brief stays for our inmate patients, are we accomplishing anything meaningful by forcing an inmate patient into Gabapentin withdrawal for them to then leave soon thereafter and restart Gabapentin through their outside provider? I don’t think so. But does that mean we continue all verified, active prescriptions? I don’t think so either. The answer, in my opinion, lies somewhere in between.
The key is to define the precise conditions for when its use is acceptable, as well as at what doses. If Gabapentin is verified, active, and is being used for seizures (although not a great seizure medication), post herpetic neuralgia or neuropathic pain, I would deem that reasonable and continue it if the dose makes sense. Sadly, due to its potential for abuse, outside providers could be coerced into higher and higher doses. The maximum dose, for any condition, is 3600mg. But many studies site little benefit over 1800mg/day.
If the medication is being used for an off-label condition for which more appropriate medications exist, and if the inmate-patient is likely to have prolonged incarceration, tapering off Gabapentin and changing to an alternative medication would be reasonable and supported by the literature. If the medication is being used for an inappropriate condition such as insomnia, it should be discontinued immediately and tapered if necessary.
Lastly, despite being FDA-approved and evidence-based supported for certain conditions, other, first line, non-drugs of abuse, alternatives exist for each of these conditions. Thus, despite the above-listed reasons it may need to be continued, but Gabapentin does not need to be newly started within our facilities.
My intent is to continue to provide hope, educational content, and thought-provoking discussion.