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Street value of neurontin?

Discussion in 'Psychiatry' started by billypilgrim37, 09.18.08.

  1. billypilgrim37

    billypilgrim37 Unstuck in Time

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    Fellow resident has a patient who is asking for refills on her neurontin (a pretty whomping dose, to boot) after just one week in to her 4 week supply. We didn't know of any street value, anything we should know about?
     
  2. TheWowEffect

    TheWowEffect The Official WowRator Moderator Emeritus

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    I had a patient in the clinic who was on Neurontin 300 mg TID. I took a detailed history but could not find any indication for her to be on it. It was started by someone in another city and she could not remember their name for me to obtain any collateral information. We tried very hard to wean her off it but she was very adamant about being on it. For us, it was just a matter of prescribing rationally. Street value factor did not cross my mind. I should have thought about it considering she stopped coming back after I made it clear to her that we will gradually taper and stop the medication. She was on a good dose of Valium and Zoloft as well.

    I have heard of some physicians prescribing it for "mood-stabilization" on an anecdotal basis but nothing beyond that.
     
  3. masterofmonkeys

    masterofmonkeys Should Have Been A Cowboy

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    I was on neurontin for three days and hated every minute of it (causalgia). I felt snowed to death. And I was on a tiny dose.

    Honestly though, the effect was pretty tiny. It was noticeable to me at the time because of some of the stuff I was engaged in that required quick thinking.

    I didn't know it had a street value.

    Some are using it off-label for 'mood stabilization' even though there are a couple of small trials showing it's pretty ineffective.

    Many people are on it for chronic fatigue/fibromyalgia, of course.

    And we (fellow students and a couple of attendings) speculated about using it for possible anxiolytic properties without the downsides but I can't think of any example of it being used as such.
     
  4. billypilgrim37

    billypilgrim37 Unstuck in Time

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    This one's on gabapentin 1200mg TID, plus 1mg clonazepam BID, and 100mg quetiapine QHS.

    I know, right? It's like, THAT'S the one she's asking for early refills on?

    Somebody needs to tell her she isn't doing it right, apparently.

    The Google didn't turn up any street value either, which is why I turned to my trusty SDN colleagues.
     
  5. TheWowEffect

    TheWowEffect The Official WowRator Moderator Emeritus

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    :wow:
     
  6. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    My thought is that she's either REALLY anxious and popping them like candy, or she's potentially trying to get a bit of cheap buzz herself (or she's sharing, or she's completely misread the instructions, or her script got filled with a different strength than she had previously and she's used to a certain # of pills instead of paying attention to the # of mg, or...).

    You're right, there's no real street value, but people who are psychologically dependent on a pill will do some nutty things.

    Benedryl would have a "street value" for its "buzz potential" if it weren't already ridiculously cheap and universally available.

    (Extra kudos for referring to "The Google". That's a first for me...)
     
  7. whopper

    whopper Former jolly good fellow

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    I have not noticed anyone trying to abuse neurontin among the patients I have. I have though noticed that abuse tends to follow certain geographic patterns. E.g. in some places--certain forms of abuse are more than others. It could be that I just haven't hit the right areas where it is being abused.

    http://en.wikipedia.org/wiki/Gabapentin
    I know its wikipedia & some people do not like it as a source. However its been one of the few sources that have mentioned the abuse potential of prescription drugs that the manuals aren't mentioning.

    e.g. with regards to Seroquel....
    Yeah well that's what Wikipedia says, but that's what I've seen going on in the South Jersey-Philadelphia area for years and I yet have seen this data published in the the "major" sources for psychiatry such as Kaplan & Sadock.

    Getting back to Neurontin, I don't see a reason to give it for psychiatric reasons except for some data showing that it may help prevention of relapse in alcoholics. That was from a study from the AJP about 1 year ago, and it really does need more data to back it up before it gains more momentum. If a psychiatrist was giving it as a mood stabilizer, I'd like to hear why, given the lack of data supporting its use as a mood stabilizer.

    I would not continue to prescribe a medication if there was no justification that could be documented. If the patient were to pull a "another doctor put me on it, I don't know why" story--well cough cough, I have seen doctors put patients on meds & not really explain why. I find that believable (though reprehensible practice--though of course sometimes doctors do educate patients, and the patients aren't listening or caring).

    But if the above situation happened, I would tell the patient that I could not continue a prescription unless the exact reason for it is known and it can't be based on a "someone else started me on it" story that could not be verified. I would also consider calling up the pharmacist because perhaps this person's doctor could be tracked through the pharmacist & the pharmacist could tell you of the patient's prescription history. If for example there were a lot of other drugs of abuse, its a red flag that this person is a prescription abuser.

    I would try to see if she had any disorder that it was FDA approved for, and if I found no evidence for such, I'd wean them off of it.
     
    Last edited: 09.18.08
  8. Encephalopathy

    Encephalopathy

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    From: http://www.erowid.org/experiences/exp.php?ID=60659

    "It took about an hour for the first dose of 1500mg to kick in, and it felt more like a subtle, but definitely noticeable, mood shift. I was expecting a rush, but that did not happen. At about 1 1/2 hour we did another 1500mg by 2 hours we were feeling the full effect. Did a couple 'boosters' over the next 2 hours and I felt the effects until about 10:30 in the evening about 10-11 hours total.

    ...

    Neurontin put me in a very easy, open mood a very good mood. Like Ecstacy, kind of a warm neutrality, where all judgments seemed 'appropriate' and issue-free.

    ...

    In conclusion, it’s a lot like a single dose of E without the rush, the edge, or the crash. I have never experienced such an easy on and easy off on any drug before. The occasional, recreational use of the drug is probably a lot different than the prescribed therapeutic experience, and I wonder if it is probably wise to not do it too often as the recreational benefits might decrease. Apparently the recreational dose is fairly high. Still it lasts longer than E and is much cheaper at about $14 a dose. Probably not a good drug for dancing all night, but a very nice daytime high.
    "

    From this guy's point of view, maybe she is doing it right. To answer your question, about a buck per 100 mg, $35 a day for your patient.
     
  9. billypilgrim37

    billypilgrim37 Unstuck in Time

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    Thanks, folks. Awesome replies.

    It's actually a medicine resident whose patient this is (well, she's a new patient), and the initial indication was appropriate (and non-psychiatric), and of course, started by some other physician. My friend has every intention of weaning the patient, but I think it's going to be a long process.

    Pretty sweet find there, encephalopathy.
     
  10. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Gotta love that erowid.org... You'll learn stuff there that Kaplan and Saddock can only dream about. :laugh:
     
  11. whopper

    whopper Former jolly good fellow

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    2 attendings I had as a resident who used to work in a prison told me that prisoners tend to be able to figure out what to use to get high. They'd try anything & everything. Once they got a hold of something, they'd also play around with that stuff, seeing if burning it, snorting it, liquifying it, insufflating it etc could somehow get you high off of it.

    In prison, they'd do anything & everything to be able to make it into something. Plastic wrap can be converted into shanks, grape juice can be made into prison wine, magazines can be used to make paint for paintings.

    Anyways, it was from these 2 guys that I first learned of the abuse potential of Seroquel, and its street value. I also learned that cogentin is sometimes used to catch a buzz, among other substances. Funny thing was some of the other attendings in the same program wouldn't listen to them & gave out seroquel like it was candy for years. It was only till my 4th year that those attendings starting seeing what those 2 were talking about.

    For that reason, I wouldn't be surprised if neurontin did do something that might make someone want to abuse it. I just haven't seen it--yet.

    & some patients are just med seeking & will take anything, abusing drug that gives them a buzz or not--for whatever reason-obsession, placebo, attention, etc. It could be that this particular person might've not been experiencing a buzz at all, but was abusing it for other reasons.
     
    Last edited: 09.18.08
  12. Still Kickin

    Still Kickin Junior Member

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  13. Anasazi23

    Anasazi23 Your Digital Ruler Moderator Emeritus

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    3g+ish isn't that outrageous for neurontin. It's fairly common for moderate to severe neuropathic pain.

    It has relatively little street value, but the patient is likely taking at least half that dose herself, giving some to her mother who ran out, etc. This happens all the time. Simply ask her where the pills went and tell her you need the truth. Then set limits and maybe go for another round.

    Of all the things to restrict, I generally don't do it with neurontin. There are bigger fish to fry. Assuming she absolutely doesn't need it, then it's a slightly different story of couse.
     
  14. rabblevox

    rabblevox

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    Hey all,
    I am a 50 yo/ male, who is employed but lacks health care (god bless America). I have been dealing with either a pinched nerve in my back, or sciatica. (chronic sharp pain near L5, constant tingling and numbness in R leg and foot).

    My neighbor recently sold me 20 300 mg Neurontin capsules for 40 dollars. It works brilliantly for pain management (2x300mg/day), but doesn't get me "high" or seem to have any serious abuse potential.

    So in my case "street value" would be $2/300mg. I hope he can hook me up with the same next week.

    I realize this is an old thread, but I was curious about exactly this subject, and thought I'd add my 2c worth.
     
    Last edited: 02.13.10
  15. TheWowEffect

    TheWowEffect The Official WowRator Moderator Emeritus

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    Based on my recent experience, Neurontin can be quite useful for a certain subset of patients, especially for the vague anxiety or mood swings that many of the substance abusing patients report. Can also be a useful drug for the vague aches and pains in many patients.
     
  16. kugel

    kugel

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    While I won't say that any medication is perfectly safe, this one comes about as close as I can imagine. Of all the meds used off-label, this one worries me so little that I don't mind continuing it if someone seems to be getting benefit. I don't tend to start it because of so little data that it's particularly useful, but I really don't mind continuing it. In cases of vague uncontrollable anxiety, that are not responding to meds + therapy + proven sobriety and I really feel quite certain that we're not in the wrong diagnostic category, then I'm willing to give it a try. Very little downside.
     
  17. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    He's overcharging you.

    Find a local charity clinic where you can get an actual physical exam and hopefully a regular prescription.

    Gabapentin is reasonably useful in chronic pain with a neuropathic origin. Also, thank God, its abuse potential is negligible.
     
  18. psychotrope

    psychotrope

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    these local charity clinics(where they are useful at least) are very rare. In small towns and rural areas they are unheard of, and in the medium sized cities(I've been in several) they are sporadically there but certainly don't provide any sort of "actual physical exam" and bloodwork to go with it.

    I've never lived in a big city so I can't comment on the availability there.

    But if he went to a pcp and had the routine workup every new patient gets(cbc, lipid panel, cmp, etc) and an office visit....even just that after the labs and everything would be 400 dollars+(probably a lot more).....thats not even counting what it would cost to fill the scripts.

    He's coming out *WAY* ahead now by buying for $2/pill. Note that Im not saying this is the best medical care for him(I have no idea), but his options are very limited by his lack of access.
     
  19. TheWowEffect

    TheWowEffect The Official WowRator Moderator Emeritus

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    Totally agree...
     
  20. whopper

    whopper Former jolly good fellow

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    It's been awhile since I last posted in this thread.

    I have done more research on Gabapentin.

    Aside from it's FDA-approved indications, there is a great double-blinded, placebo controlled study showing it can help with abstinence from the use of alcohol in those with alcohol dependence. There are also studies that it can reduce anxiety. I have one patient with panic disorder and ironically every single SSRI and SNRI we've tried she claimed made her feel suicidal. We could not get her panic attacks under control until she was tried on Gabapentin by someone else. (I'm actually speculating that she has rapid-cycling bipolar, and that the SSRIs spiked off the rapid cycling...hers is a complicated case with multiple Axis I issues).

    If you look up Erowid, Pregablin is the med of abuse people are talking about more so than Gabapentin.

    As for Bipolar, there is not one double blinded placebo controlled study showing it works, yet several doctors still give it out to treat bipolar. This has put me in an uncomfortable position a few times this year so far. Once every 2 weeks I need to evaluate about 7 people for the court, and the judge directly asks me the prognosis. I had one patient on topamax and gabapentin (I kid you not) and I had to flat out say that I could not give a prognosis because both medications are not FDA approved, nor have data other than case studies supporting their use as a mood stabilizer. The results of the case study could be argued to be no better than placebo effect.

    This then brings up a protest by the lawyer representing the patient, who then says something to the effect of "if my client is going to be held against his will in a hospital, the least they can provide is standard-of-care treatment."

    It's an awkward position because as a court evaluator, I'm strictly not allowed to cross into the treatment zone and tell the other doctor what to do, yet the judge and lawyers don't feel they can do it either.

    I have tried to contact the doctors on the occasions where this happens, and often times I do not get a call back (and mind you they are still on duty. Most of them seem to show up to work at 8-9am, leave at noon and let the treatment team do all the work. All they do is prescribe, admit, discharge and write notes. They rely on their team to do everything else.)

    Bottom line: don't give it for bipolar. Have a suspicion people are abusing it only if you have strong evidence because likely they are not abusing it. Worry more about pregabalin (Lyrica) more so than gabapentin.
     
  21. Manicsleep

    Manicsleep

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    Got a great moonlighting job a the prison this weekend. I used to work there and they pay really well plus they don't make me go through a locums company.

    Anywho...talking about prison drugs: I had a guy lock up after snorting several 80mg geodons.

    A lot of prison drugs are snorted that otherwise wouldn't be on the streets. Combine drug addicts with a lack of easily available drugs, not enough money, ignorance/stupidity, little self respect and willingness to malinger for medications: You have a prison culture

    the most common where I am are:

    Gabapentin: The prisoners say snorting is mildly like ecstasy but also takes the edge of the opiate abusers.

    Buspirone: Gives a short buzz when snorted

    Buproprion: Speedy high when snorted

    Quetiapine: I heard a lot of people want this for various reasons. Its very sedating and they just want to sleep prison away. "It makes you feel tingly" when snorted. The reasons were vast but those were probably the main 2.

    Clonidine: Makes the heroin go further. (yes heroin is available in prison but its very expensive).

    Artane/Cogentin/Vistaril/Benadryl: Short buzz when shorted

    The faking of pain symptoms is common with people running, literally running, around with canes to get in line for methadone for their back or knee pain.

    Most of these drugs are crushed and floated in water per the order but often times the LVNs are too overworked or just dont care. Even the actual medications are supposed to be dispensed and they are supposed to see the guy take it. But again the LVNs dont always do the job and the cons are cons, they will cheek the meds for later consumption or sale.
     
  22. Faebinder

    Faebinder Slow Wave Smurf

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    Lyrica, which is the cousin derivative of Neurontin, is an official drug of abuse. Well known in the middle east.
     
  23. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Heroin is probably cheaper--and obtainable without a Prior Auth.
     
  24. jettavr6

    jettavr6

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    Having worked in a correctional facility, I can say that many inmates will try to con any doctor into giving them Neurontin. It gives them a high if snorted and therefore does have a street value.
     
  25. billypilgrim37

    billypilgrim37 Unstuck in Time

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    So what drug did this thread snort to bring it back to life?
     
  26. whopper

    whopper Former jolly good fellow

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    Charles Scott, the head of the U. of San Diego forensic psychiatry fellowship program wrote an article on the abuse of Seroquel in the California prison system. He's a big shot in the field, and some speculate he may be the next generation Resnick.

    Scott has authored several articles and books specifically on correctional psychiatry.

    As far as I know, however, that's the only medication he's mentioned that's been observed to be abused in prisons. I wouldn't be surprised, however, if he wrote about more.

    Again, apologizes for not finding the specific article. I'm almost done with fellowship and will have more time in the near future to get back into the habit of putting better links to data I bring out.
     
  27. jettavr6

    jettavr6

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    Charles Scott is correct. In fact, seroquel has been in the literature frequently over the past few years due to it's abuse within the prison system. Seroquel, along with Wellbutrin and benadryl are off formulary in the CA State Correctional facilities. Neurontin is restricted on a case by case basis. Benzodiazepines are only used in extreme cases, and it's pretty much limited to IM ativan. Inmates will try anything to get high.
     
  28. sunlioness

    sunlioness

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    LOL. Too true. I don't think I've ever managed to get Lyrica approved. But having said that, I don't think I've actually tried more than twice.
     
  29. Manicsleep

    Manicsleep

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    C. Scott is at Napa State and UC Davis

    He is unlike P. Resnick (aka mr burns) in so many ways its hard to describe but he may well be the next Top Dog in forensics, he is already a big shot.

    The list earlier is based on the California correctional system.

    BTW, Napa state isn't corrections, although Scott used to go to Folsom I think.

    As far as the California forumulary. It is idiotic and not based on abuse.
    Trazodone has been off formulary for years while benadryl just went off.

    Everyone is on antichoinergics and antipsychotics for the hypnotic effects or for SSI.
    That many people dont hear voices.
     
    Last edited: 06.24.10
  30. zenman

    zenman Senior Member

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    I've been on Lycria for 5-6 months for OA pain. Seemed to help for awhile but not as much now. I'm only on 75mg. It does make me sleep a little better but I certainly get no thrill out of it.
     
  31. billypilgrim37

    billypilgrim37 Unstuck in Time

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    Are you saying it's not a drug abuse, or are you pointing out that you're just not doing it right? ;)
     
  32. zenman

    zenman Senior Member

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    Well, since I bought it from a pharmacy I guess it's not a "street drug" so I must not be using it correctly. :oops:
     
  33. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Crush first, THEN snort! :laugh:
     
  34. reedman

    reedman

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  35. Latropa64

    Latropa64

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    I've been in and out of hospital "mental health" units since I was 20 years old. I'm 30 years old now. I've had diagnoses of schizophrenia, schizoaffective disorder, severe depression, seizures, and probably some other crap.

    Other than cannabis, alcohol and prescription meds, I've been drug free for my entire life. There were times when Zoloft, Celexa, Prozac, and probably some other antidepressants were prescribed to me. I took them for months at a time with no noticeable change before finally giving up on them. I was also prescribed risperdal, seroquel and geodon on various occasions after spending unwanted days in the hospital. I would usually refuse all medications after involuntary hospital incarcerations... but shortly after, my family would talk me into seeing doctors and taking their advice led to the anti-psychotic prescriptions.

    None of those drugs really helped. In fact, the seroquel (at 400mg) would actually occasionally throw me back into psychotic episodes. The only saving grace when that happened was the benzodiazepines I also had on hand (either klonopin, ativan, or xanax)... after the seroquel kicked in and I started believing I was dead, I could usually take klonopin and start to feel normal again to stop myself from doing something stupid like randomly dialing the people in my recently called list on my phone to tell them how we were all dead and going to hell.

    I finally stopped taking the anti-psychotics and most of the completely freaked out of my mind episodes also stopped. I still had severe anxiety though. There were (and still are) times when I just can’t get a good deep breath and it feels like I’m suffocating. Klonopin absolutely helps with this. I have to take 4 to 6mg though to feel normal again. I’m told that’s a larger than normal dose and I know benzos are very adddictive. I talked to my psychiatrist about this a few months ago and told him I wanted to stop taking all benzodiazepines. He gave me a prescription for Neurontin.

    I was prescribed 600mg once a day. It had no noticeably effect at all for the first couple weeks I took it… so I stopped taking it. It wasn’t until recently (2-3 months after it was prescribed) and after I had slowly weaned myself off klonopin that I finally started taking it again because the label said it was for anxiety AND sleeplessness. It worked to put me to sleep… but only for a couple days. I took it once 3 days in a row and it didn’t help me sleep the 3rd day. Luckily, I’m not in a period where I’m desperate to fall asleep every night so I can take this 2 or 3 times a week and it works. I don’t see how it could ever be abused though. There’s nothing enjoyable I’ve ever experienced from it other than drowsiness.
     
  36. whopper

    whopper Former jolly good fellow

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    Wow, talk about change and growth. I have incorporated more use of Neurontin into practice, and surprisingly I got this data from a doctor I pretty much wrote off as incompetent. Hear me out.

    I took over someone's patients in a community setting as a moonlighting gig. Many of the patients were on regimens that I thought were ridiculous. E.g. Wellbutrin for panic disorder, large amounts of Ativan for reasons unspecified, placement on Clozaril but the patient said they were never on any other antipsychotic.

    I spent several months getting the patients on regimens that were evidenced-based. Pretty much all the changes went as expected. The anxiety disorder patients on Wellbutrin, placed on an SSRI got better, etc. During those changes, the only change I made that didn't seem to work was getting patients with anxiety off of Neurontin.

    I have a few patients that got suicidal on an SSRI or SNRI (and I tried several) that were on Neurontin for an anxiety disorder. After trying several, and noticing the Neurontin appeared to be working, and the patients telling me if I lowered the dosage their anxiety got worse, I kept them on Neurontin.

    I did some pubmed searches and there's plenty of studies showing Neurontin does work for anxiety. It's to the degree where I'm surprised the company never pursued an indication for anxiety with that medication.

    So now I am using Neurontin for anxiety if the person is treatment resistant to SSRIs, and I'm having success. I have enough articles showing it works in this manner to the degree where I feel it is evidenced-based and safe practice.

    It's also to the degree where instead of putting someone on a benzodiazapine as a stepping stone/bridge until their SSRI takes effect, I consider putting them on Neurontin instead, and I've seen good results with too. I'd rather have the person on Neurontin instead of a benzo-it's not likely to be abused, and it as far as I know has less street value. Most of the data suggests that Neurontin does not cause dependence though I have seen a few cases studies where this was proposed by the author as occurring.

    I'm also having success with it with weaning patients off of benzodiazapines. As I wean the person off of a benzo, I add Neurontin. When the person is finally completely off the benzo, then I wean them off the Neurontin. Several patients I've given Neurontin while weaning them off their benzos and those patients appear to be less anxious and their cravings for benzos are less. This makes sense IMHO. It's a seizure medication, so it may reduce the odds of a benzo-withdrawal induced seizure (I don't know this for a fact), there is a double-blinded placebo controlled study in the AJP showing that Neurontin does reduce relapse in alcoholics. As we all know the physiological changes in someone with alcohol dependence is very similar to that of benzo dependence. It also has plenty of data showing it reduces anxiety.

    Much of the above is anectdotally based, but there are plenty of studies showing Neurontin's benefits with anxiety.

    As for street value, I'm not seeing it and I'm very on guard with these things. I never give a patient a medication if I suspect the person is abusing it.

    I'm also having success with Neurontin in treating pain. I have plenty of patients with depression and anxiety with chronic pain. I also treat plenty of opioid addicts who's doctors freely give them opioids. I've been trying to get them off of the opioids and have their pain treated with Neurontin and an SNRI.

    There is plenty of data that Lyrica is being abused, but the abuse with Neurontin I'm not seeing at least in my area. That said, if you work in a prison, you have to be 10x on guard because prisoners will try to get high off of anything. In a prison, things that are pretty much never abused in the community are abused like Cogentin. The quality of the high from cogentin is nowhere near what street drugs could provide, but since street drugs are hard to obtain in prison, the prisoners will settle for Cogentin.
     
    Last edited: 09.17.10
  37. kugel

    kugel

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    You seem to be pretty careful about not "going off the reservation," so I'd like to know more.
    How do you use Neurontin in the early stages of SSRI treatment for anxiety?
    What starting dose? Do you start them prophylactically, or wait to see what sx's develop? How long till pt sees effect? How often do you see a need for increased dose? What's your impression of how often this works?

    Please provide a list of some of the articles, or what pubmed search criteria you used - when you get a chance.
     
  38. Majesty

    Majesty

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    Any sedating medication will be anxiolytic in the short term however neurontin has not had long term success with anxiety.

    I would like to see these unbiased, well done studies that show neurontin has efficacy with anxiety.

    Use SSRIs and psychotherapy.
     
  39. whopper

    whopper Former jolly good fellow

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    Gabapentin's benefits in benzo withdrawal:

    http://www.ncbi.nlm.nih.gov/pubmed/19485969

    Gabapentin in reducing alcohol relapse

    http://www.ncbi.nlm.nih.gov/pubmed/18052562

    Gabapentin benefitting OCD

    http://www.ncbi.nlm.nih.gov/pubmed/18297416

    Letters to the Editor in AJP
    http://ajp.psychiatryonline.org/cgi/content/full/155/7/992

    Gabapentin benefits preoperative anxiety
    http://www.anesthesia-analgesia.org/content/100/5/1394.full

    Gabapentin shows benefits in panic disorder
    http://journals.lww.com/psychopharm...trolled_Study_of_Gabapentin_Treatment.11.aspx

    Gabapentin shows benefits with social anxiety
    http://journals.lww.com/psychopharm...t_of_Social_Phobia_With_Gabapentin__A.10.aspx

    I could go on but I think the point is given.

    Most of the above links I provided are double-blinded placebo controlled studies.

    I don't recommend giving it as a first line therapy. Why? Mostly because it's not the norm. I always give the conventional treatments first. E.g an SSRI. I do sometimes, however, give it with an SSRI because as we know the benefits of an SSRI could take weeks to take effect. This is usually in more severe cases where the person is suffering very severe anxiety in the here and now. I am also much more likely to give it out if the person is suffering from chronic pain and anxiety. There's plenty of data showing Gabapentin's benefits with pain.

    I have given in out to one patient where several (Lexapro, Zoloft, Luvox, Paxil) SSRIs were tried and failed in the treatment of her panic disorder. SNRIs were tried as well, and both categories were also tried with Buspirone augmentation, and all the meds mentioned were tried at maximum dosages for at least one month. The person was placed on Neurontin and her panic attacks stopped. Again, this was after pretty much all the above failed. I didn't try some meds because I thought they'd be redundant (e.g. Lexapro was tried, so I skipped Citalopram---besides, she was suffering and had already gone throught he guinea pig phase for months while I tried other meds).

    How do I give it out? I give it out as it's generally recommended for other uses. E.g. start at 300 mg QHS. Gradually increase from there but ask the patient how they are feeling with each increase. I've noticed some patients feel like a zombie from it with just the starting dose. Others at higher dosages. If they get the zombie feeling--stop it, or only give it at a dose lower than the "zombie" dose if it's having a benefit.

    I also explain to the patient that Gapabentin is not the standard treatment, but that the standard treatment for treating anxiety in the here and now (remember SSRIs can take weeks to take effect)--e.g. a benzodiazapine, has a much higher likelihood of causing dependence and addiction. I only give out Gapapentin after I've explained that and the patient still wants to give it a try. If the person is suffering from an anxiety disorder, and I started the Neurontin with an antidepressant, I wean the person off of Neurontin after the SSRI starts to work.

    As for people getting off of benzos who have a substance problem, most of them want something to help with the benzo withdrawal and cravings. They beg me for something, and there really isn't something that's FDA approved for such. I have had several of them tell me that after trying Neurontin, they feel much better. I put them on Neurontin for a few weeks to months, then wean them off the Neurontin. I stop the Neurontin if the patient tells me they feel no benefit from it--which is some of them.

    The above was pretty much the only thing I got out of that previous psychiatrist who's patients I took over that seemed useful.

    Hey, EVEN A BROKEN CLOCK IS RIGHT TWICE A DAY. I think that's the case here. That same psychiatrist also gave out Depakote to treat anxiety. I never tried that, never saw any benefit with Depakote and anxiety, and the patients given Depakote for anxiety said it never helped them. I've done lit searches to see if there was any evidenced-based reason to give Depakote for anxiety and I've never seen it.
     
    Last edited: 09.19.10
  40. kugel

    kugel

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    Well, I'm not so sure the point is made.
    I'm still on the fence as to whether there is decent evidence for using gabapentin in treating anxiety.
    I don't really think it's the same as treatment of sedative withdrawal or pre-op anxiety. I don't think I believe these are the same beast as chronic anxiety disorders.

    For the OCD study:
    "METHODS: Forty outpatients with a DSM-IV diagnosis of OCD were randomized to open label treatment, 20 of whom were treated with fluoxetine alone and the remaining 20 with fluoxetine plus gabapentin during 8 weeks. The severity was assessed by Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and Clinical Global Impression (CGI).
    RESULTS: Final CGI-I and Y-BOCS scores were not significantly different in both groups. However, in repeated measures ANOVA, compared to fluoxetine group, we found significantly a better improvement in the fluoxetine plus gabapentin group at week 2 by means of YBOCS and CGI-I scores. Comparisons on weeks 4, 6 and 8 revealed no statistical differences between the groups. There was no significant difference of adverse effects between two groups."
    So the difference b/w groups was only true at week 2.

    In the panic disorder study:
    "No overall drug/placebo difference was observed in scores on the Panic and Agoraphobia Scale (PAS) (p = 0.606). A post hoc analysis was used to evaluate the more severely ill patients as defined by the primary outcome measure (PAS score ≥ 20). In this population, the gabapentin-treated patients showed significant improvement in the PAS change score (p = 0.04)."
    A post-hoc analysis of the most severely ill patients in the study always makes me think the authors were trying to salvage a negative study.

    And a letter to the editor regarding the reporting on 4 patients is hardly "good evidence" 12 years later.

    One should also note that the list of authors overlaps on most of these studies, which makes one ask what connection to manufacturers might exist.


    But, I am intrigued and I will be watching this.
     
  41. Majesty

    Majesty

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    Benzo withdrawal and alcohol aren't what I am discussing. Neither is pain or epilepsy. The OCD trial shows that after 2 weeks, its essentially the same as fluoxetine. Pre-op anxiety also takes into account the analgesic properties of gabapentin and is short term. I already said that the sedating medications work short term. The letter to the editor subjects are very 'dirty' and prove nothing. There was just not enough information in the other 2 abstracts to make any real conclusion.

    Neurontin probably was studied for anxiety and failed. They won't release the studies. If it was even marginally useful, they would have gotten an indication.
     
  42. whopper

    whopper Former jolly good fellow

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    Fair point and I'm not trying to convert anyone. I'm just saying I've had successes with it and I think this is an option, not a first line option.

    Letters to the editor are not good evidenced based medicine. Double blinded placebo controlled studies are. I see your point but there are actually more studies than I cared to post. Any pubmed or google scholar search will point them out.

    Don't agree with this. It was tried and failed? There are studies showing it worked. What the exact FDA history that occurred we do not know. We do know that the Pfizer was fined for inappropriate marketing of gabapentin. As we know the FDA approval process is not completely 100% scientific. A lot of the process is mediated by politics and profit margins.

    Wellbutrin's warnings of it's problems with seizure are now viewed as over-hyped, yet those warnings are still there. What company will want to spend the money to have that warning removed now that the medication has been generic for years? Seroquel's FDA warnings still demand a psychiatrist have a patient see an eye doctor. No one does that and the CATIE trial showed no association between cataracts and Seroquel, yet the warning is still there and may be there indefinitely. Psychiatrists in general openly ignore this recommendation despite it being there in black and white print.

    Neurontin's already gone generic. With it being generic and actually is one of those cheap meds ($4/month or $9.99/month) at one particular pharmacy (forgot which one but it's not all of them). There's less profit incentive to pursue an FDA approval when the med's gone generic. If the alcohol withdrawal benefit study was replicated several times, I doubt it would get an FDA approval for such for the reasons I mentioned.

    IMHO more studies are justified, and it'd be nice to see some of the already published studies replicated.

    Fair enough. I would completely and openly agree with someone saying "Doctor, I think you've brought some fair evidence but I'd like to see more before I start incorporating Neurontin into treatment of anxiety."

    I already do that. I've never used Neurontin instead of an SSRI or SNRI unless several were tried and failed with buspirone augmentation.
     
    Last edited: 09.20.10
  43. Manicsleep

    Manicsleep

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    Wow, people really don't like neurontin.

    I don't really like it either but I think in certain SMI populations where everything else has been utilized and only some of the symptomatology has been controlled, medication like neurontin (and even lyrica) can be used.

    I like neurontin because it is finally cheap and has low drug interactions so can be added on fairly easily. Unfortunately, these populations are never studied in the journals and the basis for treatment is based upon data from cleaner high quality studies as well as some dirtier lower quality studies.
     
  44. whopper

    whopper Former jolly good fellow

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    Lyrica (same mechanism as Neurontin) was approved for generalized anxiety disorder in Europe.

    http://www.medicalnewstoday.com/articles/40404.php

    (Yeah, the article is from Pfizer, but the news is accurate nonetheless.)

    Neurontin is also mentioned in the MGH Board Review guide as a medication commonly given out to treat anxiety.


    Personally, I'd avoid Lyrica use unless warranted because it has abuse potential.

    I have used Neurontin a few times to treat anxiety disorders. Of course I try an SSRI or SNRI first, and try Neurontin only after multiple failures of the above. I'd also rather have someone on Neurontin vs. a benzodiazepine.
     
  45. Pharmastudent77

    Pharmastudent77

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    I have been prescribed 3000 mg of gabapentin daily for the last 3 years for anxiety. I have never taken it as prescribed, always using it to get high. I have taken as much as 12,000 mg in one day. On the days I don't take it, I want to die and can't wait 'til I can do it again. At extremely high doses, it is comparable to LSD. I am not the only person I've met who has discovered this. I have no idea if it has a street value, because it's so easy to get a prescription. I'm not saying it shouldn't be prescribed, but don't make the mistake of thinking it isn't addictive or abused.
     
  46. whopper

    whopper Former jolly good fellow

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    If this person is doing this, they are likely doctor-shopping or saving their medication up and then getting high off of it. This is dangerous practice. I wrote some details as to why, but it could've been interpreted as advice to this person, so I'll just have to leave it at that.
     
    Last edited: 10.21.11
  47. NoNoNoNo

    NoNoNoNo

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    Yes! That's what I was gonna post from too.
     
  48. whopper

    whopper Former jolly good fellow

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    The more I've used K&S the less I like it. It's a type of psychiatry that IMHO is important to K&S but less so to the entire psychiatric profession. The chapters, while having a list of sources, don't point out what specific fact came from what source, making verification of it's data difficult if not impossible unless you're willing to spend about 30 hours tracking it down. Their books emphasize knowledge of terms that no one I know uses, including some of the nation's top psychiatrists and physicians, such a forme fruste. I believe the concepts of these terms are important, but the term itself, no.

    The information is not succinct, nor is it clean. For example, schizophrenia, if you look it up in the index, is pretty much all over the the entire textbook. So you just can't read the psychosis chapter, you pretty much have to read that, and every single other section where it's mentioned.

    And I've mentioned this in other threads, for board prep, forget about it. They recommend you memorize stuff that's not going to be on the actual exam, and their question book in no way, shape, or form, is similar to the real exam other than that it's the same subject and the same language.
     

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