Gabapentin for anxiety, refused by pharmacist

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
SpongeBob DoctorPants

SpongeBob DoctorPants

Full Member
5+ Year Member
Joined
Sep 28, 2017
Messages
116
Reaction score
48
I have a 17-year-old patient who was started on a low dose of gabapentin, 100-200 mg tid prn for anxiety, by her PCP a couple of years ago, and it has worked well. She doesn't really need it much, but needs a new prescription because her old one is expired. Surprisingly, it's not the insurance company preventing the prescription from being filled, but the pharmacist. I guess this pharmacist wants proof, in the form of scholarly research, showing that gabapentin is effective for treating adolescent anxiety at this dose, before they will dispense it. Unfortunately I am not able to find any really good articles demonstrating this, as it does not appear to have been rigorously tested for this purpose as far as I can tell, but I was able to find a few articles making a very brief mention about gabapentin being useful for anxiety in kids. I thought I'd reach out here to see if anyone knows of any papers showing that gabapentin can help pediatric patients with anxiety. And has anyone ever gotten pushback from a pharmacist like this, when prescribing something off label?
Members don't see this ad.
 
Members don't see this ad :)
wolfvgang22 said:
Is this sarcasm? This is low dose gabapentin, not Xanax we are talking about here. It's probably safer than that drink you are offering to buy the pharmacist.
Click to expand...

Yeah I’d love to know what EXACTLY the pharmacists concerns are in this situation given the patient has been stable on this low dose for some time it sounds like. Sounds like a blow hard pharmacist trying to show everyone that they’re a “doctor” too.

The easy answer is to just go to another pharmacy and gabapentin is super cheap with a goodrx or similar coupon if it’s an insurance thing for that pharmacy. The answer Id actually do in real life is call the pharmacist personally, ask what the safety concerns are here, alleviate those concerns by reminding them that I am following up with that patient clinically on a regular basis and then if they still wanna be a pain in the ass, ask the pharmacist for the number to the clinic where he/she treats patients so I can refer my patient there to get cross titrated to a more appropriate medication regimen, since I’m the one who will have to deal with it if the patient decompensates while I screw around with the medication.

I’d also remind them that, unlike psychiatrists, there’s literally a pharmacist on every street corner and I’m happy to send my patient to the next street corner down to get their medications filled properly. That should knock the ego down a bit.
 
Last edited:
wolfvgang22 said:
Is this sarcasm? This is low dose gabapentin, not Xanax we are talking about here. It's probably safer than that drink you are offering to buy the pharmacist.
Click to expand...

I would love to see high quality evidence demonstrating the effectiveness of gabapentin for anxiety disorders, and ‘it’s not xanax’ doesn’t count.
 
I subscribe to a pharmacy forum (not SDN). Gabapentin is sometimes locked up with C-IIs (as are benzos even though they're C-IV), and is treated like benzos by some pharmacists. And it's a controlled substance in a lot of states now. Even though the mechanism is completely different from benzos, the people I've read who have been on both say the withdrawal is similar. It's probably better than benzos, but it doesn't sound good either. I've seen the nickname "*****tin" used for it (from its trade name neurontin) for its effect of being stupefying. Anyhow, it's funny timing that this thread came up because I just saw complaints from a pharmacist of a patient wanting a gabapentin refill early.

Pregabalin, which I had heard is more potent, has approval in the EU for treating anxiety disorders. I don't hear it talked about as much anymore. For a while I saw a lot of ads for it pushing it for diabetic nerve pain. I wonder why it didn't take off in the US as an anxiety agent like it did in Europe.
 
birchswing said:
I subscribe to a pharmacy forum (not SDN). Gabapentin is sometimes locked up with C-IIs (as are benzos even though they're C-IV), and is treated like benzos by some pharmacists. And it's a controlled substance in a lot of states now. Even though the mechanism is completely different from benzos, the people I've read who have been on both say the withdrawal is similar. It's probably better than benzos, but it doesn't sound good either. I've seen the nickname "*****tin" used for it (from its trade name neurontin) for its effect of being stupefying. Anyhow, it's funny timing that this thread came up because I just saw complaints from a pharmacist of a patient wanting a gabapentin refill early.

Pregabalin, which I had heard is more potent, has approval in the EU for treating anxiety disorders. I don't hear it talked about as much anymore. For a while I saw a lot of ads for it pushing it for diabetic nerve pain. I wonder why it didn't take off in the US as an anxiety agent like it did in Europe.
Click to expand...

Probably expense. In think it’s only recently gone generic.
 
There are case reports attesting to gabapentin benefit for anxiety. Plus clinical experience. Plus given similarity to pregabalin which does have positive studies, and is approved for GAD in Europe, there are rational arguments to justify prescribing it. And gabapentin is generic so there’s no motivation to pay for a high quality study to prove anything about gabapentin, so don’t hold your breath waiting.
 
I'm a pharmacist and would have just filled that prescription no questions asked assuming it was appropriately due for a refill. Infrequent, low dose gabapentin is relatively safe for the patient's age and shouldn't have much potential for abuse or addiction. Are there any other meds on her profile that could be causing the pharmacist to refuse the fill? Perhaps call the pharmacy first and see if anything else is being filled by a different prescriber and if the pharmacist on duty still refuses to fill for whatever reason, then send it elsewhere.
 
Members don't see this ad :)
I’d be livid if the pharmacist didn’t call me. I actually appreciate not dispensing stuff they thought was bad care but I need to hear why from their mouth and I shouldn’t have to chase them or wonder if a patient is relaying the information right. You question my crap, you call me.
 
R u kidding me?! :yeahright: The pharmacist is just being difficult.
Click to expand...
Sometimes the pharmacist reminds me of the flight surgeon in Apollo 13. The astronauts were perfectly healthy but because the guy wanted to sound useful he'd mouth off all the time instead of shutting up.

Of course there's plenty of great pharmacists out there, and of course the need to stop a prescription, but the ones that stick out in the memory due to human nature are the ones that tick me off.

The lack of contact with them, discussing the case with them, and memory causing people in general to only remember the occasions where there was anger causes a bias.

But there are pharmacists out there too that just are mouthing off a bit too much.

Gabapentin never got an FDA approval for anxiety but we all know that FDA approvals only cover so much, there's politics involved with approvals, and there's plenty of meds having known benefits with no FDA approval for such. Gabapentin has the evidence base to show it can work plus it's addiction potential vs benzos is far preferable.
 
Last edited:
I've been fortunate in that I have never had a negative interaction with a pharmacist, or even pharmacy tech since residency. I'm sure there are some bad ones but I haven't met them. They have all been very professional and focused on helping the patient and the treatment team.

Whenever I'm frustrated they wont fill something, I call I and I find they always have a valid question, concern, or are facing similar bureaucratic hurdles I am. We've always been able to find a workable solution. I know they have caught my mistakes and I really appreciate it. Once a year or so they have a suggestion about an option for treatment I haven't considered, and I'll take what help I can get with my complex case load.

I don't blame a pharmacist for wanting to help avoid over medicating a teenage girl with off label gabapentin, but a quick conversation about the treatment plan would probably help clear the whole thing up. I really appreciate pharmacists.
 
Interesting topic.
I personally have no comment, but a google search revealed some recent articles regarding pharmacists and gabapentin.



“We started hearing from pharmacists about people trying to get early refills,” Van Ingram, executive director of the Kentucky Office of Drug Control Policy, told NBC News. “That is usually a sign that something is being abused. “

From Health officials are sounding the alarm on a prescription drug after a wave of overdoses. And it's not even an opioid.

In May, Quivey’s pharmacy filled roughly 33 prescriptions of gabapentin per week, dispensing 90 to 120 pills for each client. For customers who arrive with scripts demanding a high dosage of the drug, Quivey sometimes calls the doctor to discuss her concerns. But many of them aren’t aware of gabapentin misuse, she said.

From Gabapentin, a drug for nerve pain, and a new target of opioid abuse

Regulating gabapentin as a drug of abuse: A survey study of Kentucky community pharmacists.

Responding community pharmacists (n = 1084) believe that the abuse and diversion of gabapentin are a problem in their communities, with 9 in 10 (89.6%) indicating that they agree or strongly agree. More than three-fourths (87.5%) indicated support for reclassifying gabapentin as a CS.

From Regulating gabapentin as a drug of abuse: A survey study of Kentucky community pharmacists. - PubMed - NCBI
 
Last edited:
Makes me wonder what is going on in KY. Often times abuse can have a localized issue going on with it. Gabapentin does help with opioid withdrawal. It might not be abuse of gabapentin so much as it could be that several addicts are supplementing their opioid use with gabapentin between the troughs where they experience withdrawal.

Quetiapine for years in several areas had the same thing going on. It wasn't so much that quetiapine was being abused but it had use with treating withdrawal from heroin so drug dealers were willing to pay for it so they could sell it to their addicts as a "you take this after your high wears off" med. Quetiapine, however, also was being abused. Some addicts mixed it with their heroin or they were mixing it with cocaine cause it allegedly augmented the heroin effect and with cocaine preventing the sometimes feeling of being ramped up too much.
 
It's not just Kentucky. It's scheduled in many states across the US and a drug of concern in others.
 
whopper said:
Makes me wonder what is going on in KY. Often times abuse can have a localized issue going on with it.
Click to expand...

Not just KY here either

www.mprnews.org

Minn. poison centers see spike in calls related to painkiller gabapentin

Increases in gabapentin prescriptions came along with more cases of the drug being misused, causing poisonings and being used in suicide attempts, according to a new study.
www.mprnews.org www.mprnews.org

We've had numerous e-mails related to this in our system over the last year
 
Yeah, I had patients abuse Quetiapine before. I am aware.of the misuse of Gabapentin, and the enhanced risk of respiratory depression in people who also take opioids. I've also had patients crush and snort Trazodone, too, especially in correctional facilities. Some people will abuse anything that might provide a "high", or that they perceive will ease whatever their particular anguish is.

Safety is important, but at the same time I dread the future where all medications are meticulously tracked by our overlords for any potential misuse for our collective good. Maybe they will all be like Abilify Mycite. It really feels like we are heading that way sometimes.
 
Last edited:
I don’t think anyone is debating that gabapentin has street value or abuse potential espcecusllt when combined with opioids.

But there doesn’t seem to be any indication that is an issue here. That being said I don’t treat kids, but if I did I would probably be the type to be hesitant to venture far off label.

However for adults, especially for irritable/anxious folks who have gotten worse in that regard after quitting ETOH it seems to work wonders and is relatively safe if they relapse. Or for mild ETOH withdrawal that I wouldn’t bother treating at all with a benzo if that was only choice.
 
tr said:
Yes I've looked before and found only negative results for gabapentin and anxiety. But very good clinical success, anecdotally! Guess it's placebo?
Click to expand...

Mostly case reports—I haven’t seen the literature backing pregabalins approval for GAD in europe but there are enough pharmacokinetic differences that I’m hesitant to chalk up gabapentin as a cheap lyrica alternative.

Seems strange that given robust evidence for psychological txs for anxiety in adolescents and adults we easily justify continuing the use of a medication without a good evidence base in someone like a teenager. Knowing that the effect is likely placebo, why continue to advocate for the status quo?

When I’ve had this issue with pharmacists a simple call to discuss has typically alleviated it quickly.
 
calvnandhobbs68 said:
Yeah I’d love to know what EXACTLY the pharmacists concerns are in this situation given the patient has been stable on this low dose for some time it sounds like. Sounds like a blow hard pharmacist trying to show everyone that they’re a “doctor” too.

The easy answer is to just go to another pharmacy and gabapentin is super cheap with a goodrx or similar coupon if it’s an insurance thing for that pharmacy. The answer Id actually do in real life is call the pharmacist personally, ask what the safety concerns are here, alleviate those concerns by reminding them that I am following up with that patient clinically on a regular basis and then if they still wanna be a pain in the ass, ask the pharmacist for the number to the clinic where he/she treats patients so I can refer my patient there to get cross titrated to a more appropriate medication regimen, since I’m the one who will have to deal with it if the patient decompensates while I screw around with the medication.

I’d also remind them that, unlike psychiatrists, there’s literally a pharmacist on every street corner and I’m happy to send my patient to the next street corner down to get their medications filled properly. That should knock the ego down a bit.
Click to expand...
It's a controlled sub so they have to be more careful.
 
SourceOfDenial said:
Mostly case reports—I haven’t seen the literature backing pregabalins approval for GAD in europe but there are enough pharmacokinetic differences that I’m hesitant to chalk up gabapentin as a cheap lyrica alternative.

Seems strange that given robust evidence for psychological txs for anxiety in adolescents and adults we easily justify continuing the use of a medication without a good evidence base in someone like a teenager. Knowing that the effect is likely placebo, why continue to advocate for the status quo?

When I’ve had this issue with pharmacists a simple call to discuss has typically alleviated it quickly.
Click to expand...

The "why give a medication when we know psychological treatments are effective" applies with just as much force to the use of literally any medication for anxiety given the robustness of the evidence base.
 
calvnandhobbs68 said:
It’s not controlled on a federal level. It’s only schedule V in a few states. It just shows up on rx reporting sites which gives people this misconception.
Click to expand...
Correct, but the pharmacies have extra steps they have do when filling these. Maybe OP should post this on the pharmacy forum. We cant look at it from our point of view, just theirs!
 
clausewitz2 said:
The "why give a medication when we know psychological treatments are effective" applies with just as much force to the use of literally any medication for anxiety given the robustness of the evidence base.
Click to expand...

Totally, and I’m always advocating for therapy as first line. But at least with GAD you have RCTs demonstrating some effectiveness of SSRIs. I’m mean you have RCTs for gabatril for godsake.

I don’t by the argument that there isn’t any funding for an RCT for gabapentin in GAD. You have a common condition with no new drug tx, Lots of off label use and unclear benefit.
 
SourceOfDenial said:
Totally, and I’m always advocating for therapy as first line. But at least with GAD you have RCTs demonstrating some effectiveness of SSRIs. I’m mean you have RCTs for gabatril for godsake.

I don’t by the argument that there isn’t any funding for an RCT for gabapentin in GAD. You have a common condition with no new drug tx, Lots of off label use and unclear benefit.
Click to expand...

I expect it's much more effective for people who report "anxiety" who mean " I have a feeling, make it go away." Hence the popularity in the SUD population.
 
You must log in or register to reply here.

Similar threads

whopper
New vibrating device for anxiety
Replies
12
Views
1K
birchswing
B
S
How do you manage anxiety about malpractice?
Replies
9
Views
2K
HemeOncHopeful19
H
H
Signal vs. No Signal approach by programs?
Replies
5
Views
1K
LeaveNoTrace
L
PsyDr
Billionaire Psychiatrist Accused of Rape By Epstein Victim
Replies
3
Views
1K
comp1
C
lockian
Irritable hypomania vs anxiety
Replies
22
Views
2K
dl2dp2
D
Top