Lead/Presenter: Brian Lund, COIN - Iowa City
All Authors: Rottinghaus AR (Center for Access & Delivery Research and Evaluation, Iowa City VA Healthcare System), Desloover-Koch Y (Department of Pharmacy Services, Iowa City VA Healthcare System), Mosher JH (Center for Access & Delivery Research and Evaluation, Iowa City VA Healthcare System) Lund BC (Center for Access & Delivery Research and Evaluation, Iowa City VA Healthcare System)
Gabapentinoids (gabapentin/pregabalin) play an important role as an alternative, nonopioid pain modality. While occasionally added to existing long-term opioid (LTO) therapy to decease dose or facilitate discontinuation, emerging evidence suggests concurrent gabapentinoid use may increase risk for adverse events and opioid-related deaths. Our objective was to examine recent trends in LTO-gabapentin co-prescribing in the Veterans Health Administration (VHA) and characterize treatment course after adding a gabapentinoid to existing LTO therapy.
National VHA outpatient pharmacy data from 2010-2018 were accessed using the VINCI corporate data warehouse. Long-term opioid therapy was defined by more than 90 days of regular use of schedule II opioids or tramadol. The new user cohort required incident gabapentinoid use and an active LTO episode at gabapentinoid initiation. Drug discontinuation was defined as 6 months with no prescriptions. Opioid de-escalation was defined as discontinuation or > 10% dose decrease in the year following gabapentinoid initiation. Opioid escalation was defined as > 10% dose increase.
Concurrent gabapentinoid use among patients receiving LTO increased from 22.7% to 36.6% between 2010-2018. During this period, 171,859 patients with existing LTO use initiated new gabapentinoid therapy. Overall, 28.9% experienced a de-escalation in opioid therapy in the year following initiation, 24.0% experienced dose escalation in opioid therapy, with the remaining 47.1% remaining on stable LTO therapy. Approximately 35% of patients discontinued gabapentinoid treatment within one year following initiation and only 24% reached the therapeutic goal dose for pain management of 1800 mg/day (or renally adjusted equivalent).
Concurrent gabapentinoid therapy is increasing among VHA patients receiving LTO therapy, exceeding 1 in 3 in 2018. While the therapeutic intent may be to minimize opioid exposure, de-escalation occurred in fewer than 30% of patients within the year following gabapentinoid initiation.
Concurrent gabapentinoid-LTO use is common, rarely achieves meaningful reductions in opioid exposure, and is an emerging safety concern for VHA.