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Pharmacy technician Vicky is talking to customer Liza Philips.

“How’s that slipped disc treating you, Liza?” asks Vicky.

“Still in agony, to be honest,” replies Liza. “I went to see a physio, but he says it is too inflamed to do anything, and so far the GP has tried me on co-codamol, naproxen and an antidepressant, but none of them have touched it. Now he wants to put me on this.”

Liza shows Vicky a prescription for pregabalin.

“I’m really not sure about taking it,” Liza continues. “On the one hand, I’m desperate – for a good night’s sleep, for a start, which I’m sure would make a huge difference – but on the other, I’ve read that this can cause all kinds of side effects, and you can get hooked on them. The specialist at the hospital said it would get better on its own, but it’d take a few months. I really don’t know. What do you think? Should I give it a few more weeks to see if it gets easier? I could always get this prescription filled then if I think I need it.”

Answer

There are several things to unpick in what Liza is saying. The first, and probably the most practical, is that if she does want to give the pregabalin a go, the prescription is only valid for 28 days from the date it bears. This is because pregabalin, alongside gabapentin, became a Schedule 3 controlled drug earlier this year subject to all normal requirements except safe custody. This also means that no more than 30 days’ treatment should be prescribed, though note that this is a good practice recommendation rather than a legal requirement.

In terms of side effects, the best thing to do is for Vicky to talk Liza through a pregabalin leaflet, explaining the difference between those listed under “common”, “uncommon” and “rare”, and so on, and providing context and perspective through comparison with the leaflet of a medicine she is more familiar with. She should also advise on the potential for central nervous system (CNS) depression with other drugs that also cause this side effect, particularly opioids and alcohol.

When it comes to dependence, pregabalin and gabapentin are certainly associated with the potential for abuse and addiction. There are various risk factors for this, which the GP should have considered, and hence drugs of this nature should be started at a low dose and titrated up to the minimum effective dose and taken for the shortest amount of time necessary, a process that will be facilitated if Liza is being seen by the GP regularly.

However, it is worth bearing in mind that pregabalin has been shown to be effective at reducing neuropathic pain, which is what Liza seems to be experiencing as a result of the slipped disc in her spine compressing one of the nerve roots, and given the lack of success she has had with other medication and the pain she is in, it may be worth trying.

The bigger picture

Pain is horrible, and when it is persistent can result in poor health outcomes, both physically and mentally. Obviously going to the GP is the right thing to do but a broader approach to pain management is called for, as often it cannot be cured and instead patients need to find ways to live better lives. A great resource to support this is Live Well With Pain, a website that encourages both patients and healthcare professionals to shift their mindset from medication alone. Identifying how the pain is affecting the sufferer’s life is a good first step, then looking at ways to improve quality of life through the development and maintenance of skills and support such as setting goals and action plans, staying active, managing sleep quality and quantity, adopting healthy eating and relaxation habits, and finding ways of dealing with work and relationships, as well as setbacks.

Extend your learning

• Read the PSNC briefing on the reclassification of gabapentin and pregabalin as CDs 
• Get to grips with why the UK drug regulator chose to reschedule pregabalin with information from the MHRA
• Understand more about neuropathic pain and its management from NICE
• Take a look at the leaflet on pregabalin and gabapentin from Live Well With Pain.