The Role of Gabapentin in Pain Management

Gabapentin is an anticonvulsant drug prescribed for seizures and nerve pain. People who develop physical dependence to gabapentin may experience withdrawal symptoms when they try to come off it. Withdrawal symptoms can begin within 12 hours to 7 days after quitting the medication and last up to 10 days. Symptoms of gabapentin withdrawal may include nausea, dizziness, headaches, insomnia, and anxiety.

Opioids, non‐steroidal anti‐inflammatory drugs (NSAIDs), antidepressants, and anticonvulsants are used as pharmacological agents to treat pain. However, no single class of drugs has been found to be effective in all types of pain, presumably because pain syndromes involve different mechanisms.

In addition, each of the currently available drugs is associated with adverse effects, some of which are potentially serious or life‐threatening such as idiosyncratic or toxic reactions.

Traditionally, the treatment of neuropathic pain has involved anticonvulsants, such as carbemazepine, valproic acid and phenytoin, and tricyclic antidepressants, such as amitriptyline and nortriptyline and doxepin. The main disadvantages of the anticonvulsants are their potential for drug interactions via the induction of hepatic enzymes, or resulting from inhibition of hepatic enzymes by other drugs. Minor side‐effects such as sedation, ataxia, vertigo and diplopia are associated with carbemazepine and phenytoin, whereas, anorexia, nausea, vomiting and tremor are associated with valproic acid. Chronic phenytoin use may cause peripheral neuropathy (30%) and gingival hyperplasia (20%), and fetal hydantoin syndrome if administered during pregnancy. Carbemazepine can cause chronic diarrhoea or the syndrome of inappropriate ADH secretion, and rarely aplastic anaemia, thrombocytopaenia, hepatocellular jaundice and cardiac arrhythmias.

Tricyclic antidepressants also cause side‐effects that can be troublesome or potentially dangerous, such as anticholinergic effects (dry mouth, blurred vision, urinary retention, ileus), sedation, orthostatic hypotension, tachycardia and atrio‐ventricular conduction disturbances. Such adverse effects are likely to reduce the tolerance of this group of drugs in elderly or unwell patients. Some subgroups of patients with painful neuropathy such as diabetes may also have autonomic neuropathy and may not tolerate the orthostatic hypotension associated with tricyclic antidepressants.

With increasing evidence of the efficacy of gabapentin in a wide variety of pain syndromes, especially neuropathic pain, gabapentin may be potentially useful because of its relative freedom from serious adverse effects, its lack of interactions with other drugs and its lack of potential for causing drug dependence.

A comparison of the evidence available of efficacy and toxicity for anticonvulsants (gabapentin, phenytoin and carbemazepine) and antidepressants (tricyclic antidepressants and SSRIs) in patients with diabetic neuropathy and postherpetic neuralgia has recently been made by Collins et al. [129] These two neuropathic pain conditions were chosen according to strict diagnostic criteria. Although two previous systematic reviews of anticonvulsants and antidepressants in diabetic neuropathy showed no significant difference in efficacy or adverse effects between the two drug classes [130, 131], Collins et al. found that when data from randomised controlled trials for both diabetic neuropathy and postherpetic neuralgia were pooled, the NNT for at least 50% pain relief was identical for both classes of drugs. When gabapentin was compared with other anticonvulsants, there was no significant difference in efficacy.

The NNT for gabapentin was 3.4 compared with 2.2 for phenytoin/carbemazepine. The number needed to harm (NNH, defined as the number needed to harm one patient from the therapy) for minor adverse effects was 2.7 for both antidepressants and anticonvulsants. Collins et al. used two trials to provide data on minor adverse effects for gabapentin and two trials for phenytoin. The NNH (minor adverse effects) was 2.6 similar to that of gabapentin and 3.2 for phenytoin. The NNH (major adverse effects) for the tricyclic antidepressants was 17, and no significant difference in the incidence of major adverse effects was found between anticonvulsants and placebo.

Collins et al. suggested that the difference in the incidence of major adverse effects can be compared by using the ratio between treatment specific benefit and treatment specific harm (defined as the number of patients needed to experience at least 50% benefit for one to experience a major adverse effect that warranted discontinuation of treatment). The ratio for gabapentin was 6 compared with an average of 8 for all anticonvulsants, and 6 for all antidepressants. As adverse data were pooled from both diabetic and postherpetic neuralgia studies, methodological factors and heterogenicity in these data may limit the validity and robustness of these ratios. The spectrum of the pain and short study duration tend to underestimate the treatment effect, whereas the small sample size of the studies overestimate the treatment effect.

The above evidence suggests that gabapentin is as efficacious at treating neuropathic pain with no significant difference in minor adverse effects and a low propensity for serious adverse effects compared with other anticonvulsants and antidepressants. Therefore, gabapentin is a useful agent in the multimodal approach in the management of neuropathic pain.

What is Chronic Pain and How to Deal With Pain ?

Chronic pain is complex, and it can take a person some time to find the best pain relief methods that work for them. There are many options to try, such as hot and cold therapy, yoga, or drug treatments.

Chronic pain may develop after an injury or due to a medical issue. Healthcare professionals define pain as chronic if it lasts longer than 3 months, or beyond the normal healing time for the underlying condition or injury.

Chronic pain can affect every part of a person’s life, from work and social life to sleep and mental health.

10 ways to reduce pain

Whether your pain has just come on or you’ve lived with it for years, these tried-and-tested self-help steps can bring you relief.

Get some gentle exercise

Simple, everyday activities like walking, swimming, gardening and dancing can ease some of the pain directly by blocking pain signals to the brain.

Activity also helps lessen pain by stretching stiff and tense muscles, ligaments and joints.

It’s natural to be hesitant if exercise is painful and you’re worried about doing more damage. But if you become more active gradually, it’s unlikely you’ll cause any damage or harm. The pain you feel when you start gentle exercise is because the muscles and joints are getting fitter.

In the long term, the benefits of exercise far outweigh any increase in pain.

Breathe right to ease pain

Concentrating on your breathing when you’re in pain can help.

When the pain is intense it’s very easy to start taking shallow, rapid breaths, which can make you feel dizzy, anxious or panicked. Instead, breathe slowly and deeply.

This will help you to feel more in control and keep you relaxed and prevent any muscle tension or anxiety from making your pain worse.

Talking therapies can help with pain

Pain can make you tired, anxious, depressed and grumpy. This can make the pain even worse, making you fall into a downward spiral. Be kind to yourself.

Living with pain is not easy and you can be your own worst enemy by being stubborn, not pacing your activities every day and not accepting your limitations.

Some people find it useful to get help from a psychologist or hypnotherapist to discover how to deal with their emotions in relation to their pain.

You can also find out more about talking therapies, also known as psychological therapies.

Distract yourself

Shift your attention on to something else so the pain is not the only thing on your mind. Get stuck into an activity that you enjoy or find stimulating. Many hobbies, like photography, sewing or knitting, are possible even when your mobility is restricted.

Share your story about pain

It can help to talk to someone else who has experienced similar pain themselves and understands what you’re going through.

Pain Concern, Action on Pain and Versus Arthritis all have telephone helplines staffed by people with long-term pain, who can put you in touch with local patient support groups.

The sleep cure for pain

Many people with long-term pain find it difficult to sleep at night. But it’s important to try to stick to a normal sleep routine so you’ve got the best chance of sleeping through the night.

Sleep deprivation can also make pain worse. Go to bed at the same time each evening, and get up at a regular time in the morning and avoid taking naps in the day. If sleep problems persist, see a GP.

Keep in touch with friends and family

Do not let pain mean that you lose contact with people.

Keeping in touch with friends and family is good for your health and can help you feel much better. Try shorter visits, maybe more often, and if you cannot get out to visit people, phone a friend, invite a family member round for tea or have a chat with your neighbour.

Aim to talk about anything other than your pain, even if other people want to talk about it.

Relax to beat pain

Practising relaxation techniques regularly can help to reduce persistent pain.

There are many types of relaxation techniques, varying from breathing exercises to types of meditation.

Ask a GP for advice in the first instance. There may be classes available locally or at your local hospital’s pain clinic.

What are Physical Techniques ?

Various physical methods can help relieve pain, including physical therapy, hot and cold therapy, massage, and acupuncture.

Hot and cold therapy

Hot and cold therapy is a common and safe technique to reduce pain.

Heat can help relax the muscles and dilate the blood vessels. It can also promote healing after an injury.

Cold therapy reduces blood flow and reduces inflammation that causes pain. It often involves applying an ice pack wrapped in a towel to the skin.

Massage

Massage is a type of soft-tissue manipulation. People may benefit from this technique when used with other pain management treatments, such as physical therapy and pain medication.

The benefits of massage include:

  • relaxation
  • increased flexibility
  • reduced inflammation
  • improved posture
  • improved circulation
  • reduced stiffness

A 2007 review on massage found that it may be effective for lower back pain. However, there is mixed evidence from examining its benefits for other chronic pain types.

Physical therapy

Physical therapy involves physical techniques to strengthen and stretch the muscles and joints. It can relieve pain throughout the body, while the specific methods will vary by body part.

Therapeutic exercise can have long-term benefits for chronic pain, including helping people cope.

Techniques may involve massage, exercise plans, and red light therapy.

Acupuncture

Acupuncture involves a practitioner applying thin needles to the skin at precise points in the body.

According to the National Center for Complementary and Integrative HealthTrusted Source, evidence suggests this technique could help people manage certain pain conditions.

This includes short-term relief from pain in the lower back, neck, knee, and osteoarthritis. However, there is little evidence to suggest it is effective over the long term.

The proposed benefits of acupuncture are:

  • pain relief
  • reduced inflammation
  • relaxation
  • reduced muscle spasms

Acupuncture is generally safe when performed by trained practitioners using sterile needles.

What is Mind-body Techniques ?

Methods that combine psychology and the body can help many people manage chronic pain.

Cognitive behavior therapy

Psychological treatments for chronic pain include talking therapies, such as cognitive behavioral therapy (CBT).

Psychological treatments aim to reduce the negative impact that chronic pain can have on a person’s mental health.

A 2013 review on the effectiveness of psychological pain management techniques concludes that CBT is effective at reducing pain immediately after treatment compared with using no strategies.

The review also found that there was no evidence that CBT can reduce long-term pain. However, the technique was useful for reducing anxiety around pain and for improving quality of life.

Yoga

Yoga aims to relax, strengthen, and keep the body flexible through stretching, with specific poses focusing on particular body areas.

A 2010 study into yoga’s effects on chronic pain found that it did not decrease participants’ pain, but it did help them cope, and they were more in control of how their pain affected their everyday life.

However, other studies have found yoga to be effective in reducing pain.

Yoga is a safe and accessible pain management technique that people can try at home, using online videos, or in a class with an instructor.

Tai chi

Tai chi is an exercise therapy involving slow, continuous, fluid body movements combined with breathing and relaxation techniques. The method is also gentle on the joints and muscles.

Tai chi can improve strength and joint stability, and the concentration it requires can improve a person’s mood.

What is Relaxation Techniques ?

Dealing with chronic pain can be stressful for many reasons, such as not feeling in control regarding a person’s discomfort.

Relaxation techniques can help ease muscle tension, muscle spasms, aches, and pains. They can also release endorphins, which are the body’s natural painkillers.

A person can help reduce stress through relaxation, which can ease some of the burden of chronic pain while promoting better sleep.

Relaxation methods for chronic pain include:

  • Deep breathing techniques: Slow and relaxed breathing methods, such as box breathing, help relieve tension.
  • Progressive muscle relaxation: Involves tensing and relaxing each muscle group in turn, for 10 seconds each, from the head to the toes. Focus on breathing and avoid muscles that feel painful.
  • Thinking calmly: Spend 5 minutes imagining a calming scene, such as a sunny afternoon in nature, surrounded by green trees and birdsong.
  • Calming activities: Set aside time for relaxing activities such as having a warm bath, reading a book, or crafting.

What is Drug Therapies?

There is a wide range of medications to relieve pain. Each class and type of drug work differently, while some may be more suitable for certain people than others.

Acetaminophen

Acetaminophen helps many kinds of chronic pain. One brand name is Tylenol. It is also found in many over-the-counter and prescription pain medicines. If you’re not careful, you could take more acetaminophen than is good for you. Too much acetaminophen can cause liver damage, especially if you drink alcohol. Tell your doctor if you have to take more than 2 acetaminophen pills a day.

Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of medications that reduce inflammation and pain. They are available in capsules, tablets, or as creams or gels for the skin.

However, NSAIDs may cause issues with the stomach and the cardiovascular system in some people. Talk with a doctor before beginning treatment with NSAIDs.

Opioids

Opioids can treat moderate-to-severe pain and are generally only appropriate for short periods, as they can be addictive.

CDC guidelines recommend people should only use opioids when the benefits outweigh the risks.

There is a lack of evidence that this treatment works for chronic pain, as people typically use opioids for short periods.

Antidepressants

Some antidepressants, such as amitriptyline, can help with pain relief.

Amitriptyline is an antidepressant that, at lower doses, people also use for chronic pain, such as diabetic neuropathy and fibromyalgia.

It can take 2–4 weeks for a person to feel the effects of the medication.

Side effects of amitriptyline can include:

  • dizziness
  • dry mouth
  • fatigue
  • headaches

Anticonvulsants

Your doctor may want you to try an anticonvulsant medicine. It may help reduce some types of chronic pain, such as low back pain. Examples of anticonvulsants are:

  • gabapentin (Neurontin)
  • carbamazepine (Tegretol)
  • phenytoin (Dilantin)
  • pregabalin (Lyrica)
  • topiramate (Topamax)

Like antidepressants, your doctor may start you on a low dose of anticonvulsants. This helps prevent or reduce side effects. The doctor may increase the amount over time. Contact your doctor right away if you have suicidal thoughts. Minor side effects may include:

  • drowsiness
  • nausea or vomiting
  • restlessness
  • dizziness
  • loss of appetite
  • weight gain
  • itching or swelling

Anti-seizure medications

Medications for epilepsy interrupt pain messages to the brain.

Types include gabapentin (Gabarone®) and pregabalin (Lyrica®).

These medicines can ease nerve pain and fibromyalgia.

Muscle Relaxant

Healthcare providers in the United States can currently prescribe the following antispasmodic skeletal muscle relaxants:

  • Carisoprodol (Soma®, Vanadom®).
  • Chlorzoxazone (Lorzone®, Parafon Forte DSC®, Relax-DS®, Remular S®).
  • Cyclobenzaprine (Fexmid®, Flexeril®).
  • Metaxalone (Metaxall®, Skelaxin®).
  • Methocarbamol (Robaxin®).
  • Orphenadrine (Norflex®).

Antispastic skeletal muscle relaxants that providers can currently prescribe in the U.S. include:

  • Baclofen (Lioresal®).
  • Dantrolene (Dantrium®).

Two skeletal muscle relaxants have both antispastic and antispasmodic effects. They include:

  • Tizanidine (Zanaflex®).
  • Diazepam (Valium®).

Beta-blockers

Beta-blockers slow down the heart and stop hormones, such as adrenaline, from working. Some people use them to treat migraines.

A study shows that beta-blockers at low doses can temporarily improve chronic pain in females with fibromyalgia and temporomandibular syndrome.

However, beta-blockers may not be suitable for everyone. Consult with a doctor before using them for chronic pain.

Cannabis

Medicinal cannabis and cannabidiol (CBD) are increasingly common pain treatments.

A 2017 review states that cannabis may ease neuropathic pain, but not pain due to fibromyalgia, headaches, or rheumatoid arthritis.

In addition, cannabis for medicinal purposes may not be legal everywhere. High doses can trigger side effects, so it is best to check with a health professional before using cannabis CBD for pain relief.