Pregabalin Misuse in North India: Epidemiology, Addiction Potential, and Implications for Public Health Policy

INTRODUCTION Pregabalin, originally developed as an anticonvulsant and now commonly prescribed for neuropathic pain and anxiety disorders, has witnessed increasing patterns of misuse, particularly in North India. Over the past decade, numerous reports have surfaced documenting its nonmedical use among youth and opioid-dependent populations. This letter seeks to bring to attention a recent and deeply concerning regulatory development with far-reaching implications for clinical pain practice: The ban on the over-the-counter sale of pregabalin in the states of Haryana and Punjab, owing to its increasing misuse as a psychoactive substance. Furthermore, it outlines the significant risks associated with a blanket regulatory ban and proposes practical, evidence-based strategies to mitigate misuse while ensuring continued access for chronic pain patients. Pregabalin, a gamma-aminobutyric acid analog, is a Schedule H drug in India with approved indications for neuropathic pain, partial seizures, and generalized anxiety disorder. Marketed under the trade name Lyrica, it has become a mainstay in chronic pain management due to its efficacy and relatively favorable side effect profile. However, over the last 10 years, concerns have mounted about its potential for misuse and dependence, especially in northern states of India such as Punjab, Haryana, Himachal Pradesh, and Uttar Pradesh. The psychoactive effects of pregabalin – euphoria, relaxation, and sedation – have contributed to its rising popularity as a recreational drug. This review seeks to provide a comprehensive analysis of the evolving patterns of pregabalin misuse, identify high-risk populations, and recommend regulatory and clinical measures to curb this public health concern without jeopardizing patient care. HISTORICAL OVERVIEW AND EPIDEMIOLOGY OF MISUSE The first concerns about gabapentinoid misuse were raised internationally in the early 2010s. In India, Chiappini and Schifano (2016)[1] identified early patterns of misuse among opioid-dependent individuals. In 2017, a cross-sectional study from Punjab (Sharma et al., 2017)[2] found that 9.5% of opioid users had misused pregabalin, often at high doses (>300 mg/day). Kumar et al. (2020),[3] in a study of 450 patients at a tertiary deaddiction center in North India, found that 20% had a history of nonmedical pregabalin use. More alarmingly, a 2023 survey[4] by the Department of Psychiatry at PGIMER, Chandigarh, reported that 31% of male patients aged 18–35 had misused pregabalin, frequently in combination with alcohol or opioids. The drug was often procured over-the-counter from pharmacies without a prescription. ADDICTION POTENTIAL AND PHARMACOLOGY Pregabalin acts by binding to the alpha-2-delta subunit of voltage-gated calcium channels in the CNS, reducing excitatory neurotransmitter release. Although not classically addictive, its euphoric effects at supratherapeutic doses, combined with rapid onset, contribute to its abuse potential. Tolerance and physical dependence have been well documented (Bonnet and Scherbaum, 2017).[5] Withdrawal symptoms include anxiety, tremors, insomnia, palpitations, and agitation. Reports also indicate an increased risk of respiratory depression when pregabalin is used with opioids, benzodiazepines, or alcohol (Evoy et al., 2021).[6] CLINICAL CONSEQUENCES OF MISUSE Impaired cognition, coordination, and psychomotor function Increased emergency visits due to overdose or withdrawal High treatment burden at deaddiction centers Legal issues and criminal behavior related to drug procurement. RISKS OF A BLANKET BAN Despite the emerging misuse, pregabalin remains a cornerstone in managing conditions such as diabetic neuropathy, postherpetic neuralgia, and fibromyalgia. Moore et al. (2009)[7] concluded that pregabalin significantly improves pain scores and quality of life when used appropriately. Jain et al. (2012)[8] reported that 60% of chronic pain patients under tertiary care experienced significant improvement with pregabalin. Banning pregabalin or severely restricting its use would leave a large subset of patients with inadequate treatment options. Alternatives such as opioids pose a higher risk of dependency and adverse events. In addition, many rural healthcare providers may lack access to or training in complex multimodal pain regimens, exacerbating the treatment gap. POLICY RECOMMENDATIONS TO CURB MISUSE Reclassification: Shift pregabalin to Schedule H1 or a newly created subcategory requiring strict prescription protocols Pharmacy monitoring systems: Implement real-time prescription monitoring to track dispensing patterns and flag overuse Training and guidelines: Conduct continuing medical education programs to train prescribers on rational pregabalin use and identify signs of misuse Public education campaigns: Launch targeted campaigns in high-risk states to raise awareness about the dangers of nonmedical use Access control: Restrict pharmacy sales to licensed prescriptions and penalize unauthorized sales Research and surveillance: Strengthen epidemiological surveillance through regular surveys and state-level reporting mechanisms De-addiction services: Expand mental health and deaddiction services in affected districts with tailored interventions for pregabalin dependence. CONCLUSION Pregabalin misuse has emerged as a critical public health issue in North India, fuelled by its psychoactive properties and easy over-the-counter access.[9] The dual identity of pregabalin – as both a life-altering medication for patients with neuropathic pain and a drug of abuse for nonmedical users – necessitates a nuanced and balanced approach. We urge the pain medicine and regulatory community to come together to devise context-specific solutions that protect patients while addressing the public health threat. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.