Things We Do for No Reason™: Prescribing gabapentinoids for pain

Gabapentin and pregabalin are among the most frequently prescribed medications in the United States, with gabapentin in the top 10 and pregabalin in the top 100. Despite FDA approval for only select neuropathic conditions, most use is for off-label pain indications. Randomized trials show minimal or clinically insignificant benefit for most off-label pain syndromes. In contrast, gabapentinoids are associated with sedation, falls, delirium, respiratory depression, misuse, and hospitalization, especially with opioids or renal impairment. Given limited efficacy and harms, they should not routinely substitute for opioids. Clinicians should reassess indications, deprescribe when appropriate, and prioritize nonpharmacologic strategies.