How to reduce risks when taking anxiety drug Pregabalin

There has been a significant rise in deaths linked to the commonly prescribed anxiety drug, pregabalin. While in 2018 there were 187 deaths linked to pregabalin in England and Wales, this number was more than double in 2022 – with 441 deaths linked to the drug. Recent press reports have framed these deaths as signalling a “US-style opioid epidemic” caused by a medicine that “destroys lives”. This is not an equitable comparison, given hundreds of thousands of Americans have died due to opioids. These reports may only serve to cause undue panic about the drug, especially among those who have been prescribed it.

Pregabalin (also known by the brand names Lyrica and Alzain) is used to treat a variety of health conditions, including epilepsy, nerve pain and anxiety. The drug was first approved for use in Europe and the US in 2004. Pregabalin has rewarding properties, and can produce feelings of euphoria, calmness and relaxation. These effects may explain why even people who don't have a prescription seek out pregabalin.

Pregabalin on its own is typically not dangerous, although as with all medication there are potential side effects – including confusion and headaches. It can also carry the risk of dependence, especially if taken long term. But where pregabalin can become dangerous, whether used as prescribed or not, is if it's taken alongside other drugs that it interacts negatively with.

Pregabalin should ideally be avoided alongside other opioids, certain sleep aids, benzodiazepines (another class of anxiety drug), muscle relaxants and even certain diabetes and epilepsy drugs. Most fatalities attributed to pregabalin are due to interactions with other drugs, leading to a suppression of breathing.

An analysis of pregabalin deaths in England between 2004-2020 has shown that in over 90 per cent of deaths, the presence of other opioids (including methadone or morphine) was detected. However, in only a quarter of cases were these opioids actually prescribed to the person. This suggests that people were probably sourcing these drugs through illicit means and not through their doctor. Likewise, it's not clear from the data whether pregabalin had been prescribed, or if the person sourced it without a prescription. Although this data only goes up to 2020, it's likely that the picture is similar for the recent deaths linked to pregablin.

Fatalities

The recent rise in pregablin deaths partly coincides with an increase in the number of people prescribed the drug. In the UK alone, there were 8.4 million prescriptions for pregabalin in 2022. This is up from 5.5 million in 2016. This might suggest that more support needs to be provided to reduce patient risk – particularly in relation to co-use of other drugs.

Prescribers and patients both need to be educated about the potential risks of using pregabalin – including the potential of dependency. Patients and prescribers also need to be aware of the drugs that pregabalin interacts with and the effects such combinations might have. Prescribers should also regularly review pregabalin prescriptions to ensure that patients are still benefiting from it. If not, recommending other treatments – such as psychological therapies, if a person is taking the drug for anxiety – might be more suitable. But in light of the profile of drugs involved in deaths previously linked to pregabalin, it's clear that drug education alone won't be enough.

Certain groups may be at greater risk of harm from pregabalin. For example, people with a history of substance use disorder have a high level of co-occurring mental health problems, and may be prescribed pregabalin as a short-term treatment for anxiety.

But because mental health and drug treatment support are typically provided by different services, a lack of communication between these services can sometimes mean that one service is not always fully aware of what drugs the other is prescribing – potentially leading to harmful drug interactions. Evidence also suggests that illicit pregabalin use is a growing problem in both Europe and North America. Its availability as a street drug may mean users aren't aware of the risks of taking pregabalin alongside other drugs – such as the synthetic opiate, methadone.

There's the added complication of fear of negative consequences. Someone prescribed pregabalin who uses illicit drugs may not declare this to their doctor. People who use illicit opioids less frequently (such as for recreational purposes or to self-treat pain or mental health problems) are also at elevated risk.

Evidence also shows that more people living in the north of England are prescribed pregabalin compared to those living in the south. Other research has also shown a link between social deprivation and drug prescribing – with people living in more deprived areas of England being prescribed drugs such as pregabalin at higher rates. Those living in deprived areas may not get the support they need – including support to know the risks of taking or combining certain drugs, putting them at greater risk of harm.

Understanding exactly why these deaths are happening is important for developing strategies to reduce harm and deaths from the drug. Simply stopping pregabalin prescriptions does not seem practical or safe, as it's considered a useful and effective medicine that many people benefit from.

Placing tougher restrictions on illicit pregabalin would also not be practical, and could even lead to greater harm – which is exactly what happened after it was made a Class C drug in 2019. Understanding why people are combining pregabalin with other drugs, prescribed or not, is crucial for anything meaningful to be done.

(Harry Sumnall, Professor in Substance Use, Liverpool John Moores University and Ian Hamilton, Honorary Fellow, Department of Health Sciences, University of York)