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PostPosted: Wed Aug 03, 2011 1:51 am 
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This is a reply to a private message, but I have deleted the sender's message and info. I think MDs and patients should consider pregabalin (Lyrica) as a very helpful agent in acute and post-acute detoxification from buprenorphine and other long-acting opioids. In my opinion, it is underutilized and can be quite effective for some people.

Pregabalin was approved by the FDA for the purposes of treating fybromyalgia and other conditions, but as you know it is common for MDs to prescribe approved medications "off-label" for many conditions. Pregabalin is classified as an AED (Anti-Epileptic Drug) and functions by, among other mechanisms, upregulating the GABA levels in the amygdala. It has also been shown to increase glutamate, which is increasingly being identified as the "next key neurotransmitter" affecting depression and anxiety (the current ones being serotonin, dopamine, norepinephrine and GABA). For this reason, many psychiatrists are now prescribing pregabalin for a range of mood disorders, including bipolar disorder (II) and treatment-resistant depression, GAD, etc, etc. It is generally regarded as a stronger version of gabapentin (neurontin).

I think it is useful in *both* a general psychopharmacological context and in treating *withdrawal* from opioids, because it is basically non-habit forming (yes, it is a Schedule V controlled substance, which means that the DEA agrees - Schedule V substances can be regulated by individual states but are not strictly controlled by the Federal Government).

Dosage should be calculated on a mgs/kg basis and there is no "right" or "maximum" dosage, except to say that beyond 1200mg or so it has a self-limiting effect; that is, taking 2000mg has little additional effect over taking 1000mg. THAT SAID, an initial dose of 1000mg would be preposterous for anyone. Even the Lyrica prescribing information from Pfizer states clearly that the dose has to be slowly increased over time. The UK has issued "guidelines" stating that 600mg/day is a safe maximum dose; the US has not (and generally does not) dictate maximum doses of anything. Usually, a patient would begin at 50mg a day, and only in rare circumstances increase to a dosage like 1000mg over a month or more, with close medical supervision.

In a detoxification environment (in the hospital), I think it is safe to prescribe 200mg or even 400mg/day *immediately* to a patient in acute detoxification from opioids. Pregabalin does a good job of controlling anxiety and akathesia, two of the most painful symptoms of opioid detoxification. Post-detoxification, a healthy dose - I think - can help keep a patient calm while they are experiencing the rather mind-ravaging hyperkinetic (physical and mental) symptoms of PAWS (post acute withdrawal syndrome). It is a very effective anxiolytic and sedative agent with very low abuse potential. More importantly it is better than the two realistic alternatives:

(1) Benzodiazepines (eg clonazepam, diazepam, etc) - highly addictive (and rapid tolerance development), obviously.
(2) Ayptical antipsychotics (eg seroquel, zyprexa, etc) - which are basically ineffective and patients also develop rapid tolerance, not to mention (well documented) risk of irreversible tardive diskinesia.

I think that pregabalin, prescribed responsibly and at the appropriate dosage (although close to or above 600mg/day) can be a very effective tool in preventing relapse to opioids. I don't know about its long term health effects (you mention them) as there are no studies available - the only studies I am aware of on pregabalin last at most 12 weeks. Patients develop tolerance to pregabalin as well, but only over a 6-8 month time frame, and with careful dose escalation, this can be extended to a year. It is not a long-term solution/replacement for opioids, but it can dramatically diminish both acute and post-acute withdrawal pain when benzos are clearly contraindicated because of high abuse potential and fast tolerance development. I think pregabalin is SUBSTANTIALLY UNDERUSED by both detoxification MDs and by psychiatrists treating PAWS. Instead, they often revert to benzos thinking they are substituting a less harmful addiction for a more harmful one, or not even thinking that benzos are "serious" drugs when in fact they are extremely serious. I think benzos are OVERPRESCRIBED (diazepam is still the most widely prescribed drug in the world) although the better detox MDs avoid them because they are so addictive (although appropriate in some acute situations, e.g. injections of lorzepam, etc).

My view is that anything relatively safe which can ease detox/PAWS and reduce relapse risk should be strongly considered when treating opioid withdrawal (and especially withdrawal from methadone or buprenorphine, should the patient decide to end maintenance medication). As I'm sure you know, both US-approved maintenance opioids are very painful to withdraw from. This forum forbids the debating the merits of maintenance therapy, and I agree with that ban because it is such a polarizing and potentially destructive debate (esp to a patient on maintenance therapy).

If someone prescribed 1000mg/day to you without any dose escalation, it would be quite irresponsible in my opinion, and it would disregard all caution to the contrary by pretty much everyone in the medical community. However, I think pregabalin should be used more widely in treating opioid-dependent patients in any phase of withdrawal. If 600mg or 1000mg/day keeps a patient from returning to opioids, it may keep them alive, which I think outweighs the downside risks of pregabalin

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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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