Your Medication

Hi Friend,

Firstly thank you for all of you who joined the live video call, the link to the full video is here. I will be doing these every week, and you will get access to the closed group forum which will go live next week. Treatment therapists will be going live in 2-3 weeks time. Going forward this will be a pid service, as you can see the check in call went on for 90 mins when it was only scheduled for 45! You can sign up to get this every week here.

Medication!! This was a huge topic that was raised during the call, lots of questions, so the topic this week is all on medication!

Under NICE guideline NG193 (“Chronic pain – assessment and management of chronic primary pain in over 16s”), pharmacological treatment is explicitly very limited. For chronic primary pain (pain persisting > 3 months with no clear underlying cause, or out of proportion to any observable injury), NICE recommends only:

• Antidepressants (off-label for pain): amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline, for people aged 18 and over, after a full discussion of benefits and harms.

  • Young people (16–17 years) should have specialist advice before starting an antidepressant.

NICE specifically advises against initiating the following for chronic primary pain:

• Antiepileptic drugs (including gabapentinoids such as pregabalin or gabapentin), unless used in a clinical trial for complex regional pain syndrome

• Antipsychotics

• Benzodiazepines

• Corticosteroid trigger-point injections

• NSAIDs, paracetamol, opioids and muscle relaxants (noted elsewhere as lacking evidence of long-term benefit for primary pain)

Gabapentin and Pregabalin

It has become clear that many of you have been prescribed one of these medications. I have to stress the evidence for chronic pain is very limited, and side effects can be extensive. However, it has a number of limitations and risks that make it a poor choice in many situations:

1. Sedation, Dizziness & Cognitive Impairment

   • Up to one-third of patients experience drowsiness, dizziness or “brain fog,” which can interfere with daily activities and increase risk of falls—particularly in older adults.

2. Off-Label Overuse with Limited Evidence

   • Despite widespread use for “chronic pain,” robust trials show little to no benefit of gabapentin for many non-neuropathic pains. NICE explicitly recommends against starting gabapentinoids for chronic primary pain because the harms outweigh the unproven benefits.

3. Potential for Misuse & Dependence

   • Gabapentinoids can produce euphoria at high doses and are increasingly implicated in misuse, especially in people with a history of substance use disorder. Withdrawal syndromes (anxiety, insomnia, sweating) can occur if it’s stopped abruptly.

4. Respiratory Depression Risk

   • When combined with opioids or other central depressants, gabapentin can potentiate respiratory depression, significantly increasing overdose risk.

5. Dose Titration & Renal Clearance

   • It must be started low and titrated slowly, with dose adjustments for kidney function—making it inconvenient compared to many other pain or mood medications.

6. Adverse Effects on Mood & Weight

   • Weight gain, peripheral edema (swelling), and occasional mood changes (including depression) can offset any pain-relief benefit.

7. Withdrawal & Rebound Pain

   • Abrupt discontinuation may lead to rebound pain or seizure risk in epileptic patients, requiring careful tapering.

In short, while gabapentin has its place, its high side-effect burden, abuse potential, and weak evidence for many off-label uses mean that prescribers and guidelines often favour other treatments first.

Now please I must stress this is just for chronic pain, however if you have been on pregabalin or gabapentin and have found that your pain is no better or side effects are extensive, please mention this to your doctor, as more than likely the benefit would be greater if you come off them.

I dont want this to be all doom and gloom, in previous letters we have discussed Tonmya and somatic therapy which are both very exciting developments, next week I will discuss what other methods we can use to actually help your pain or fatigue.

Regards

Dr Ahmed