SPPCP 2026: Lorin Fisher, PhD, Examines Gabapentin’s Expanding Role in Pain Care

Pharmacy Times interviews Lorin Fisher, PhD, BCACP, on her presentation, “Gabapentin for Pain Management: Well Done or Overdone?,” presented at the 2026 SPPCP conference. Fisher discusses the evolving role of gabapentin in pain care, highlighting where evidence supports its use, where it may be overprescribed, and key considerations for pharmacists in optimizing safe and appropriate therapy.

Pharmacy Times: Your presentation is titled “Gabapentin for Pain Management: Well Done or Overdone?”—what prompted you to explore this question, and why is it particularly relevant right now?

Lorin Fisher PhD, BCACP: There was a disconnect that I see in clinical practice about how frequently Gabapentin is actually prescribed to patients, but then comparing that disconnect with the benefit to burden ratio as especially for patients that I take care of, they live with serious illness, they may receive palliative care, that those burdens are very, very high, and sometimes the benefits are very, very limited. And really that's what the evidence says as well regarding efficacy, is that the that the efficacy is really modest for a limited number of conditions. I've witnessed this firsthand, of course, and again, that's been shown in the literature. And as I mentioned, particularly in older adults and vulnerable patient populations like those with serious illnesses, there's a number of different adverse effects that come along with gabapentinoid prescribing. And just to know, like, just to have an understanding of how frequently Gabapentin is prescribed, it is within the top 10 most prescribed medications within the United States. And most recently, data shows that there's been about 46 million prescriptions for it on an annual basis.

Pharmacy Times: Gabapentin has seen widespread use across multiple pain-related conditions. In your view, where is the evidence strongest for its effectiveness, and where might it be overutilized?

Fisher: The strongest evidence for Gabapentin efficacy is really in
early or acute neuropathic or nerve related pain. And really that gets down to how the mechanism of action of the medication works.
So Gabapentin targets the alpha two, delta one calcium channel subunit, and particularly this subunit is upregulated early after nerve related injury. So in a setting where Gabapentin is becoming over utilized is in the setting of chronic, long standing neuropathic pain, or non neuropathic conditions that Gabapentin may be prescribed for, or pain that has merit mixed characteristics, like low back pain in chronic pain, that mechanistic target that I talked about before the alpha two, delta One, calcium channel subunit that becomes a little bit less relevant over time and likely. That's why we see diminished efficacy with Gabapentin.

Pharmacy Times: How has the role of gabapentin evolved in pain management, especially in the context of efforts to reduce opioid prescribing?

Fisher: Over time, particularly within the last couple of decades, Gabapentin prescribing has really grown to help reduce the amount of opioid prescribing as anecdotally, it's been used viewed as a safer alternative, because it is not an opioid. However, more recently, we're recognizing that gabapentin, as I described to you previously, with the mechanism, may not be as effective as we hope, in many cases, particularly chronic pain cases, and Gabapentin itself is not benign. I mentioned that there's a very high burden to benefit ratio, but particularly when we combine Gabapentin with opioids, we see an increased risk of respiratory depression and even opioid related death. So it's not necessarily that we're thinking about like replacing opioids with the truly safer analgesic Gabapentin. Really, what we've done, we've just added another layer of complexity, or another layer of additional risk that we need to think about.

Pharmacy Times: What are some of the most common misconceptions clinicians may have about gabapentin’s safety or efficacy?

Fisher: I think the first big misconception is that it can be very effective for most types of pain, especially neuropathic pain. In my clinical practice, I often see providers just do it as a knee jerk reaction. They prescribe it to any patient that describes characteristics of neuropathic pain so numbly, numbness, tingliness in the fingers, toes, or any other type of like pin prick type sensations. However, even with that pain character, which is, you know, hallmark for neuropathic pain patients don't often receive meaningful relief, and the never needed to treat. And the data that we do have is relatively high, indicating that it may not be super effective. And then the other piece is, as I mentioned before, is that providers or others within healthcare may view that Gabapentin is safe, especially when comparing it to opioids. So in addition to the increased risk of respiratory depression when used in combination with opioids, when used individually and in combination with other medications, the side effects that we often see with gabapentinoids include edema, sedation, increased risk, or falls there can be worsening cognitive effects, or patients becoming more cognitively impaired, and prescribing cascade, so the phenomenon of prescribing a medication to treat the side effects of another medication. So for example, let's say someone may have a comorbid diagnosis of heart failure and are prescribed Gabapentin. And so if a patient is experiencing worsening edema or new onset edema, it may be chalked up to exacerbated heart failure, which may lead to higher doses of diuretics, potentially changes in potassium doses. And so it's kind of these downstream effects by not addressing the root cause, which was the adverse effects caused by the Gabapentin so gabapentinoids really aren't harmless. I think just due to this sense of familiarity prescribing them may feel safer or better just because we see them so often in clinical practice. And really this Familiarity is thought to be potentially biased by inappropriate marketing practices of pharmaceutical companies for off label use of Gabapentin indications in the 90s, so those inappropriate marketing practices may be the reason why we're still seeing so frequent Gabapentin prescribing today.

Pharmacy Times: Are there specific patient populations or clinical scenarios where gabapentin use should be approached with greater caution?

Fisher: So I'd specifically be cautious of prescribing or recommending gabapentin, or even increasing the dose, or really even just, I mean, if thinking twice again, it's not a hard and fast No, but really cautious in patient populations, like older adults, particularly those at high risk for falls or more frail older adults, patients with renal impairment, because Gabapentin does accumulate in patients whose kidneys aren't working as well, patients who may be on opioids or other central nervous system or CNS depressants, patients with comorbid substance use disorder, as there's evidence to show that Gabapentin may have some addictive traits as well. Different states are having Gabapentin be a controlled substance and a state by state basis. So that's also something to be mindful of. I mentioned the cognitive impact of gabapentins adverse effects, and so patients that have baseline cognitive impairment or fatigue, those are important considerations. And then patients that may be at high risk for developing congestive heart failure, or have a develop or currently have a diagnosis of congestive heart failure due to the risk of volume overload with Gabapentin.

Pharmacy Times: With increasing concerns around misuse and off-label prescribing, how can pharmacists play a role in ensuring appropriate use of gabapentin?

Fisher: Pharmacists really are key in ensuring that there is a valid indication for Gabapentin and that there is supporting evidence. So pharmacists asking questions, is this truly neuropathic pain, and is this neuropathic pain recently developed, or has it been chronically existing for months or years? If we're thinking more in the months to years timeframe, Gabapentin may not be as effective as other analgesics, potentially for treatment of that neuropathic pain. Also, we should be assessing patient specific risk factors like renal function, heart failure, fall risk, interactions with other medications, particularly those contributing to CNS and sedation and CNS depression. And then, if we truly feel that there is a lack of benefit or the burdens outweighs any benefit, the pharmacist should promote de prescribing of Gabapentin. And so Gabapentin is a medication that has to be tapered. It cannot be abruptly discontinued, so providing a very clear plan on how to reduce the dose over how long of time it will take to get to the lowest effective dose or off of Gabapentin. And then pharmacists also can monitor for any risks for misuse or diversion, particularly in those states where Gabapentin is a controlled substance. So checking prescription drug monitoring programs, assessing fill histories that community pharmacists may have access to, are all really important. So if a patient is prescribed gabapentin, I would say that it would be important to have a good trial to see whether or not it is effective, so anywhere between four to 12 weeks and only to continue it if there is a clear, meaningful patient perceived benefit.

Pharmacy Times: What key takeaways do you hope attendees will walk away with after your presentation at the SPPCP conference?

Fisher: I've talked a lot about maybe why I don't like gabapentin, but my goal isn't to say never use Gabapentin. I really want to encourage attendees to use it more intentionally. So my key takeaways are, is that I want attendees to really recognize the mechanism of action of Gabapentin and how that may not really align with chronic pain biology. I want them to pay attention to the modest efficacy data as we dive into the literature a bit more as oftentimes in clinical practice, we are applying this data to patient populations that the drug wasn't originally studied in the safety concerns that are real, so evidence based, but often under recognized, because it's chalked up to either another medication or an exacerbation of a disease state. Gabapentin should not be a default therapy or a knee jerk reaction, as I mentioned previously. It should be carefully assessed and considered for each individual patient based on their painful conditions, other medications and other comorbidities. And so to wrap everything up, I would say that if you're thinking about starting gabapentin, do so thoughtfully, reassess early and often and really only continue Gabapentin if it's only truly helping the patient with their pain, and really not just assessing pain on a zero to 10 scale of severity, also considering the functional impact. So what is Gabapentin allowing the patient to do, and how does that align with their goals? So to come back to the the title of the presentation that I'll be giving Gabapentin could be well done in select cases, but in many scenarios, it's likely to be overdone.