Clinician Perspectives on Increased Gabapentinoid Prescribing in Nursing Homes

Abstract

Gabapentinoid use in nursing homes (NHs) is rapidly increasing, though the reasons for this evolving trend remain opaque [1, 2]. To bridge this knowledge gap, we conducted two iterative surveys of NH prescribing clinicians. The first survey focused on why gabapentinoids are prescribed in NHs; the second assessed the magnitude of prescribing for each identified indication. Both explored provider perspectives on factors influencing gabapentinoid increases and barriers to deprescribing [3]. These surveys revealed that gabapentinoids are increasingly applied off-label not only for all neuropathic pain but also for every form of pain. Most clinicians also perceive gabapentinoids as helpful in moderating behavioral and psychological symptoms, and neuropsychiatric treatment goals influence prescribing. Furthermore, clinicians directly linked gabapentinoid gains with opioid and psychotropic reduction policies as gabapentinoids are viewed as reasonable but unmonitored alternatives to these medications [3]. In addition to these structured responses, results also included 111 clinician free-text responses, offering granular insights into gabapentinoid prescribing practices unobtainable by descriptive statistics alone. This qualitative analysis of that free-text response data deepens our understanding of NH prescribers' increasing reliance on gabapentinoids.

In October 2023 and May 2024, we used SurveyMonkey to anonymously survey NH clinicians about their gabapentinoid prescribing practices, exploring the indications for use and the factors driving prevalence gains. The first survey inventoried why gabapentinoids are prescribed in NHs, the second iteratively quantified the relative scope of such prescribing [3]. A multidisciplinary team developed the surveys, grounding them in existing literature and emerging data [4-6]. We employed convenience sampling through crowdsourcing, engaging with NH clinician networks to reach a diverse range of clinicians. Participants had four opportunities to provide open-ended insights to enrich responses. Both surveys included the open-ended question “Is there anything else you feel is important for us to know about your use of gabapentin or the challenges of managing behavioral symptoms related to dementia?” Two additional questions also allowed free responses, “I would use gabapentin less if…,” and “I use pregabalin (Lyrica) less often than gabapentin because….” From these observations, themes were identified through an iterative process of immersive crystallization using codes that emerged during data collection and early immersion/crystallization, with differences reconciled by team consensus [7]. Both survey instruments and additional methodological detail are available as online supplements.

One-hundred-eighty-seven NH clinicians participated in the surveys of which 78 provided 111 free responses. All major geographic regions in the United States were represented by free respondents. About 30% were from rural regions, two-thirds were from middle-income areas, and a quarter was from high-income areas. Clinicians who volunteered free responses were more likely to be physicians and had greater NH experience than those who gave no free responses; otherwise no important differences were detected. The characteristics of the free responders are summarized in Table 1 and reasonably approximate the NH clinician population [8]. Five themes emerged regarding increased gabapentinoid use in NHs where respondents generally agreed. Table 2 outlines exemplar quotes.

Theme 1: Polarized beliefs about safety and efficacy. Clinicians displayed divergent opinions about gabapentinoids. Some viewed them as low-risk and beneficial for various off-label uses; others described significant potential for harm and minimal benefits. Notably, there were no meaningful differences in characteristics between these clinician subgroups.

Theme 2: Influence of opioid and psychotropic reduction policies. Gabapentinoids are appealing as less scrutinized alternatives to opioids and psychotropics since they are not included in federal reporting mandates or quality-measure grading.

Theme 3: Challenges of deprescribing. Gabapentinoids are easily initiated for diverse reasons yet difficult to stop. Once prescribed, clinical inertia tends to prevail, regardless of initial intent.

Theme 4: Payor influences. Many clinicians prefer pregabalin to gabapentin but economic factors, including cost and coverage, limit application. Lack of payor support for non-pharmacologic treatment options also contributes to all psychotropic and pain prescribing, a situation exacerbated by NH staffing deficiencies.

Theme 5: Initiation of gabapentinoids outside NHs. Most gabapentinoids prescribed in NHs are started by non-NH clinicians, linking NH increases to broader prescribing trends. Emerging application for postoperative analgesia was highlighted.

Though limited in scope, this study offers insights into increased NH gabapentinoid use, a subject lacking concrete data. Most NH prescriptions are started in other care settings, underscoring that NH prescribing increases are not siloed but rather engrained in global prescribing trends. To curb NH gabapentinoid increases, deprescribing existing prescriptions must be emphasized as much as limiting new NH prescriptions. Moreover, strategies reducing gabapentinoid use in other settings could positively impact downstream NH prescribing.

Deprescribing is complicated by the “sticky” nature of gabapentinoids, often initiated without clearly defined therapeutic goals or discontinuation criteria [9]. Expanding federal mandates for gradual dose reductions to include gabapentinoids might aid in navigating these difficult decisions. Including gabapentinoids under current regulations for long-stay psychotropics would also discourage their use as substitutes for other medications targeted by reduction measures, promoting accountability [10].

The preference for gabapentin over pregabalin highlights the influence of payors on prescribing practices. Many clinicians preferred pregabalin, yet financial and coverage constraints limited its application. Similar factors limit non-drug therapies, which are time- and labor-intensive. These are essential for reducing medication overuse but lack payor support. Until effective non-pharmacologic solutions become as affordable and accessible as drugs, the over-reliance on potentially harmful medications—and inequity in such prescribing—will persist.

The stark divergence of NH clinician opinions on gabapentinoid safety and efficacy is striking and could affect efforts to moderate NH increases. This underscores the need for regularly updated, consensus-driven policy development considerate of different viewpoints and encourages ongoing research into effective, evidence-based alternatives for managing pain and behavioral symptoms in NH residents.

Drs. Jonathan D. Winter, J. William Kerns, Danya M. Qato, Nicole Brandt, Linda Wastila, Rebecca S. Etz, and Alex H. Krist, as well as Mrs. Katherine M. Winter all significantly contributed to design, acquisition, interpretation, and drafting of this submission while Mrs. Sarah R. Reves, Ms. Eposi Elonge, Ms. Yu-Hua Fu, and Mr. Christopher Winter significantly contributed to design, analysis, drafting, and revision.

The authors declare no conflicts of interest.