Gabapentin & Your Brain Health

hey there good evening welcome back to i care for your brain with neuropsychologist dr karen sullivan that is me i am here because i truly care for your brain we started this about five years ago july 24th will be our fifth year anniversary of offering free evidence-based brain health lectures to you the brain health community on facebook we are about 200 followers shy of meeting our 10 000 follower mark so if you've liked the page before or maybe if you haven't liked it or followed it you could give us a follow and help us reach that goal that's going to be very very exciting this week's topic is gabapentin you might also know it by the name neurontin i picked this topic because this medication has been on my radar for maybe about a year or so i started to have patients who were complaining to me that at higher doses they were having some cognitive symptoms so what i mean by that is they were concerned that they were feeling foggy that they couldn't pay attention and some even saying that they thought their memory was being impaired so i started looking into it in depth and by the time i'm into doing a research project uh you know by at least a couple hours i then think you know what i should put this into a powerpoint and share it with our people on facebook so tonight you're gonna learn a lot of what i learned about gabapentin i'll tell you in advance there's not a lot of very strict hard and fast rules in my recommendations we're still learning a lot but i certainly think there are things that you should know to be a more empowered and educated consumer of this medication so it was actually discovered in japan in the 1970s and the way they first considered this compound was as something that would help people have relaxation of their muscles and would prevent spasms it then gets bought by a major american pharmaceutical company and in 1993 it first gets fda approved to help with partial seizure control so there are many different subtypes of epilepsy and seizures and so partial seizures are one type and then in 2003 it gets its second fda approval for nerve pain and so now generally it's considered to be an anti-convulsant and something to help calm nerve pain specifically the doses can range quite a bit all the way from 100 milligrams a day all the way up to 3600 and more per day one of the things i found to be fascinating about gabapentin is they actually don't have a super clear idea of how it works and they actually think it works really differently in different people but the mechanism of action so to speak how does it work is typically thought to be related to something called gaba a chemical in the brain called gaba so it increases gaba which has an inhibitory effect which helps cells fire less kind of calms brain cells down but it also uh reduces so it increases gaba it reduces several other neurotransmitters specifically calcium in the brain and something called substance p so what these things do is they reduce the excitability of a brain cell of a neuron when brain cells are firing too much this is when we can get seizures or this also contributes to the experience of pain so it is reducing the firing of certain brain cells in the brain so even though you may still have you know an injury to your hand the pain is perceived in your brain and we are able to calm specific nerves in the brain that will help reduce the experience of pain it basically you can kind of think of it it's like a calming drug for brain cells it takes an average dose of 300 milligrams about two to three hours to reach its peak effectiveness in a person and it stays in your system for between five and seven hours the most common side effects are fatigue unsteadiness and dizziness which is something that really was on my mind when i figured out that it is being recommended for people with tremor disorders movement disorders i kind of thought huh without being some of the highest side effects you know are we helping more than we're hurting so it is wildly popular this is why it was on my radar screen the prescribing in the us of gabapentin from 2012 to 2016. shot up by 64 that is really really high as of 2020 gabapentin was the sixth most commonly prescribed medication in the us and the uk with almost 400 million prescriptions from 2004 to 2018. that is really high here's where things got really interesting in my research over 95 percent of the prescriptions for gabapentin today are considered to be off-label usage meaning it's not for seizures and it's not for pain control the main reason for this is really due to the medical community's resistance to want to prescribe two other classes of medications think about it in the last few years people have gotten very aware of the dangers of opioids uh so the oxycontins of the world but also benzodiazepines things like xanax and klonopin doctors don't want to over prescribe those there are not only ethical considerations and issues of it really not being great for your patient very easily addicting drugs but also there's a lot of liability there's a lot of monitoring that happens around doctors prescribing those two classes of medications an opioid or a benzo so here comes gabapentin kind of considered to be wow there's this new safe medication but that is really being questioned not that it's been proven that it's unsafe by any means but more and more doctors are saying how can this one drug be a balm for so many ailments how is it that there are so many conditions that would benefit from this one compound so let me just go through and tell you this is like the top 15 reasons people get prescribed gabapentin so first we have anxiety social anxiety in particular alcohol withdrawal hot flashes itchy skin attention deficit disorder migraines bipolar disorder post traumatic stress disorder obsessive compulsive disorder low back pain sciatica insomnia irritable bowel syndrome overactive bladder restless leg syndrome hiccups and chronic cough how wildly different are all of these different things so there is very little evidence to support that it is effective in any of those populations and if it was we would see fda approval with those things because they would have the standard of evidence the volume of evidence to go in and get it fda approved which is what a pharmaceutical company would love to do so this is kind of the concerning like huh you start to feel like okay what has been behind the amazing amount of over prescribing and yes maybe it is all just that doctors needed an alternative but there's also some really interesting research that maybe what gabapentin does really is has ties to all these different disorders because of its calming properties because of its ability to reduce hyperexcitability in brain cells when you are calming parts of the nervous system we can't select for it to specifically treat hiccups we can't select for it to specifically reduce nerve pain what you're going to get is a general calming of the nervous system and the idea is that maybe hyper excitability of the nervous system is a common thread amongst all of those other disorders so there's a really interesting debate going on in the literature right now that's kind of like wow is this kind of a wonder drug or is it really just that it's been over prescribed and it can't possibly be a something that is going to soothe and help manage all these wildly different disorders so that's a question that's not been answered yet but it's definitely in the literature uh quite a few of you wrote me questions on my facebook page asking about this drug which i absolutely love and at the end i'm going to try to get to a good number of those um but one of the things i really wasn't aware of until you all informed me which i love is how often it's used in essential tremor and i know i have a lot of my et people out there and so i wanted to tell you about a 2020 study that is kind of like as good as it gets when it comes to gabapentin and essential tremor so basically this is a double-blind placebo-controlled study crossover design it's like ideal okay so what they did is they had um 25 people which not great had them at two different doses eighteen hundred a day milligrams and thirty six hundred a day they also had them stay on their other e.t medicine so these are people who could have also been taking clonazepam these are also people who could have been taking propranolol so it is a little dirty there and only 20 of the people pardon me 20 of the 25 people in the study continued it so we have data on 20. so what they found is that their observed tremor scores decreased when they were taking the gabapentin they got better at pouring water and their activities of daily living scores significantly improved okay but what didn't get better was their spirograph so when they drew the spiral um how shaky it was um they didn't get better at walking anymore um and so what they basically said was gabapentin may be effective in some people who have et so not very satisfying not very insightful we certainly need higher numbers in future studies but i think one thing i've learned from doing this research is how individual responses are to gabapentin and i'm going to encourage you as always to be a really good communicator and advocate to your brain health provider whether you have a good or bad experience with gabapentin because it really depends on quite a few variables so i grew to understand that the very thing that's good about gabapentin might be the thing that's problematic so basically this global effect on the central nervous system as i was saying before we can't pick and choose within the nervous system the brain you know what parts get calmed and what parts get excited right uh excitable drugs would be something like a stimulant like ritalin or some antidepressants things like wellbutrin or effexor these things we know in general in the whole central nervous system elevate excite activate this is a compound that calms inhibits soothes okay so what's what's hard about that is you're going to have some cognitive consequences when that happens so we know a lot about this from looking at pain medications in general or really even anti-seizure medications in general because at the end of the day gabapentin is an anticonvulsant that's really its primary property prevents brain cells from tipping over into a seizure state we want the positive properties of gabapentin but we also know that when we inhibit brain cells too much we can get slowed reaction time slowed processing speed we can have trouble multitasking and we can have trouble with memory and sure enough those are the very things that when you find literature scientific high quality literature on gabapentin what it's really saying is that there may be some effects and they're more likely mild so that sticks in my craw for two reasons one is what might be mild in a scientific study might not be mild to you uh being absent-minded being forgetful having trouble multitasking that could actually be catastrophic to you so that gets a little weird um the other thing is that on google okay i saw a ton of postings from people who take avapenton who said it really hurt them cognitively but when you go to the actual scientific literature pubmed google scholar all of these different research journals that i search to get my information it's really a different picture so what that tells me is there's a lot of patient complaints and not so much verification of that in the scientific literature why that is i'm not quite sure um but what i know about is gabapentin is always written about as though what's so good about it is it's better than what came before it so in seizures the first generation of seizure medications were really hard on people people definitely had cognitive symptoms they definitely struggled they had seizure control better seizure control but they certainly struggled cognitively so gabapentin is a second generation seizure medication and it is very much more human friendly than the ones that came before it okay so we think that it has at least 26 to 50 percent uh less side effects than something like tegritol or carbamazepine these old-school seizure medications but that still doesn't mean that it's cognitive risk-free now so that's kind of what i kept coming up against is well hey it's better than what we had before okay but that doesn't necessarily matter to the person who's taking it now i also mentioned to you that gabapentin is fda approved for nerve pain so i wanted to look into that group and that once you start to look into chronic pain folks man your populations just explode so you've got all sorts of reasons people have nerve pain so one of the things i looked into was people who have spinal cord injuries often have nerve pain because of the accident or the injury that caused the spinal cord injury and what they said is that gabapentin did negatively affect cognitive function but typically just within the first week okay so that was interesting so is it just something you need to get used to um it did look like it did a decent job with pain so they reported a 13 decrease and i know that might not sound like a lot but pain is extremely complex and notoriously hard to control pain is a very subjective thing it's very hard to communicate to a doctor how you're feeling when you're in pain and i think that's part of the disconnect nobody knows until they walk a mile in our shoes what it feels like to be with our chronic pain and so when doctors are prescribing you kind of have a communication system that just isn't going to work because you're relying on human language right so many times people who take gabapentin are also taking things like tramadol things like oxycodone even morphine and this is really a problem when you're actually trying to understand gabapentin and isolation many of the research studies i looked at always had people taking other medications so that complicates it quite a bit it seemed that nerve pain patients reported drowsiness as a very common side effect and it was much more typical once you reach 2400 milligrams for whatever that's worth um the kidneys do almost all the excreting of gabapentin so this raises my concerns about folks over the age of 65 who are at much more higher risk for things like kidney function issues and in general their brains the the quality of their blood brain barrier is less as we get older that's kind of the wear and tear of the human brain over time so we want to be especially careful of our older folks when they're taking gabapentin we also for all our motivation to get away from opioids what i'm definitely seeing in this research i did was that more and more we're understanding that gabapentin can be misused and abused this happens in about 15 of people most often these folks have a past history of substance use or are also using opioids as they're using the gabapentin so this became a concern to law enforcement because actually as they were going through autopsies more and more in toxicology reports they were saying gabapentin was listed as one of the things that went along with the accidental overdose there's a clear relationship between inpatient stays for people drug related stays emergency room use and increased levels of gabapentin so the higher dose you take the more likely you are when combined with other drugs that depress your breathing to have an accidental overdose and i think that that's really important in quite a few guidelines they suggest being very cautious if at all ever combining opioids and gabapentin so that's important nowadays the fda has required manufacturers to put new warnings on gabapentin including that it can cause respiratory distress i'm going to talk about lyrica in a second which is kind of the sister drug of gabapentin it's now considered a schedule 5 controlled substance in the us and gabapentin and pregabalin or lyrica have been class reclassified as class c drugs in the uk as of 2019 following an increase in the use of death and overuse reports so what is pregabalin we call it lyrica here in the u.s there is a little bit of a difference between the two uh lyrica is absorbed much quicker and starts working a lot faster it reaches peak concentrations within an hour whereas i said before gabapentin is like three to four hours um and there's some evidence that lyrica might be a little bit more addictive because of these properties the big difference in terms of abuse is that about 15 percent of people using lyrica report euphoria so it's a drug that comes on fast it leaves relatively fast and some people are getting high from it so that's the definition of something that's going to be addictive both lyrica and gabapentin have withdrawal symptoms if you go off of them too quick more memory symptoms are reported in the literature with lyrica with pre-gabilan okay so there's been reports of issues with memory for both verbal and visual information so things you've seen and for things that people have told you but the the lyrica cognitive issues are reported to be temporary under titration so as we go up that's when we seem to see the issue when we're increasing doses okay and the the really bad problems with lyrica also come along with the opioid co-combining so if you're taking it on your own you have less to worry about than if you're taking it together so again this is a complicated question it's not as easy as well i'm going to tell you don't take gabapentin or hey have a free-for-all you have to remember the issue the medical conditions we're wanting to treat with these drugs also have cognitive symptoms so chronic pain in addition to making you feel awful provides a very significant internal distraction that can divide our attention and as human beings we are no good at doing two things at one time we like to think we are but both things suffer i also told you before when you inhibit the brain cells in the central nervous system things slow down and this can reduce processing speed to the point where you can't remember because you weren't fully present when something was said and this can happen just with pain so we want to remember sometimes we are choosing between the lesser of two evils this is why we need skilled doctors to work as our partners because it's sometimes not a black or white decision it can be very very um gray okay so we want to be um cautious we want to be good communicators i want you to talk to your doctors if you feel like you're experiencing anything out of the ordinary with this drug do not abruptly stop um if you are taking an opioid you need to be extra careful if you're over the age of 65 i want you to be extra careful i want you to remember that this is all running through the kidney so you want to make sure hydration is at the top of your priority list if you're taking these drugs for any reason at all what i'm going to do right now is go through some specific questions that you asked me i can't get to them all obviously and if i don't answer your question please don't think it wasn't a good question it either means i just can only do so many i didn't find a lot about it when i went doing my research i got a couple questions about weight gain this is the thing with gabapentin the research says it happens at the higher doses but because this drug affects people in so many unique ways it's actually kind of a hard question to answer so there was one study in 1997 that looked at body weight in 44 patients who were treated with gabapentin over a year and what they found and these people were gabapentin over three thousand milligrams a day ten percent of the people gained more than ten percent of their baseline body weight fifteen percent gained five to ten percent of baseline body weight sixteen percent had no change and three percent lost five to ten percent of their body weight so it's kind of a crap shoot but i know from seeing patients when they only add gabapentin there's definitely a group that can gain weight and put on fluid in a pretty short amount of time so that would be something that you should talk to with your doctor the research suggests that between the second and third months of taking gabapentin is when the weight tends to come on and they feel like it stabilizes after six to nine months and i'm not sure that would be tolerable to many of you the next question is related to brain fog now this is where i found a lot on google in chat rooms in people's complaints but not so much in the scientific literature clinically this is a fascinating concept to me part of the problem with brain fog is we're not saying the same thing when i say it versus when you say it right we don't even have a definition for doctors to understand what this means it can mean cognitive complaints it can mean i can't cope with multiple inputs it can mean my thinking is in mud we need a better definition of what brain fog is if you can articulate that and put that in a post here that would be very helpful for me i think of it sometimes like kind of thinking through cobwebs that it is just a feeling of being fuzzy of having a hard time focusing and that is going to give you downstream cognitive effects like trouble with memory you can't be foggy headed and be focused you can't be fuzzy in your thinking and be able to pay attention and attention is the gateway as you all know if you follow me to things like memory and decision making you have to have good attention on the front end the best i can say is listen to your body listen to your brain be neutral about what you expect when you take these drugs we've talked about the placebo effect and the no sibo effect if you expect negative things from a drug you're really you're scientifically increasing the chances that you're going to have a negative reaction so try to be neutral and really work on being a good communicator someone asked me is gabapentin the only drug to treat nerve pain and the answer is no many anti-seizure medications are used to calm the nervous system some older antidepressants called tricyclic antidepressants opioids but what they really prefer nowadays where pain control is really going is things like topical gels things like cortisone shots things like lidocaine gel patches that don't get into the central nervous system as much as a pill that you directly put into your body that can cross over into the brain someone also asked about it for stroke recovery and provided me with a wonderful link which i so appreciated so first thing i noticed about this link is it's a media site that was summarizing a scientific article that was in a very well respected journal called brain i believe it's out of the uk the first thing i wanted to do was go to the original source at the very end of any media report they should write this came from the journal brain it's the first thing i want you all to start getting in the habit of doing go to the original source media often spin to get the the sensational headline okay when i went to go get the original article after about 20 minutes of signing up for this and that i basically realized i had hit a paywall and if i wanted to read the study i had to pay 52 now i don't have much to say about this because it's uk i think but this really bothers me in america with the vast majority of scientific studies are paid for by taxpayers that we don't have access to scientific journal articles that's a real disservice to the public that's part of why i'm here is we need more bridges from the world of academic science to the public that's a real real problem in public health in the united states at least but i did find the abstract and so this is a very recent study from may 2022 and it was a mouse model which is interesting and insightful not quite done on humans but i have to say i was impressed it really gave some good arguments that gabapentin may increase neuroplasticity what they found in the mouse was that they had more connections between brain cells when they were on the gabapentin they had better integration from spinal cord circuits going up to the brain connected to four limb muscles and the most important thing is that they saw an improvement in function you can tell me about an improvement at the structural level of the brain until you're blue in the face i start to care when you tell me people or animals got better because there's not a direct relationship in the brain between structure and function what happens at the level of the brain doesn't necessarily translate over into people getting better or feeling any different so what they found was that these little mice were able to recover the use of their little front paws better with gabapentin than without so i think that is hopeful hopeful i can't wait to read more about it another one of your questions was long-term use so about 20 percent of people put on gabapentin never get off of it it becomes a long-term thing and again this is because it's considered to be the lesser of two evils but again there's been a lot of studies that doctors need to monitor the use of gabapentin more so for example there's some work following older adults who are in the hospital and they got put on gabapentin because you know after a joint replacement or something we need to follow these people very closely and make sure that they don't just stay on the medication because no one is providing oversight that they're still on it this is why i recommend that at least once a year you do schedule a medication review with your primary care doctor and you bring in everything supplements vitamins prescriptions everything goes in front of them and there should be a discussion is there still a benefit that exceeds the risk of taking this medication that is very basic good patient care that you can provide to yourself okay i hope that you found this discussion to be interesting i certainly think it's worthy of your attention like i said before if you would give us a follow here on our icare for your brand page we would be so grateful i hope that you will share this far and wide on facebook i think there's a lot of folks out there who take this medication who have questions and i hope this was just the beginning of a conversation with you and your medical provider to get the answers that you specifically need so thank you all so much let me know what you think in the comments and i'll see you sometime soon bye

Channel: I CARE FOR YOUR BRAIN with DR. SULLIVAN

Views: 1,511,330

Keywords: i care for your brain, neuropsychology, dr karen d sullivan, gabapentin, brain, brain health

Id: acEZNSabrgY

Length: 29min 3sec (1743 seconds)

Published: Thu Jun 02 2022