Long-stay gabapentin increases explained: A national nursing home clinician survey on prescribing intent

Context: Much conjecture but little hard data exists to explain why gabapentin prescribing in nursing homes (NHs) has doubled in the last decade. Gabapentin, an anti-seizure medication, is approved to treat partial seizures as well as post-herpetic neuralgia. While details on prescribing intent are lacking, gabapentin is believed to be used primarily off-label. Since the long-stay use of anti-seizure medications like gabapentin are not reported to CMS by federal mandate, many aspects of such prescribing in NHs remains opaque relative to other monitored psychotropics.

Objectives: This NH clinician survey sought to clarify indications for gabapentin use and also the factors spurring prescribing gains in NHs.

Study Design: National online survey: distributed via anonymous email using SurveyMonkey (09/15/2023-12/31/2023). Recruitment sought maximal participation by 1) directly contacting a 10% sample of 1493 NHs randomized by size, ownership, and region; 2) leveraging collaborations with NH clinician organizations; and 3) modified-Dillman methods to facilitate engagement. A multidisciplinary team developed the instrument with content informed by pilot data, existing literature.

Population: US NH clinicians who prescribe psychotropic drugs, including physicians and APPs.

Results: 131 surveys completed (~5% response rate).

Participants: 71% White, 52% female, 72% physicians. Almost all gabapentin use in NHs was off-label. While most prescribing was for neuropathic – and increasingly all – pain, gabapentin also was used for psychiatric symptoms and behaviors.

Prescribing was influenced by opiate and also antipsychotic, and anxiolytic reduction policies because gabapentin was perceived as an unmonitored and safer alternative to these medications. Only a fraction of long-stay gabapentin prescriptions were initiated in NHs; long-stay prevalence was influenced by increasing popularity in other care locations.

Conclusion: Off-label use for all forms of pain is a key driver of NH gabapentin increases, and closely tied to opiate reduction policies. Also highlighted is the less recognized significance of long-stay prescribing for psychiatric symptoms, and the similarly meaningful contribution of antipsychotic, anxiolytic, and other psychotropic reduction initiatives. Prescribers commonly perceive gabapentin as effective, safe, and safer than the drugs it is replacing. Whether this is true remains unclear; the risks of gabapentin use in NHs are largely unknown.