Chapter 10: Pain Medicine 2026

Dr Sunil Dasari

Why do this quality improvement project?

Gabapentinoids, Gabapentin and Pregabalin are licensed for the treatment of neuropathic pain and epilepsy. Neuropathic pain⁴ is due to a lesion or disease affecting the somatosensory pathways in the peripheral or central nervous system. It is associated with many neurological diseases like peripheral neuropathy, radiculopathy, spinal cord injury, stroke and multiple sclerosis. Pregabalin is also licensed for treating generalised anxiety disorder. 

Gabapentinoids are sometimes prescribed as an alternative to opioids, but are often co-prescribed with opioids and benzodiazepines, which also have sedative effects. Patients may be prescribed gabapentinoids for a long period without much benefit and without any follow-up. Misuse and illegal diversion of gabapentinoids had led to their ¹ rescheduling as a controlled class C drug,² with advice for prescribers on the risk of misuse³ offered by Public Health England.  After reclassification as controlled drugs, the incidence of gabapentinoid prescribing has started to fall, but the specific impact of reclassification on prescribing rates remains unclear .¹

This QI project aims to ensure safe and effective prescription of Gabapentinoids for appropriate indications, with resulting improvements in safety and reduction in use of inappropriate therapies. 

Best Practice

Gabapentinoids have been shown to be effective for the management of neuropathic pain when used appropriately. As per NICE guidance,⁴ a choice of amitriptyline, duloxetine, gabapentin or pregabalin can be offered as initial treatment for neuropathic pain. If the initial treatment is not effective or is not tolerated, one of the remaining drugs needs to be offered, and consideration given to switching again if the second and third drugs tried are also not effective or not tolerated. If initiated at non-specialist settings, referring to a specialist pain service and/or specialist services should be considered at any stage if they have severe pain or their pain significantly limits their lifestyle, daily activities and sleep.

Patients need to have regular follow-ups for assessment of effectiveness in pain control, impact on functionality and quality of life, including sleep, physical and psychological wellbeing, side effects and continued need for treatment. Caution should be exercised with patients on sedatives like benzodiazepines or opioids,⁵ and also with patients with renal and liver impairment. Adjustments in dose or dosing regimen might be necessary in patients with compromised respiratory function or respiratory disease, with neurological disease, with renal impairment, who are using concomitant central nervous system depressants⁶, or who are older than 65 years. When weaning or switching treatment, take account of dosage of the tapering agent and any withdrawal symptoms. Specialist pain service and/or specialist services should be considered at any stage if the patient has severe pain or their pain significantly limits their lifestyle, daily activities and sleep.

Suggested data to collect

Proportion of patients where indication is appropriate:

• Was a screening tool e.g. LANSS⁷ used to diagnose neuropathic pain?
• Were non-gabapentinoid neuropathic agents tried before starting gabapentinoids?
• Is there a documented discussion about the indication, side effects and weaning.
• Was a patient information leaflet provided or was the patient signposted to resources where the information is available?
• Was the patient on other sedatives such as opioids, or benzodiazepines?
• Was there an initiation plan with a titration approach?
• Was the patient followed up 4-6 weeks after initiation?
• Is there a plan for regular review every 12 months on the effectiveness, side effects and review for need for weaning? 

For patients where weaning is appropriate:

• Proportion where weaning plan in place and discussed with the patient
• Was adequate support provided for weaning?

Quality improvement methodology

A structured approach could be taken such as:

1. Analyse the Current Process: Understand the existing process of initiation, maintenance and weaning using process mapping.  Identify stakeholders and gather baseline data. Use fishbone diagrams to identify the root causes of the problem, e.g., a lack of education, training and updates for health care professionals; time pressure due to lack of sufficient time during consultation to do a proper assessment; lack of resources; or patient pressure to continue a prescription despite lack of clinical benefit?   

2. Define the Problem: Consider utilisation of a Pareto chart, use this to identify the specific area for improvement and its impact.  For example, the problem could be indiscriminate prescription or a lack of follow-up to monitor effectiveness and side effects.                                                                                                       

3. Develop and Test Changes: Generate ideas for improvement.  Consider the co-design process with staff and patient stakeholders. This could be done by developing an ideal process map for initiation, maintenance and weaning and comparing it to the current practice.

Test interventions using PDSA cycles-Plan Do Study Act and refine them based on results.  Ideas for PDSA include: 

• Initiation:

Assessment: Improving documentation of biopsychosocial assessment by using a formal tool, e.g. LANSS, to confirm neuropathic pain

Patient education: Using templates for documentation of indication and side effects, discussion with the patient, trial period, dose, and agreed outcomes. 

Formalisation: Who reviews the patient after the trial period. Introduction of a formal plan for weaning after the trial period (if not effective or causes more harm than benefit). 

• Maintenance: 

Formalising local policies to identify: time period for follow-up; who does the review and is it at primary care or at secondary care level; whether the indication is still relevant; whether there is a plan for checking any sustained improvement in pain and functionality; whether side effects are within tolerable levels; if there is identification of patients who need pain specialist input if followed up at a non-specialist setting; and if initiation of weaning is needed.

• Weaning: 

Policies for documenting and agreement for weaning, speed of weaning; provision of support for weaning, monitoring and managing symptoms related to weaning.

4. Implement Changes: Test implementation, including using stakeholder interviews and scale changes on a wider scale.  Check balancing measures, such as impact on time/capacity to see patients.  Consider using patient experience and safety data to monitor their impact. 

5. Sustain Improvements: Ongoing monitoring and process adjustments. 

References

1.Ashworth J, Bajpai R, Muller S et al. Trends in gabapentinoids prescribing in UK primary care using the Clinical Practice Research Datalink: an observational study. The Lancet Regional Health - Europe. 2023;27

https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(22)00275-

2.https://www.gov.uk/government/publications/circular-0192018-control-of-pregabalin-and-gabapentin-under-the-misuse-of-drugs-act-1971/control-of-pregabalin-and-gabapentin-under-the-misuse-of-drugs-act-1971

3.https://www.gov.uk/government/publications/pregabalin-and-gabapentin-ad…

4.Magrinelli F, Zanette G, Tamburin Neuropathic pain: diagnosis and treatment Practical Neurology 2013;13:292-307.

5.https://www.nice.org.uk/guidance/cg173/chapter/Recommendations#treatment

6.https://www.gov.uk/drug-safety-update/pregabalin-lyrica-reports-of-severerespiratory-depression.

7.Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain. 2001 May;92(1-2):147-57.