Chronic pain management in older adults often involves the use of opioids. However, many patients continue to experience significant pain despite opioid therapy, leading clinicians to explore additional medications like gabapentin. This trend has resulted in a decrease in opioid prescriptions but an increase in the concurrent use of gabapentin and opioids over the last years.
The concern
Studies have reported a high proportion of opioid-related overdose deaths involving concurrent gabapentin use. This raises questions about the safety of combining these medications, particularly in older adults who are more vulnerable to adverse effects.
Research insights
At our CLEAR Center, a study [1] evaluated the mortality risk in a very large population of older adults with spine-related pain who were prescribed gabapentin and opioids concurrently. the study compared this combination with the use of antidepressants (tricyclic antidepressants or duloxetine) alongside opioids. Antidepressants are commonly used in chronic pain management, not only for co-existing depression but also for their direct pain-relieving effects (read more here).
The study included 134,266 participants with a median age of 73.4 years, of whom 66.7% were female. During the follow-up period, 2,360 participants died. The analysis revealed no significant difference in mortality between the gabapentin-opioid group and the antidepressant-opioid group (see figure below). However, those treated with gabapentin and opioids were at a slightly increased risk of major medical complications compared to those treated with antidepressants and opioids. This finding could not be explained by this study because it was not its major focus, and warrants further investigation.
Balancing efficacy, risks, and side effects
While gabapentin may not increase the risk of death when used with opioids, its safety profile warrants cautious use and further investigation to fully understand the implications of gabapentin use when added to opioids. Despite the potential benefits of gabapentin in pain management, its use must be carefully weighed against the risk of adverse effects such as sedation, cognitive impairment, and increased risk of falls, especially in elderly and frail individuals (read more here).
[1] Gold LS, Heagerty PJ, Hansen RN, Friedly JL, Johnston SK, Deyo RA, Curatolo M, Turner JA, Rundell SD, Wysham K, Jarvik JG, Suri P. Mortality after concurrent treatment with gabapentin and opioids in older adults with spine diagnoses. Pain 2025;166:e51-e59.
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