Abuse, Diversion, and Mortality: How Gabapentinoids Entered the Illicit Drug Market

Introduction

Gabapentin was never expected to end up here, in toxicology reports, overdose surveillance dashboards, and European drug mortality registries. When it was introduced in the 1990s as an anticonvulsant, and later repurposed for neuropathic pain, gabapentin carried the comforting aura of a medication that was safe, non-addictive, and uninteresting to the drug market. Yet the landscape of addiction, chronic pain, and illicit drug use has changed dramatically, and gabapentinoids (gabapentin and pregabalin) have changed with it. What began as a pharmacologically modest, relatively low-risk medication now occupies a very different role in 2025. Data collected over the past decade reveal a troubling and unmistakable trend. Among people with opioid dependence, gabapentin misuse rates have risen to 15–22%, a stark contrast to the single-digit prevalence in the general population. In the United States, the Centers for Disease Control and Prevention report that gabapentin appears in roughly 10% of fatal overdose toxicology screens, often alongside opioids, benzodiazepines, alcohol, or fentanyl. Across Europe, the European Drug Report 2025 notes a steady increase in deaths involving gabapentinoids. In Finland alone, 87 fatalities in 2023 involved gabapentin or pregabalin. In the United Kingdom, especially Scotland’s Tayside region, up to 40% of drug-related deaths show gabapentinoids on toxicology reports. This is enough to prompt formal prescribing warnings to physicians.

These numbers do not suggest gabapentin kills on its own. Instead, they show how a once-benign prescription drug has migrated into the illicit market, where it is used to potentiate opioids, intensify intoxication, or self-manage withdrawal symptoms. This article examines how gabapentinoids entered this space, why they have become such a common feature of overdose deaths, and what clinicians must do to recognize diversion, unsafe behavior, and prescription patterns that contribute to harm.

The Scale of Abuse: What the New Data Shows

The last ten years have produced a steady body of evidence indicating that gabapentinoid misuse is no longer a marginal phenomenon but a firmly established pattern within populations affected by opioid use disorder (OUD). Updated reviews from addiction medicine and toxicology researchers consistently show that among people with OUD, 15–22% report misusing gabapentin: a prevalence dramatically higher than the low single-digit percentages seen in the general population. These figures come from treatment programs, street-level ethnographic reports, prison healthcare services, and postmortem toxicology audits, all pointing to the same conclusion: gabapentinoids have become embedded within the opioid-using ecosystem.

The expansion of misuse is closely tied to the opioid crisis itself. As fentanyl supplanted heroin in many markets and patients cycled repeatedly through withdrawal and relapse, gabapentin emerged as an inexpensive and accessible adjunct that could soften withdrawal symptoms, amplify opioid effects, or provide a sedative, dissociative escape when other drugs were unavailable. In multiple surveys, individuals with OUD describe gabapentin as offering a “benzo-like” feeling — not identical to benzodiazepines but reminiscent enough to be attractive.

For some, it becomes a cheap way to stretch the perceived high from fentanyl; for others, it helps reduce symptoms of restlessness, anxiety, or insomnia during withdrawal, making it functionally valuable in the absence of formal treatment.

Since gabapentin is prescribed so widely for chronic pain, anxiety, and sleep problems, diversion is easy. Many people first encounter the drug through legitimate prescriptions, particularly for back pain or neuropathic symptoms, and then begin experimenting with higher doses. The transition from therapeutic use to misuse often looks subtle at first: early refills, dose escalation beyond what was prescribed, or “borrowing” pills from friends or relatives who have unused supply. As tolerance develops, especially at high doses, cravings can intensify, leading individuals to seek multiple prescribers or obtain pills through informal or illicit channels.

Pregabalin, while not the focus of this article, plays a parallel role and is often misused interchangeably with gabapentin in many communities. Addiction specialists note that pregabalin has higher abuse liability due to its faster onset and more pronounced psychoactive effects. However, gabapentin remains more visible in overdose surveillance due to its vastly higher prescribing volume and availability, particularly in the United States and the UK, where prescriptions number in the tens of millions annually. Importantly, this rise in misuse is not limited to individuals with severe opioid dependence. In some settings, particularly rural areas with high prescription drug availability, gabapentin misuse has been documented among people with mild substance use histories or those seeking inexpensive sedatives. The drug’s low cost, perceived safety, and unscheduled status in many regions create an ideal environment for experimentation and diversion.

Taken together, the new data illustrate a shifting reality: gabapentinoids have become deeply integrated into contemporary patterns of drug misuse. Their role is not random or incidental but structurally linked to opioid supply, withdrawal cycles, and the widespread assumption that gabapentin is a “safe” alternative with minimal oversight. This assumption is no longer tenable.

Why People With OUD Misuse Gabapentinoids

Gabapentinoid misuse among people with opioid use disorder (OUD) is not accidental. It reflects a combination of pharmacological synergy, economic accessibility, and the shifting nature of the drug market. To understand why gabapentin and pregabalin have become so embedded in OUD communities, it is essential to look at the specific functions these medications serve.

The most significant driver is opioid potentiation. Users consistently report that combining gabapentin with heroin or fentanyl produces a more dissociative, longer-lasting, and smoother high. On their own, gabapentinoids rarely cause euphoria, but when layered onto opioids, they can intensify sedation, emotional blunting, and intoxication. In an era dominated by fentanyl, a drug with a short duration and steep withdrawal curve — the ability to “stretch” or enhance the high is especially attractive. For people with limited resources, gabapentin functions as a cheap “booster,” reducing the amount of opioid needed to feel the desired effect. Gabapentinoids also play a role in self-managed withdrawal. Harm-reduction workers and clinicians frequently observe individuals using high-dose gabapentin to dampen withdrawal symptoms such as anxiety, agitation, insomnia, and restlessness. For many people unable to access methadone or buprenorphine, gabapentin becomes a do-it-yourself substitute for professional treatment. This pattern often leads to rapid dose escalation and unpredictable intoxication, but it meets a real need in populations with limited access to care.

A major contributor to misuse is gabapentin’s reputation as a “safe” or “legal” drug. In many regions, it is unscheduled or lightly regulated, fueling the misconception that it lacks abuse potential. Users describe feeling more comfortable misusing a prescription medication than counterfeit benzodiazepines or stolen opioids. The absence of stigma lowers barriers to experimentation, and high prescribing rates create easy access: unused pills, expired supplies, and shared prescriptions all feed the informal market.

Economic forces also shape the pattern. Gabapentin is inexpensive, far cheaper than diverted alprazolam or oxycodone, and often widely available in low-income communities. This makes it particularly appealing in prison systems, shelters, and neighborhoods where illicit drug markets operate under financial pressure.

Finally, tolerance develops surprisingly fast. Within weeks, some users escalate from therapeutic doses (300–900 mg/day) to massive amounts, such as 3,000 mg, 6,000 mg, or more. At these levels, gabapentin produces sedation, dizziness, and dissociation, effects more reminiscent of benzodiazepines than of a sleep aid or anticonvulsant. But because the drug still retains its “prescription” identity, many people underestimate its risk.

These overlapping motivations (potentiation, withdrawal relief, affordability, legal status, and rapid tolerance) explain why gabapentinoids have become woven into the daily survival strategies of many people with OUD. Their perceived safety is precisely what makes them dangerous.

Diversion: How Legitimate Prescriptions Enter the Illicit Market

The rise of gabapentinoid misuse cannot be separated from the issue of diversion, the leakage of legitimate prescriptions into illicit channels. Unlike opioids and benzodiazepines, which face strict regulatory controls in many regions, gabapentin has historically been loosely monitored, making it exceptionally easy to obtain, stockpile, and redistribute. This low barrier to access has created a parallel supply chain that feeds the demand in opioid-using communities.

A major structural issue is the sheer volume of prescribing. In the U.S. alone, tens of millions of gabapentin prescriptions are dispensed each year, largely for chronic pain, anxiety, and sleep-related complaints. Many of these prescriptions are written with limited follow-up, renewed without in-person visits, or continued long after patients stop experiencing benefit. This surplus of tablets – “leftovers” sitting in medicine cabinets, half-used bottles, or automatic pharmacy refills – becomes the foundation of diversion. Patients sell, trade, or give away unused gabapentin without perceiving themselves as contributing to harm, because the drug lacks the stigma associated with opioids.

Another significant source of diversion is doctor shopping and fragmented care. Patients experiencing escalating tolerance or withdrawal may seek prescriptions from multiple providers. Pain practices, urgent care centers, psychiatric clinics, and primary care all prescribe gabapentin, often without communicating with each other. In states where gabapentin is not classified as a controlled substance, Prescription Drug Monitoring Programs (PDMPs) may not track it, allowing individuals to accumulate large quantities without triggering alerts. This creates an ideal environment for covert overacquisition and redistribution.

Illicit markets exploit these vulnerabilities. Reports from addiction medicine and law enforcement indicate that gabapentin has become a regular commodity in prison drug economies, where it is crushed and snorted or combined with methadone or buprenorphine to intensify intoxication. On the outside, gabapentin is frequently traded on social media platforms, informal neighborhood networks, and cash-only “pill exchanges,” valued for being cheap, abundant, and perceived as low-risk. Pregabalin, with its stronger psychoactive profile, circulates similarly but commands a higher street price. Digital infrastructure has also accelerated diversion. Unregulated online pharmacies and gray-market resellers offer bulk gabapentin with minimal verification, enabling individuals to purchase quantities far higher than therapeutic norms. Packages shipped from overseas or compounding suppliers can bypass conventional pharmacy oversight entirely.

Underlying all of this is a cultural misconception: many people, including some clinicians, continue to view gabapentinoids as harmless. This perception lowers the guard against diversion. Patients may not recognize that selling or sharing gabapentin can contribute to overdose deaths; clinicians may underestimate the risks of prescribing large, repeated quantities without follow-up.

Diversion of gabapentinoids is not simply a side effect of their therapeutic use, it is a structural outcome of high-volume prescribing, weak regulation, and a drug identity rooted in the myth of safety. Addressing it requires acknowledging how easily legitimate pathways feed illicit demand.

Mortality: The Hard Numbers Behind the Trend

When examining gabapentinoids in the context of public health, no data point is more sobering than their growing presence in fatal overdose toxicology reports. Ten years ago, gabapentin rarely appeared in forensic databases. Today, it is a routine analyte in many regions because it shows up so consistently in drug-related deaths. The rise is not subtle. It is a defining feature of the evolving overdose crisis.

In the United States, the CDC reports that gabapentin is detected in approximately 10% of analyzed overdose deaths, a proportion that has steadily climbed in parallel with fentanyl saturation of the illicit market. Importantly, gabapentin almost never acts alone. Instead, it functions as a multiplier in polydrug fatalities: opioids + gabapentin; opioids + benzos + gabapentin; fentanyl + alcohol + gabapentin. Toxicologists emphasize that gabapentin’s presence is often the factor that turns a “near miss” into a fatality by further suppressing respiratory drive that opioids have already weakened.

Gabapentin’s pharmacologic role in mortality is subtle but powerful. It does not directly stop breathing in therapeutic doses. What it does is blunt the brainstem response to rising CO₂, reduce arousal, and impair airway protective reflexes. Combined with potent opioids, especially fentanyl analogues, this suppression becomes lethal. During sleep, when natural respiratory variability increases and arousal thresholds rise, the effect is even more dangerous. Many fatal cases document a simple, tragic pattern: a person lies down after using opioids and gabapentin together and never wakes up. International data mirror this trend. The European Drug Report 2025 notes a continent-wide rise in deaths involving gabapentinoids, with key hotspots in the United Kingdom, Finland, and parts of Scandinavia. Finland, for example, recorded 87 deaths in 2023 where pregabalin or gabapentin was implicated – a staggering figure for a country of its size. Investigators highlight a recurring pattern: polydrug use involving buprenorphine, illicit benzodiazepines, alcohol, and gabapentinoids.

The situation in the United Kingdom is even more dramatic. In some regions, particularly Tayside, Scotland, up to 40% of drug-related deaths involve gabapentinoids. These are not isolated events but sustained patterns documented over multiple years. Public health officials have explicitly warned clinicians to reassess prescribing, noting that gabapentin and pregabalin often serve as inexpensive, easily obtainable sedatives in communities already overwhelmed by opioid use. In many cases, gabapentinoids are not detected because of curiosity, they are detected because coroners learned to expect them.

What makes mortality analysis challenging is that many people assume gabapentin’s lack of direct euphoria means it cannot be dangerous. But toxicity patterns reveal a different picture. Gabapentinoids dramatically increase overdose lethality when combined with opioids, particularly fentanyl. They prolong sedation, suppress compensatory breathing, and reduce the chances of spontaneous recovery. Some coroners describe them as “silent contributors” — the agent that tips already dangerous intoxication into fatal territory.

Even the absence of malicious intent does not lessen the danger. Many users take gabapentin not to get high but to manage withdrawal, sleep, or anxiety. Yet the physiologic interaction remains the same: when opioids are present, gabapentinoids increase the risk of dying.

The hard numbers across multiple countries point to a clear conclusion: gabapentinoids are no longer peripheral in overdose epidemiology. They have become central players in the modern polydrug landscape, a role that demands urgent clinical and policy attention.

Public Health and Policy Responses in 2024–2025

As mortality data mount and diversion accelerates, public health agencies on both sides of the Atlantic have shifted from passive observation to active intervention. The years 2024–2025 mark a turning point in how gabapentinoids are regulated and monitored. What was once considered a benign drug class has now become a focal point of overdose-prevention policy, addiction-medicine guidelines, and prescribing regulation.

In the United States, policy changes have emerged primarily at the state level. Since gabapentin is not federally scheduled as a controlled substance, individual states have taken action by placing it under Schedule V or requiring mandatory reporting to Prescription Drug Monitoring Programs (PDMPs). By 2024, over a dozen states, including Kentucky, Tennessee, Alabama, and Michigan, had integrated gabapentin into PDMP tracking systems. This allows clinicians to detect multiple prescribers, overlapping fills, or unusually high quantities that may indicate diversion or escalating misuse. Some states have also issued prescriber advisories reminding clinicians that gabapentin is now implicated in a meaningful share of overdose deaths and should be treated with caution when combined with CNS depressants.

In Europe, responses have been more unified. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has explicitly flagged pregabalin and gabapentin as “emerging contributors” to overdose mortality. Several countries, such as the UK, Ireland, Finland, Sweden, have implemented tighter controls, ranging from reclassifying gabapentinoids as controlled substances to restricting high-dose prescriptions. The UK’s advisory boards have gone further, recommending that clinicians reassess ongoing gabapentinoid therapy every 3–6 months, especially in patients with polysubstance use or OUD. Some regions of Scotland, overwhelmed by rising death rates, have issued direct warnings to prescribers after local investigations revealed that gabapentinoids were present in up to 40% of drug-related fatalities.

Public health authorities have also revised clinical guidelines. Addiction-medicine societies now recommend screening for gabapentinoid misuse in all patients receiving opioids, buprenorphine, or methadone. Toxicologists emphasize that clinicians should consider gabapentin a high-risk agent in OUD, particularly when prescribed at doses exceeding 1200 mg/day or combined with sedatives. Harm-reduction programs have been adapted as well, educating clients about the risks of co-use and encouraging safer practices, such as avoiding gabapentin during opioid intoxication or ensuring supervision when sedative combinations cannot be avoided.

A recurring theme across all policy responses is the shift in perception: gabapentinoids are no longer seen as mere adjuncts for pain but as drugs with real abuse liability, diversion pathways, and mortality impact. Public health systems are responding accordingly, albeit unevenly, by tightening oversight, mandating monitoring, and urging clinicians to reconsider long-term prescribing.

Clinical Practice: Recognizing Misuse, Diversion, and Unsafe Behavior

For clinicians, the rapid rise of gabapentinoid misuse and its appearance in overdose deaths require a different level of attention than this drug class historically received. For decades, gabapentin was viewed as a safe adjunct, a benign alternative to benzodiazepines and a low-risk co-analgesic alongside opioids. But the reality of 2025 is fundamentally different. In pain clinics, primary care settings, emergency departments, and addiction services, gabapentinoids now behave much more like controlled sedatives: potentially helpful, but requiring vigilance.

A major clinical challenge is distinguishing legitimate pain escalation from misuse-driven behavior. Patients may request early refills with increasing frequency, report losing prescriptions, or complain that only high doses “touch the pain.” Some may move between multiple providers like telehealth platforms, urgent care clinics, psychiatric services, and pain specialists, each unaware of the others’ prescriptions if gabapentin is not logged in the state PDMP. These patterns mirror the early warning signs historically associated with opioid misuse, yet they often fly under the radar because gabapentin lacks the same stigma. There are also clear physical red flags. Sedation out of proportion to the prescribed dose, difficulty maintaining alertness during visits, slurred speech, oscillating pupils, or unstable gait may indicate high-dose misuse or combinations with opioids, alcohol, or benzodiazepines. Recurrent falls, particularly in younger or middle-aged patients, are a major clinical clue. For those in medication-assisted treatment (MAT), such as buprenorphine or methadone programs, gabapentinoid misuse can destabilize recovery, increasing emergency visits and overdose episodes.

Recognizing dangerous combinations is essential. Gabapentinoids markedly increase the risks associated with opioids, Z-drugs, benzodiazepines, alcohol, and carisoprodol. Even at ordinary doses, these combinations suppress respiration and blunt protective arousal responses. Clinicians should consider any patient on such combinations to be high-risk. Documentation should reflect a clear rationale, with close follow-up and slow titration if continuation is necessary.

When misuse or diversion is suspected, the response must be structured, not punitive. Clinicians can review PDMP data, require in-person visits for refills, perform pill counts, or prescribe smaller quantities at shorter intervals. If misuse is confirmed, a gradual taper is essential; abrupt discontinuation may provoke withdrawal symptoms like anxiety, sweating, tremor, insomnia, that push the patient back to illicit drug use. Collaboration with addiction specialists or integrated pain-addiction programs can provide stability during deprescribing. Above all, gabapentinoid misuse rarely occurs in isolation. It tends to emerge in the context of untreated pain, psychiatric distress, trauma, socioeconomic instability, or a chaotic polysubstance environment. Effective clinical response requires recognizing the whole picture, not only the pills, and guiding patients toward safer, more sustainable care paths. In 2025, gabapentinoids sit at the intersection of chronic pain and addiction medicine, and clinical practice must evolve to reflect the risks revealed by current evidence.

Conclusion

Gabapentinoids were never intended to become fixtures of the illicit drug market, yet the data from 2024–2025 make it clear that they now play a significant role in polydrug use and overdose mortality. What began as a medication for epilepsy and neuropathic pain has, through a combination of high prescribing volume, perceived safety, and potent synergy with opioids, become a substance frequently misused by individuals with opioid use disorder. The result is an unmistakable global pattern: rising rates of gabapentinoid-related deaths, increasing diversion, and widespread misuse in vulnerable populations.

The key message is not that gabapentin or pregabalin are inherently dangerous, but that their risk profile changes dramatically outside controlled medical use. When combined with opioids, benzodiazepines, alcohol, or illicit sedatives, gabapentinoids act as respiratory depressant amplifiers, increasing the likelihood of fatal overdose. The responsibility for managing this reality falls to clinicians, public health systems, addiction specialists, and policymakers alike. Recognizing misuse, adjusting prescribing practices, and strengthening monitoring are essential steps in reducing harm.

Gabapentinoids still hold therapeutic value, but only when used intentionally, monitored carefully, and protected from misuse. In 2025, the stakes are too high for complacency.

References

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