Gabapentin abuse is surging because the drug produces a euphoric high when taken in large doses or combined with opioids, and for years it flew under the radar of prescription monitoring programs that track more tightly controlled substances. Between 2012 and 2023, gabapentin misuse reports to poison control centers increased by more than 200 percent, and emergency departments across the country now routinely see patients who have taken handfuls of the pills — sometimes 10 or 15 at a time — to chase a sedative, almost dissociative buzz that users describe as a “poor man’s high.” For families dealing with dementia care, this trend matters in a very specific way: gabapentin is one of the most commonly prescribed medications in older adults, often given for neuropathic pain, restless legs, or even off-label for anxiety and agitation in dementia patients. Doctors are alarmed not just because gabapentin misuse can cause respiratory depression, seizures, and death, but because the medical profession itself created the conditions for this crisis by prescribing the drug so freely.
When the opioid epidemic prompted tighter restrictions on painkillers, clinicians pivoted to gabapentin as a supposedly safer alternative — and prescriptions exploded from around 39 million in 2012 to over 70 million annually by 2020. The drug was not even classified as a controlled substance at the federal level until individual states began taking action on their own. This article examines why gabapentin misuse has accelerated, how it specifically affects older adults and those with cognitive decline, what warning signs caregivers should watch for, and what the medical community is doing — or failing to do — in response.
Table of Contents
- Why Is Gabapentin Abuse Skyrocketing While Doctors Looked the Other Way?
- How Gabapentin Misuse Affects Older Adults and Dementia Patients Differently
- The Opioid Connection — Why Gabapentin Has Become a Co-Abuse Drug of Choice
- What Caregivers Should Watch For — Recognizing Gabapentin Misuse and Side Effects
- The Regulatory Patchwork — Why Federal and State Responses Have Been Inadequate
- Safer Alternatives for Managing Pain and Agitation in Dementia Patients
- Where the Gabapentin Crisis Is Heading
- Conclusion
- Frequently Asked Questions
Why Is Gabapentin Abuse Skyrocketing While Doctors Looked the Other Way?
Gabapentin was originally approved in 1993 as an anti-seizure medication, then gained wide off-label use for nerve pain, fibromyalgia, migraines, hot flashes, anxiety, and insomnia. Because it was not scheduled as a controlled substance by the DEA, physicians wrote prescriptions without the same oversight required for opioids or benzodiazepines. There was no mandatory reporting to state prescription drug monitoring programs in most jurisdictions, which meant a patient could visit five different doctors, get five gabapentin prescriptions, and no one would know. By contrast, if that same patient tried to obtain multiple oxycodone prescriptions, the system would flag it immediately. this regulatory blind spot gave gabapentin the reputation of being essentially harmless — a perception that turned out to be dangerously wrong. The tipping point came as opioid prescribing restrictions tightened in the mid-2010s.
Patients with chronic pain were switched to gabapentin, and people with substance use disorders quickly discovered that gabapentin could potentiate the effects of opioids, methadone, and even alcohol. A 2017 study published in Addiction found that roughly 15 to 22 percent of people who misused opioids also misused gabapentin, often to enhance or extend their high. In Appalachian communities hit hardest by the opioid crisis, gabapentin became so widely diverted that it earned street names like “johnnies” and “gabbies.” In one particularly grim example, the state of Kentucky found gabapentin present in nearly a third of all drug overdose deaths in the state, prompting it to become one of the first states to classify the drug as a Schedule V controlled substance in 2017. The medical community’s delayed response has been staggering. Even after evidence of widespread misuse emerged, many clinicians continued to view gabapentin as essentially benign. A 2022 survey of primary care physicians found that fewer than half considered gabapentin to have meaningful abuse potential. This disconnect between clinical perception and street-level reality is part of what makes the gabapentin crisis so insidious — the drug is still prescribed casually in settings where tighter scrutiny is warranted.
How Gabapentin Misuse Affects Older Adults and Dementia Patients Differently
For older adults, gabapentin misuse carries risks that are qualitatively different from those in younger populations. Age-related changes in kidney function mean that gabapentin — which is cleared almost entirely by the kidneys — accumulates in the body more readily. A dose that produces mild sedation in a 35-year-old might cause profound drowsiness, confusion, and loss of balance in a 75-year-old. Falls are the most immediate danger, and they are not a minor concern: hip fractures in elderly patients carry a one-year mortality rate approaching 30 percent. A 2019 study in JAMA Internal Medicine found that gabapentin use in older adults was associated with a significantly increased risk of falls and fractures, even at prescribed doses. In patients with dementia, the picture becomes even more complicated. Gabapentin is sometimes prescribed off-label to manage agitation, anxiety, or sleep disturbances associated with cognitive decline — conditions that are genuinely difficult to treat.
However, the drug can worsen confusion and cognitive function in these patients, creating a vicious cycle where the medication prescribed to calm a dementia patient actually accelerates their apparent decline. Caregivers may not realize that the increased confusion or lethargy they are seeing is drug-induced rather than disease progression. If the gabapentin dose is then increased to manage worsening agitation — which was caused by the drug in the first place — the patient spirals further. There is an important caveat here: not every older adult on gabapentin is at risk of misuse or harm. For some patients with severe neuropathic pain, gabapentin remains a reasonable option when used at appropriate, renally-adjusted doses with proper monitoring. The concern is not that gabapentin should never be prescribed to elderly patients, but that it should never be prescribed thoughtlessly. If a patient with moderate-to-severe dementia is started on gabapentin for vague complaints of “not sleeping well,” that deserves a much harder look than current practice often provides.
The Opioid Connection — Why Gabapentin Has Become a Co-Abuse Drug of Choice
One of the most disturbing aspects of the gabapentin crisis is how tightly it has become linked to opioid misuse and overdose deaths. Gabapentin enhances the respiratory depressant effects of opioids, which is precisely what makes combining them so lethal. A person taking gabapentin alongside even a modest dose of an opioid faces substantially higher overdose risk than with the opioid alone. The FDA issued a safety warning in December 2019 about serious breathing difficulties in patients using gabapentinoids with CNS depressants, acknowledging what coroners and addiction medicine specialists had been reporting for years. In forensic toxicology data, gabapentin keeps appearing at the scene.
Ohio’s state crime lab found gabapentin in roughly 30 percent of all drug-related deaths analyzed in 2018. In West Virginia, the drug showed up in autopsies so frequently that medical examiners began specifically testing for it as a matter of routine. These are not cases where someone took an extra gabapentin pill for their back pain — these are polysubstance overdoses where gabapentin was part of a cocktail that typically included fentanyl, heroin, or prescription opioids. For the dementia care community, this connection matters because older adults are also frequently prescribed opioids for chronic pain, particularly after surgeries, falls, or cancer diagnoses. A patient on both gabapentin and an opioid is carrying compounded sedation risk, and in someone whose cognition is already impaired, the warning signs of over-sedation — slowed breathing, excessive drowsiness, confusion — can be mistaken for normal features of their dementia. Family caregivers and nursing home staff need to understand that the combination of gabapentin and opioids in an elderly patient demands heightened vigilance, not the casual reassurance that gabapentin is “not a narcotic.”.
What Caregivers Should Watch For — Recognizing Gabapentin Misuse and Side Effects
Spotting gabapentin problems in an older adult requires knowing what to look for, because the symptoms overlap considerably with normal aging and dementia progression. The most common red flags include new or worsening drowsiness, unsteadiness or increased falls, slurred speech, swelling in the legs and feet, and sudden changes in mood or cognition that do not track with the patient’s usual pattern. If a previously stable dementia patient suddenly becomes much more confused or lethargic within days or weeks of starting or increasing gabapentin, the medication should be the first suspect. Misuse in older adults does not always look like the stereotypical picture of addiction. It may present as a patient insisting on higher doses, reporting lost prescriptions, or becoming unusually anxious about medication refills.
In memory care settings, staff should note if gabapentin pills go missing or if patients are obtaining medications from other residents. There have been documented cases in assisted living facilities where cognitively intact residents stockpiled and traded gabapentin with others. The tradeoff caregivers face is real: gabapentin may genuinely help a patient’s nerve pain or nighttime restlessness, but those benefits must be weighed against the sedation, cognitive dulling, and fall risk. Unlike simply stopping an opioid, abruptly discontinuing gabapentin can trigger withdrawal seizures, so any changes must be tapered under medical supervision. For family members managing care at home, keeping a simple daily log of alertness, mood, and mobility can be invaluable. If there is a clear temporal relationship between gabapentin doses and periods of confusion or unsteadiness, that information gives the prescribing physician something concrete to work with — far more useful than a vague report that “mom seems worse lately.”.
The Regulatory Patchwork — Why Federal and State Responses Have Been Inadequate
As of early 2026, gabapentin is still not classified as a controlled substance at the federal level. The DEA has not scheduled it, and the FDA has limited its response to label warnings and a safety communication. This means that oversight of gabapentin prescribing varies dramatically from state to state. Kentucky, West Virginia, Virginia, Tennessee, Michigan, and several other states have independently classified gabapentin as a Schedule V controlled substance, requiring it to be reported to prescription drug monitoring programs. But in many other states, gabapentin prescriptions remain invisible to the monitoring systems designed to catch dangerous prescribing patterns. This patchwork creates absurd situations.
A patient in Virginia who is flagged for obtaining gabapentin from multiple providers can simply cross into a neighboring state without gabapentin scheduling and fill prescriptions with impunity. The inconsistency also means that prescribers in non-scheduling states may have a false sense of security about their patients’ gabapentin use, since the monitoring tools they rely on for other drugs simply do not capture gabapentin data. For older adults in long-term care, the regulatory gap means that facilities in some states have gabapentin under tighter medication management protocols while facilities in other states treat it no differently than ibuprofen. The limitation here is political as much as scientific. Scheduling gabapentin federally would impose administrative burdens on prescribers already overwhelmed by documentation requirements, and it would complicate access for the millions of patients who use the drug appropriately. Advocacy groups for chronic pain patients have pushed back against scheduling proposals, arguing that restricting yet another pain medication punishes legitimate patients for the behavior of those who misuse it. This is a genuine tension with no clean resolution, but the current status quo — where a drug implicated in thousands of overdose deaths remains less regulated than cough syrup with codeine — is difficult to defend.
Safer Alternatives for Managing Pain and Agitation in Dementia Patients
For clinicians looking to reduce gabapentin reliance in their older patients, several alternatives exist, though none are perfect. Non-pharmacological approaches — physical therapy, transcutaneous electrical nerve stimulation, cognitive behavioral therapy for insomnia, structured activities for agitation — should be the first line, but they require time, training, and staffing that many care settings lack. When medication is necessary, topical lidocaine patches for localized nerve pain avoid systemic sedation entirely.
Duloxetine, an SNRI antidepressant, has good evidence for neuropathic pain and may also help with the depression and anxiety common in early-stage dementia, though it carries its own risks of falls and hyponatremia in the elderly. For agitation specifically, the FDA approved brexpiprazole (Rexulti) in 2023 for agitation associated with Alzheimer’s dementia — the first drug approved for this indication. While its effect size is modest and it carries a black box warning about mortality risk in elderly dementia patients (as do all antipsychotics), it at least represents a medication studied in the specific population where it will be used, unlike gabapentin’s entirely off-label use for this purpose.
Where the Gabapentin Crisis Is Heading
The trajectory of gabapentin misuse suggests the problem will worsen before it improves. Pregabalin (Lyrica), gabapentin’s chemical cousin that is already a Schedule V controlled substance, has seen its own misuse rates climb, indicating that scheduling alone does not eliminate the problem. Meanwhile, generic gabapentin remains extraordinarily cheap and accessible, and awareness among people who misuse substances continues to spread through online communities.
For the dementia care field, the most important shift may be cultural rather than regulatory. Prescribers need to stop treating gabapentin as a harmless utility drug and start applying the same risk-benefit scrutiny they would give to any psychoactive medication in a vulnerable, cognitively impaired patient. Families and caregivers, for their part, should not hesitate to ask direct questions: why is gabapentin being prescribed, what are the alternatives, how will we monitor for problems, and what is the plan for discontinuation if it is not working? Those conversations, uncomfortable as they may be, are the most practical defense available right now.
Conclusion
Gabapentin’s rise from obscure anticonvulsant to one of the most prescribed — and most misused — drugs in the country is a case study in how good intentions and regulatory complacency can collide. The medical system embraced gabapentin as a safer alternative to opioids without adequately studying its own abuse potential, and the consequences have been measured in overdose deaths, emergency room visits, and quietly worsening outcomes for vulnerable older adults whose cognitive decline was accelerated by a drug that was supposed to help them. For anyone involved in dementia care, the practical takeaway is straightforward: treat gabapentin with respect, not complacency.
Know why it was prescribed, monitor its effects closely, understand that it interacts dangerously with opioids and other sedatives, and do not assume that worsening confusion is simply the disease progressing. Ask the prescriber hard questions, keep a symptom log, and advocate for the lowest effective dose or a trial discontinuation if the risks appear to outweigh the benefits. Gabapentin is not evil — it is a useful drug in the right circumstances — but the era of prescribing it without a second thought needs to end.
Frequently Asked Questions
Is gabapentin addictive?
Gabapentin does not produce physical dependence in the same way that opioids or benzodiazepines do, but it can cause psychological dependence, tolerance, and a withdrawal syndrome that includes anxiety, insomnia, pain, and — critically — seizures. People who take high doses for extended periods should never stop abruptly.
Can gabapentin make dementia worse?
Yes, gabapentin can worsen confusion, drowsiness, and cognitive function in dementia patients. These effects may be mistaken for disease progression rather than drug side effects. If a patient’s cognition noticeably worsens after starting or increasing gabapentin, a medication review with the prescribing physician is warranted.
How much gabapentin is too much for an elderly person?
Dosing must be individualized based on kidney function, which declines with age. Many experts recommend starting older adults at 100 to 300 milligrams at bedtime and increasing slowly, with a maximum that is often well below the 3,600 milligrams per day sometimes used in younger patients. A creatinine clearance test should guide dosing.
Is gabapentin safer than opioids for pain in older adults?
Gabapentin avoids some opioid-specific risks like constipation and direct respiratory depression at therapeutic doses, but it introduces its own risks — falls, cognitive impairment, sedation, and dangerous interactions when combined with opioids. It is not categorically safer, just differently risky. The choice between them should depend on the type of pain, the patient’s other medications, and their cognitive baseline.
What states have made gabapentin a controlled substance?
As of early 2026, states including Kentucky, West Virginia, Virginia, Tennessee, Michigan, Minnesota, North Dakota, Alabama, and several others have classified gabapentin as a Schedule V controlled substance. The list continues to grow, but there is no federal scheduling, so coverage remains inconsistent.
