Hello and welcome to this short presentation on the clinical use of gabapentinoids. My name is Liz Colquhoun and I am one of the teaching fellows on the MSC clinical management of pain. I also worked clinically as a senior pain nurse specialist working in both inpatient and outpatient settings. You've been given recommended texts regarding the use of gabapentinoids but I hope this presentation will reflect the use of gabapentanoids from a more clinical perspective. In this presentation, I will provide an introduction to gabapentinoids. We will briefly discuss their mechanisms of action. I'll give you a brief overview of the clinical use of gabapentin and pregabalin. And we'll touch on some of the risks of misuse with this group of medications. Gabapentinoids belong to the anticonvulsant group of medications, which are also used to treat epilepsy. If we consider the way in which they work, this makes perfect sense. They are used to treat persistent neuropathic pain, which is often described as burning, shooting, stabbing, or altered unpleasant sensations such as electric shocks, tingling, and painful numbness. Gabapentinoids are also sometimes used as an adjunct in perioperative pain management. As they use intensifies opioid effects and can be used as part of balanced analgesia. This clip allows a visual representation of the effect of medications and changes in transmitters at the synapse. I'll now provide you with some information on gabapentin and pregabalin in turn. As previously detailed. Gabapentin is used for the treatment of neuropathic pain. It can also sometimes be used as an adjunct for nociceptive pain management due to the possibility of augmenting opioid analgesics in the acute phase. It's  important for concordance and compliance with prescribing that patients understand the time it can take to work and the need for a slow stepwise titration. Any side effects are usually time-limited, however, can be so problematic that they preclude further titration. And I often find it's hard to increase a patient to therapeutic dose due to problematic side effects. Side effects listed can include dizziness, tiredness and nausea. The list of side effects is very long as, as with most medications. Other slightly less common side effects that I've come across in clinical setting are tremor, fluctuations in mood, and also significant fluid retention. We'll now consider the alternative of pregabalin, which works in a very similar way to gabapentin. Pregabalin is also used to treat epilepsy and neuropathic pain, but also has an effect on anxiety, and is often used in psychiatry. The fact that it can help anxiety may influence the choice of gabapentinoid from a clinical perspective. In my role as a pain specialist, I may choose Pregabalin for a patient with pain and concomitant anxiety. and I often describe this as a buy one, get one free for my patients. Clinically, pregabalin can be observed to have a slightly better side effect profile and be better tolerated. Although this is a patient-specific, some patients do better on one gabapentinoid, some on another. It can also be titrated to therapeutic dose slightly quicker. Common side effects. include drowsiness, dizziness, headache. Other side effects that I regularly see are, increased appetite and therefore weight gain, erectile dysfunction, and lack of sex drive, and an increase in suicidal ideation. The other common side effect with Pregabalin is what patients describe as  "brain fog". They can have problems with their memory. And in fact, I did recently have an elderly patient who thought they were suffering with the start of dementia. But in fact, it was a side-effect of pregabalin. As prescribing has increased for both pain and epilepsy. So has the amount of illicit drug circulating in the population. This leads to an increase in illicit use. Gabapentinoids can result in feelings of relaxation, calmness, and euphoria. An individual may self treat conditions such as insomnia, anxiety, and substance withdrawal with non prescribed Gabapentinoids  Patients may be surprised at questioning of illicit use within clinical situation. There's clearly a big difference from the  "I borrowed a pill from...." to illicit substance misuse, but both are illicit use. Individuals may also utilise non prescribed gabapentanoids to Augment an opioid high, particularly when opioid availability is lower. And we've seen that in the UK, when heroin availability has been lower. Obviously the risk of harm from illicit use increases with the concomitant use of other central nervous system depressants such as opioids, benzodiazepines, alcohol, or cannabis. This graph shows the pattern of drug deaths relating to specific preparations in Scotland, including opioids, benzodiazepines, gabapentinoids, and cocaine. These drug deaths represent a significant global public health issue. As stated on the slide, gabapentin was implicated in 1 in10 overdose deaths in the United States 2019 2020, gabapentin or pregabalin were also implicated in 36% of drug-related deaths in Scotland in 2021. We see the increase in excess deaths from non prescribed medications increasing overall. However, it's interesting to see there's been a slight decrease in Scotland, perhaps due to health improvement programmes in Scotland over the last couple of years, or perhaps related to COVID-19 pandemic and lock downs. So in summary, gabapentinoids are really useful medications for the treatment of neuropathic pain. Prescriptions should start at a low dose and be titrated to effect or side effect. And a slow titration can avoid problematic side effects. It's worth noting that these side effects are usually time limited. And it's important to explain that to the patient to ensure compliance and concordance. Gabapentinoids continue to be implicated in drug-related deaths and patient harm, which is a significant public health concern. There's been a change in their legislation in Scotland and the UK in general, and I think this will change worldwide. The last slide is just some references to give evidence to the statements within the presentation. If anyone has any specific questions, please. Don't hesitate to get in touch via email. Thanks very much.