Perioperative Gabapentin Use in Older Adults: Revisiting Multimodal Pain Management

In response to the opioid crisis, surgeons nationwide have sought to decrease opioid use by adopting opioid-sparing multimodal medication regimens to treat perioperative pain.¹ For example, gabapentinoids (gabapentin and pregabalin) are now commonly administered during the perioperative period as part of “enhanced recovery after surgery” pathways, protocols designed to streamline and improve patient care after surgery. In fact, the use of gabapentinoids has tripled in the US over the past decade.² However, the safety of gabapentinoids in older adults has been questioned, and, according to the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,³ the medications are considered “potentially inappropriate” when used with opioids owing to increased risk of severe sedation-related adverse events. While multimodal pain management is promoted in perioperative care by both anesthesia and surgical societies, specific guidelines for older adults fail to address the risks or benefits of gabapentinoids.⁴ In this issue of JAMA Internal Medicine, the work of Park et al⁵ provides additional evidence of the potential harms of gabapentin use in older adults, key to understanding the overall risk-to-benefit ratio for prescribing gabapentinoids.