Gabapentinoid Safety: Dosing, Dizziness, and Misuse Prevention

When gabapentin or pregabalin are prescribed for nerve pain, many patients expect relief - not dizziness that makes them stumble, or a growing urge to take more than prescribed. These drugs, known as gabapentinoids, are among the most commonly prescribed medications for chronic pain, yet their risks are often underestimated. Between 2005 and 2015, prescriptions for gabapentinoids in the U.S. jumped from 39 million to 69 million. By 2018, pregabalin was the 10th most prescribed drug in the country. But behind those numbers is a growing crisis: dizziness that leads to falls, misuse that fuels addiction, and doses that far exceed what’s safe or effective.

What Gabapentinoids Are and How They’re Used

Gabapentin and pregabalin are structurally similar to GABA, a calming brain chemical, but they don’t work the same way. They don’t boost GABA levels. Instead, they bind to calcium channels in nerve cells, reducing the release of pain signals. Originally developed for seizures, they’re now mostly used for neuropathic pain - like diabetic nerve pain, post-shingles pain, or spinal cord injury pain. They’re also used for restless legs syndrome and sometimes for anxiety.

But here’s the catch: they’re not opioids. They don’t trigger the same rush of dopamine. Yet, for people with substance use disorders, gabapentinoids can be a dangerous substitute. Some take them to smooth out opioid withdrawal. Others mix them with opioids or alcohol to intensify the high. That’s why the CDC reports a 497% increase in gabapentin-related overdose deaths between 2012 and 2020.

Dosing: More Isn’t Better

Many doctors still start patients at high doses, thinking stronger = better. But research shows otherwise. The American Academy of Neurology’s 2022 guidelines say doses above 1,800 mg per day for neuropathic pain offer little extra relief - but double the risk of side effects. In fact, the FDA says there’s no proven benefit for doses higher than 1,800 mg for postherpetic neuralgia.

Here’s what safe dosing looks like:

• Gabapentin: Start at 300 mg once a day. Increase by 300 mg every 3-7 days. Most people find relief between 900 mg and 1,800 mg daily, split into three doses. The maximum is 3,600 mg daily - but only if absolutely necessary.
• Pregabalin: Start at 75 mg twice daily. After 3-7 days, increase to 150 mg twice daily. If needed, go up to 300 mg twice daily (600 mg total). Never exceed that.

Renal function changes everything. If your kidneys aren’t working well - common in older adults or people with diabetes - you need lower doses. For example:

• CrCl 50-79 mL/min: max 1,800 mg gabapentin daily
• CrCl 30-49 mL/min: max 900 mg daily
• CrCl under 30 mL/min: max 600 mg daily, or even less

Many patients are started on 1,200 mg or more on day one. That’s dangerous. A 2023 study in the Journal of Pain Medicine found that patients started on low doses and increased slowly had 40% fewer side effects and were more likely to stick with treatment.

Dizziness: The Silent Risk

Dizziness isn’t just a nuisance - it’s a red flag. About 20-30% of people taking gabapentinoids report it. But it’s worse than that. In older adults, it’s the leading cause of falls - and falls mean broken hips, hospital stays, and even death.

Here’s what the data shows:

• At doses under 900 mg/day: 15.3% experience dizziness
• At doses over 1,800 mg/day: 32.7% experience dizziness
• For patients over 65: rates jump to over 40%
• 68% of dizziness cases happen during the first week of dose increases

One Reddit user, a 72-year-old woman with diabetic neuropathy, wrote: “I was on 1,800 mg a day. I couldn’t walk to the bathroom without holding onto the wall. My doctor said it was ‘just side effects.’ I switched to 900 mg - suddenly I could garden again.”

Prevention is simple:

• Start low: 100-300 mg daily, especially if you’re over 65
• Go slow: Wait 5-7 days between dose increases
• Avoid evening doses: Dizziness can linger into the morning
• Check for fall risks: Remove rugs, install grab bars, get a cane if needed

The American Geriatrics Society’s 2022 Beers Criteria says: never exceed 900 mg daily for anyone over 80. Many patients over 70 get full pain relief at just 600-900 mg.

Misuse: When a Pain Med Becomes a Drug of Abuse

Gabapentinoids aren’t addictive in the same way as opioids, but they can be misused - and often are. The National Survey on Drug Use and Health found that 15.5 million people in the U.S. misused prescription pain relievers containing gabapentin in 2021. Many of them already had opioid use disorder.

Why? Because gabapentinoids can:

• Reduce opioid withdrawal symptoms
• Enhance the euphoria of opioids or alcohol
• Produce a mild high at high doses (over 3,600 mg)

On forums like PainForum.org, users report taking 3,600-4,800 mg daily to get high. One person wrote: “I used to take 4,000 mg with my oxycodone. I’d feel floaty. Then I’d black out. Ended up in the ER twice.”

Prevention isn’t just about patient education - it’s about system changes:

• 49 U.S. states now track gabapentin in prescription drug monitoring programs (PDMPs)
• The CDC recommends limiting initial prescriptions to 7-day supplies for acute pain
• Universal screening for substance use disorder is now standard before prescribing
• Urine drug testing every 3-6 months catches misuse early

The American Society of Addiction Medicine (ASAM) says: if someone has a history of opioid use, alcoholism, or benzodiazepine misuse, gabapentinoids should be avoided unless absolutely necessary - and even then, with close monitoring.

What You Should Do Now

If you’re taking gabapentin or pregabalin:

1. Check your dose. Are you on more than 1,800 mg of gabapentin or 600 mg of pregabalin daily? Ask your doctor if it’s still needed.
2. Track your dizziness. Do you feel unsteady when you stand up? Have you bumped into things more often? Tell your doctor - even if you think it’s normal.
3. Review your history. Have you ever misused pills, alcohol, or opioids? Be honest. It changes your risk.
4. Ask about alternatives. Topical lidocaine, duloxetine, or physical therapy might work just as well - with fewer risks.
5. Never stop cold turkey. Withdrawal can cause anxiety, insomnia, and even seizures. Taper slowly: reduce by 300 mg every 3 days.

If you’re a prescriber:

• Use the START protocol: Screen for kidney function and substance use, Titrate slowly, Assess dizziness weekly, Review necessity monthly, Taper properly.
• Don’t prescribe more than 1,800 mg gabapentin daily unless you’ve documented clear benefit and no side effects.
• Check PDMPs before prescribing - and every time you refill.
• Document why you’re prescribing it. Was it for neuropathic pain? Or just because the patient asked?

The Bottom Line

Gabapentinoids can help. But they’re not harmless. The biggest danger isn’t the drug itself - it’s how we use it. Too many people are started on too much, too fast. Too many older adults are left dizzy and at risk of falling. Too many people with addiction histories are handed a script without a safety net.

The science is clear: lower doses work just as well. Slower titration prevents side effects. Screening prevents misuse. And stopping when it’s no longer needed saves lives.

The days of prescribing gabapentin like it’s aspirin are over. The new standard is cautious, thoughtful, and patient-centered. That’s not just good medicine - it’s essential.

Next Steps for Patients and Providers

If you’re a patient:

• Write down your current dose and how you feel daily - especially dizziness, balance, or mood changes.
• Bring this log to your next appointment.
• Ask: “Is this dose still necessary? Can we try lowering it?”

If you’re a provider:

• Use the CDC’s 2022 guideline: limit initial prescriptions to 7 days for acute pain.
• Check PDMPs before every new prescription and every refill.
• Document renal function and substance use history - every time.
• Offer a taper plan before prescribing - not after problems arise.

The goal isn’t to stop gabapentinoids entirely. It’s to use them wisely - only when needed, at the lowest effective dose, and with constant attention to safety. Because when it comes to pain relief, the best outcome isn’t just less pain - it’s less risk, too.