Why Gabapentinoids Are More Dangerous Than You Think
Millions of people take gabapentin or pregabalin for nerve pain, anxiety, or sleep issues. But behind the quiet effectiveness of these drugs lies a hidden risk: gabapentin isn’t just a harmless pill. At high doses, it can cause severe dizziness, increase fall risk in older adults, and even be abused to get high-especially when mixed with opioids. The FDA, CDC, and top medical societies now agree: these drugs need careful handling. If you’re taking them-or prescribing them-you need to know the real numbers, the real dangers, and how to stay safe.
How Much Is Too Much? The Dosing Trap
Doctors often start patients on low doses of gabapentin: 300 mg once a day. That’s fine. But many patients end up on 3,600 mg daily-three times the recommended maximum for most conditions. Why? Because some believe more equals better. It doesn’t.
For postherpetic neuralgia, the FDA says 1,800-3,600 mg daily can work. But a 2021 FDA Drug Safety Communication found no extra pain relief above 1,800 mg. Meanwhile, dizziness, confusion, and falls spiked. The American Academy of Neurology’s 2022 guidelines say: stop increasing when you feel better or when side effects start. That’s it. No need to push to 3,600 mg.
Pregabalin follows similar logic. The max is 600 mg daily. Start at 75 mg twice a day. Increase slowly. If you’re over 65, or have kidney trouble, your dose should be even lower. Kidney function is critical. If your creatinine clearance is below 50 mL/min, your gabapentin dose shouldn’t exceed 1,800 mg daily. Below 30 mL/min? No more than 900 mg. Many doctors skip this check. That’s a mistake.
Dizziness Isn’t Just an Annoyance-It’s a Red Flag
One in three people on gabapentinoids get dizzy. That’s not rare. That’s expected. But dizziness isn’t just about feeling off-balance. It’s about falling. And falling can break hips, cause brain bleeds, or kill.
Studies show dizziness hits hardest at doses above 1,800 mg/day. In people over 65, it’s worse-up to 40% report severe dizziness. A 2021 review in the Journal of Pain Research found that at doses under 900 mg, only 15% had dizziness. At doses over 1,800 mg? Jumped to 33%. That’s not a coincidence. It’s dose-dependent.
Real-world data backs this up. On Drugs.com, 41% of users quit gabapentin because of dizziness. On Reddit’s pain forum, 78% of 1,245 posts called dizziness their biggest problem. And in one group of patients taking over 2,400 mg daily, 58% stopped the drug entirely because they couldn’t stand the spinning, the unsteadiness, the fear of falling.
Here’s how to reduce it:
- Start at 100-300 mg daily, not 300 mg three times a day.
- Wait 5-7 days before increasing-don’t rush.
- Avoid taking it at night if you’re older. Morning dizziness is more dangerous.
- Check your balance monthly. Use a cane if needed.
- For patients over 80, cap gabapentin at 900 mg daily. That’s enough for pain relief with far less risk.
Misuse Is Real-and It’s Rising Fast
Gabapentin isn’t an opioid. But it’s being used like one. People with opioid use disorder take it to smooth out withdrawal, boost euphoria, or get high on their own. The CDC says gabapentin-related overdose deaths rose 497% between 2012 and 2020. In 2021, 15.5 million Americans misused prescription pain relievers containing gabapentin.
Why? Because at doses above 3,600 mg, some users report a calming, euphoric buzz-especially when combined with alcohol or opioids. A 2022 study in Addiction found that 15-22% of people with opioid addiction deliberately sought gabapentin for this reason. Some reported taking 4,800 mg daily-four times the safe limit.
And it’s not just street users. In online forums, people with no history of addiction describe increasing doses because they “felt nothing” at 1,200 mg. So they went to 2,400 mg. Then 3,600 mg. Then they couldn’t stop. Emergency visits spiked. One user on PainForum.org wrote: “I took 4,200 mg to get through withdrawal. I passed out in the shower. My wife called 911.”
Here’s how to prevent misuse:
- Screen for substance use before prescribing. Ask directly: “Have you ever used drugs to get high?”
- Use your state’s prescription drug monitoring program (PDMP). All but one U.S. state now tracks gabapentin.
- For high-risk patients, start with a 7-day supply. No refills until you reassess.
- Use urine drug tests every 3-6 months. Look for alcohol, opioids, benzodiazepines.
- Never prescribe gabapentin for “mild anxiety” or “sleep trouble” without a clear diagnosis.
What the Experts Are Saying Now
Leading pain specialists are changing how they prescribe. Dr. Sarah Smith, lead author of the 2022 American Academy of Neurology guidelines, says: “Doses above 1,800 mg/day for nerve pain offer no extra benefit-just more dizziness and fall risk.”
Dr. John Markman from the University of Rochester says: “Start low. Go slow. Stop when it works-or when you feel weird.”
The American Geriatrics Society’s 2022 Beers Criteria warns: “Avoid gabapentinoids in frail elderly unless absolutely necessary. If used, max 900 mg/day.”
The European Pain Federation agrees: “Frail patients often respond to 900 mg/day. Higher doses just add danger.”
And the FDA’s 2023 safety update now requires labels to explicitly warn about dizziness-induced falls in older adults. That’s new. That’s serious.
The START Protocol: A Simple Way to Stay Safe
Doctors are now using a simple checklist called START:
- Screen for kidney function and substance use history before prescribing.
- Titrate slowly-no more than 300 mg every 3-7 days.
- Assess for dizziness every week during the first month.
- Review necessity every month. Is it still helping? Or just causing problems?
- Taper slowly if stopping. Cut by 300 mg every 3 days. Don’t quit cold turkey-it can trigger seizures or severe anxiety.
This isn’t extra work. It’s standard care now.
What’s Changing in 2025?
The landscape is shifting fast. Gabapentinoid prescriptions dropped 8.7% between 2021 and 2022-the first decline in 20 years. Why? More awareness. More regulation. More fear of lawsuits.
As of 2025, 49 U.S. states classify gabapentin as a controlled substance. The CDC projects a 12.3% annual rise in emergency visits if current trends continue. But there’s hope: Pfizer’s extended-release gabapentin XR is under FDA review. It’s designed to be harder to crush, snort, or inject.
The NIH has invested $15.2 million to find biomarkers that predict who’s at risk for dizziness or misuse. That means one day, a simple blood test might tell your doctor: “Don’t give this patient gabapentin.”
Bottom Line: Less Is More
Gabapentinoids can help. But only if used wisely. Higher doses don’t mean better pain control. They mean more dizziness, more falls, more misuse, more ER visits.
If you’re a patient: Don’t take more than your doctor tells you. If you feel dizzy, tell your doctor. Don’t power through it. If you’re a prescriber: Start low. Go slow. Check kidneys. Screen for addiction. Stop if it’s not working.
The goal isn’t to eliminate these drugs. It’s to use them like tools-not crutches. And to remember: sometimes, the safest dose is the lowest one that still helps.
Can gabapentin cause falls in older adults?
Yes. Dizziness from gabapentin increases fall risk significantly in adults over 65, especially at doses above 1,800 mg daily. Studies show up to 40% of elderly patients experience severe dizziness, and falls are a leading cause of hospitalization in this group. The American Geriatrics Society recommends avoiding gabapentin in frail older adults or capping doses at 900 mg daily if absolutely necessary.
Is 1,200 mg of gabapentin safe?
For most adults, 1,200 mg daily is considered a moderate and generally safe dose for neuropathic pain, especially if taken in divided doses (e.g., 400 mg three times a day). It’s below the maximum recommended dose and often provides good pain relief with fewer side effects than higher doses. However, safety depends on kidney function and age. Elderly patients or those with kidney issues should still be monitored closely.
Can you get high on gabapentin?
Yes, especially at high doses (above 3,600 mg daily) or when combined with opioids or alcohol. Some users report feelings of calm, euphoria, or intoxication. This is why gabapentin is increasingly misused, particularly among people with opioid use disorder. The FDA added misuse warnings to labels in 2019 after reports of recreational use and overdose deaths. It is now a controlled substance in 49 U.S. states.
How long does it take for gabapentin to cause dizziness?
Dizziness usually starts within the first week of treatment, especially during dose increases. Studies show 68% of dizziness cases occur during the initial titration phase. It’s most common when doses are raised too quickly-like jumping from 300 mg to 900 mg in three days. Slowing the titration to every 5-7 days reduces this risk significantly.
What should I do if I want to stop taking gabapentin?
Never stop abruptly. Sudden discontinuation can cause anxiety, insomnia, nausea, sweating, and even seizures. The FDA recommends tapering slowly: reduce your dose by 300 mg every 3 days. For example, if you’re taking 1,800 mg daily, drop to 1,500 mg for 3 days, then 1,200 mg for 3 days, and so on. Work with your doctor to create a safe taper plan based on your dose and how long you’ve been taking it.
Next Steps: What to Do Today
If you’re taking gabapentin or pregabalin:
- Check your current dose. Is it above 1,800 mg? Talk to your doctor about lowering it.
- Ask if your kidney function has been tested in the last 6 months.
- Write down any dizziness, unsteadiness, or memory lapses. Bring them to your next appointment.
- If you’ve ever used drugs to get high, be honest with your prescriber. There’s no shame in asking for help.
If you’re a clinician:
- Use the START protocol for every new prescription.
- Check your state’s PDMP before writing a script.
- Don’t prescribe more than a 7-day supply for acute pain without a follow-up plan.
- Remember: the goal isn’t to eliminate pain-it’s to improve function without harm.
