The Quiet Rise of a “Harmless” Drug
In 1993, the FDA approved gabapentin under the brand name Neurontin for partial seizures.
There was no national uproar. No front page controversy. No cultural debate.
Just another medication entering the system.
Fast forward three decades.
Gabapentin joined the top ten most prescribed drugs in the United States. In 2024 alone, 15.5 million prescriptions were written.
How does a seizure medication become one of the most common pain drugs in America?
To understand that, we need context.
Table of Contents
The Quiet Rise of a Harmless Drug (Gabapentin)
America’s Expanding Drug Economy
In 2024, Americans spent approximately $806 billion on prescription medications.
An additional $43 billion went to over the counter drugs.
Pain medications alone account for roughly $35 billion annually.
Zoom out further.
Total U.S. healthcare spending is about $4.5 trillion per year.
When Medicare Part D was introduced in 2003, federal drug spending accelerated. By 2023, Medicare Part D spending reached approximately $450 billion, with more than 50 million Americans enrolled.
The system is massive.
And when systems get big, patterns matter.
Polypharmacy and the Senior Population
A December 2025 Wall Street Journal investigation reported:
- 6 million seniors are prescribed eight or more medications
- 9 million are prescribed ten or more
- 419,000 are prescribed fifteen or more
- One in six Medicare drug beneficiaries takes eight or more medications at the same time
Among them?
Gabapentin.
But layering drugs increases risk of interaction, cognitive effects, and systemic stress.
Especially when prescriptions are used off label.
The “Safer Alternative” Era
As opioid scrutiny intensified, the medical community searched for alternatives.
Gabapentin increasingly filled that role.
Originally approved for seizures and later postherpetic neuralgia, it began to be widely prescribed for various forms of back pain, including radicular low back pain.
At one point, 83 percent of gabapentin prescriptions were for off label uses.
Off label prescribing is legal.
But legal does not always mean evidence supported.
Prescriptions more than doubled over a fifteen year period.
That is not organic growth.
That is systemic shift.
What the Literature Began to Show
In January 2023, the journal Pain Practice published a 72 reference review titled “Gabapentin—Friend or Foe?”
The conclusions were sobering:
- Efficacy for neuropathic pain is reportedly low
- Adverse events are common
- Insufficient data supports use in chronic low back pain and sciatica
- Long term use may cause more harm than benefit
The authors cautioned against prolonged use until clearer benefit outweighing harm is demonstrated.
That is not anti medication rhetoric.
That is published literature.
A Clinical Fork in the Road
In 2023, BMJ Open published a large retrospective cohort study examining adults aged 18 to 49 with radicular low back pain.
Researchers compared:
- Patients who received chiropractic spinal manipulative therapy
- Patients who received usual medical care
Over one year, patients who initially received chiropractic care had 47 percent lower odds of receiving a gabapentin prescription.
The authors noted:
- Gabapentin prescribing for low back pain has been described as a marker of low value care
- Several clinical guidelines do not recommend gabapentin for low back pain
- Chiropractic spinal manipulation is supported by systematic reviews and recommended by guidelines
That is a meaningful divergence.
Two starting points.
Two downstream paths.
The Dementia Signal
In 2025, a ten year retrospective cohort study of 26,416 adults with chronic low back pain examined the association between gabapentin prescriptions and dementia.
Findings included:
- Six or more prescriptions correlated with a 29 percent increased incidence of dementia
- Mild cognitive impairment increased by 85 percent
- Adults aged 18 to 64 showed a 110 percent higher dementia risk compared to non users
- Prescription frequency correlated with risk
Chronic exposure has been associated with reduced neurogenesis and altered synaptic plasticity.
These findings do not prove causation.
But they raise a signal.
And in medicine, signals deserve attention.
The Marketing History
Gabapentin’s rise was not purely clinical.
In 2004, a Pfizer subsidiary pleaded guilty and paid $430 million related to illegal off label promotion.
In 2010, Kaiser Foundation was awarded $142 million in litigation.
Internal communications reportedly described the drug as “the snake oil of the twentieth century.”
Sales grew from $98 million in 1995 to over $2 billion by 2003.
Marketing matters.
Narrative matters.
Prescribing patterns often follow both.
The Bigger Question
The issue is not whether gabapentin has value.
It does, in specific contexts.
The issue is alignment.
Does the prescription pattern match the evidence?
Low back pain remains one of the leading causes of healthcare expenditure in the United States.
It is also the most common reason patients seek chiropractic care.
In my chiropractic office in Davie, we see this fork in the road on a daily basis.
One path leans pharmacologic.
One path leans mechanical.
Understanding Radicular Low Back Pain
Radicular low back pain involves irritation or compression of a spinal nerve root. Symptoms may include pain radiating down the leg, numbness, tingling, or weakness.
When symptoms like this appear, a proper mechanical evaluation becomes important. In many cases, patients in our areas seek us out to determine whether the issue is structural.
The underlying driver is usually mechanical.
Disc bulge. Joint dysfunction. Inflammatory cascade secondary to mechanical stress.
If the root issue is mechanical, the primary intervention should consider mechanics.
Not just neurochemistry.
Where Chiropractic Fits
Chiropractors do not prescribe medications.
Our intervention is structural.
Spinal manipulation aims to restore joint motion, reduce mechanical irritation, and improve load distribution.
When joints move better, nerve irritation can decrease.
When load distribution improves, inflammatory signaling may reduce.
When mobility improves, muscular guarding often decreases.
That changes the environment.
And Adjustments Don’t Lie.
When the joint regains motion, the body responds.
Not because we numbed it.
Because we improved its mechanics.
The Philosophy Behind the Fork
Relief is step one.
Resilience is the mission.
Medication can suppress symptoms.
Sometimes that is necessary.
But suppression without mechanical correction leaves the original driver intact.
Life is stress, gravity, and repetition.
If your spine cannot absorb those forces efficiently, symptoms return.
Often stronger.
Often more frequent.
Health is not something you buy.
It is something you build.
Early Intervention Matters
The BMJ Open study suggests that early non pharmacologic care may reduce downstream drug exposure.
That is significant.
Because once medication becomes chronic, tapering can be difficult.
Withdrawal symptoms have been reported.
Autonomic instability has been reported.
Cognitive changes have been reported.
More than 5,000 deaths annually have involved gabapentin in recent years, often in combination with other substances.
These are not fringe anecdotes.
They are reported patterns.
This Is Not Anti Medicine
Let’s be clear.
There are situations where medication is appropriate.
There are cases where surgery is necessary.
There are moments where pharmaceuticals save lives.
But for common mechanical low back pain, evidence supported conservative care should not be an afterthought.
It should be front line.
Clinical guidelines increasingly reflect that.
What This Means for Patients
If you are experiencing radiating low back pain, ask:
- Has the mechanical source been evaluated?
- Are we addressing joint motion and load distribution?
- Is this medication short term or indefinite?
- What is the exit strategy?
Informed patients make better long term decisions.
Silencing pain without correcting structure often prolongs the problem.
Spinal Freedom means restoring adaptability.
When the spine adapts well, downstream stress decreases.
Frequently Asked Questions
My Final Thoughts
Gabapentin did not explode in popularity because it was evil.
It expanded because it was positioned as safer.
Safer than opioids. Safer than surgery. Safer than doing nothing.
But safer does not automatically mean optimal.
When low back pain is mechanical, mechanics deserve attention.
Early structure focused care may change the trajectory.
Not dramatically overnight.
But steadily.
And in health, steady often wins.
If you are weighing your options, here is my two cents.
Ask better questions.
Understand your fork in the road.
Then choose intentionally.
About the Author:
Dr. Zev Mellman is a licensed chiropractor serving patients throughout South Florida and beyond. His practice focuses on spinal health, mechanical causes of pain, and conservative approaches to musculoskeletal care.
- Licensed Doctor of Chiropractic in the State of Florida
- Florida License Number: CH9524
- License Original Issue Date: 01/15/2008
