Pregabalin and gabapentin prescriptions have risen sharply in recent years. Both medications were developed as anticonvulsants for epilepsy and were later approved for certain nerve pain conditions. Prescribers now use them off-label for anxiety, sleep problems and other conditions where the evidence is limited, and one common moment for that prescription is when a benzodiazepine is being reduced: the gabapentinoid is offered as the “safer” drug to take its place.
This article is about that substitution. Both drugs act by binding to a subunit of voltage-gated calcium channels, which reduces the release of excitatory neurotransmitters. Both are perceived as gentler than benzodiazepines. Both, according to their own prescribing information, produce physical dependence and a withdrawal syndrome when stopped, and both carry a label warning about serious breathing problems when combined with other central nervous system depressants, benzodiazepines included. A drug with its own dependence and withdrawal syndrome is not an exit from dependence; it is a change of address.
The potential dangers of using anticonvulsants as benzodiazepine alternatives
The main danger is a false sense of safety. Because gabapentinoids produce a calming effect that feels similar to a benzodiazepine, a person may accept one without understanding that it brings its own tolerance, dependence and withdrawal. A second danger is specific to tapering. If a gabapentinoid is added while the benzodiazepine is still being reduced, the withdrawal symptoms the benzodiazepine taper produces can be masked, the taper may be pushed faster than the nervous system can follow, and the person ends up with two drugs to come off instead of one.
Long-term use for conditions the drugs were not designed to treat adds a third layer: cognitive dulling, dizziness, weight gain and mood changes that accumulate quietly and are easy to blame on the original anxiety rather than the medication.
Understanding the differences between anticonvulsants and benzodiazepines
Benzodiazepines enhance the effect of gamma-aminobutyric acid (GABA), the brain’s main inhibitory neurotransmitter, which is why they act quickly and why tolerance and withdrawal follow the GABA system. Gabapentinoids do not act at the GABA receptor despite their names. They bind to a calcium channel subunit and reduce the release of glutamate and other excitatory transmitters, so their calming effect arrives more slowly and through a different door.
That difference matters in one practical way for a person leaving a benzodiazepine: a gabapentinoid does not replace what the benzodiazepine was doing at the GABA receptor. It does not prevent benzodiazepine withdrawal; it layers a second drug, with a second adaptation, on top of it.
The dependence potential of pregabalin and gabapentin
The two drugs are not scheduled the same way, and this is worth stating precisely. Pregabalin’s own prescribing information states that it is a Schedule V controlled substance under the federal Controlled Substances Act. Gabapentin’s prescribing information states that it is not a scheduled drug. Both labels describe physical dependence and withdrawal symptoms on discontinuation.
Dependence here means what it means for benzodiazepines: the nervous system adapts to the drug’s presence, and removing the drug too quickly produces withdrawal. That is a predictable physiological response to regular dosing and it is not addiction. A person who takes gabapentin exactly as prescribed and then cannot stop without symptoms has a medication-caused medical condition, and the answer is a gradual taper, not an addiction label.
The side effects and risks associated with long-term use of anticonvulsants
Common effects of long-term gabapentinoid use include dizziness, drowsiness, fatigue, blurred vision, swelling of the hands and feet, weight gain and impaired concentration and memory. The labels of both drugs also warn of serious, life-threatening breathing problems when they are combined with other central nervous system depressants or taken by people with lung disease, and of mood changes including suicidal thoughts, a warning that applies to all antiepileptic drugs.
Beyond these effects, the practical long-term risk is the one this article is about: the longer the drug is taken, the more established the dependence, and the more carefully it must eventually be tapered.
The lack of evidence supporting the efficacy of anticonvulsants for anxiety and insomnia
In the United States neither drug is approved for anxiety or insomnia. Gabapentin’s label lists postherpetic neuralgia and adjunctive treatment of partial-onset seizures. Pregabalin’s label lists neuropathic pain from diabetic neuropathy, postherpetic neuralgia and spinal cord injury, fibromyalgia, and adjunctive treatment of partial-onset seizures. Anxiety and sleep are off-label uses, and the evidence for them is limited. That should be said plainly to any person offered one of these drugs for those reasons, along with the fact that the dependence and withdrawal described on the label apply whatever the drug is prescribed for.
The importance of informed consent when prescribing anticonvulsants
Many people who are dependent on a benzodiazepine were never told, before the first prescription, that dependence, tolerance and withdrawal were on the list of risks. Informed consent for a gabapentinoid means not repeating that omission. Risks come first: dependence, withdrawal, the breathing warning, the cognitive effects. Then the benefits and the alternatives, including the alternative of no new medication at all. Then the exit plan: how long the drug is expected to be taken and how it will be tapered off, agreed on the day it is started, not the day it is stopped. Consent also includes the right to decline and to withdraw consent later, without penalty to the relationship with the prescriber. It is a continuing conversation, not a signature.
The potential for withdrawal symptoms and dependence with anticonvulsant use
Both labels advise against abrupt discontinuation and call for a gradual taper over at least one week. Pregabalin’s label lists insomnia, nausea, headache, anxiety, sweating and diarrhea after abrupt or rapid discontinuation. Gabapentin’s label warns that antiepileptic drugs should not be stopped abruptly because of the risk of increased seizure frequency, and describes withdrawal symptoms such as agitation, confusion and disorientation after stopping high doses. In practice, people who have taken either drug for months at ordinary doses often find that the minimum one-week taper on the label is far too fast and need a slow, stepwise reduction of the kind used for benzodiazepines.
This is why substitution is not a taper. The Ashton Manual’s method is a slow, patient-paced reduction of the benzodiazepine itself, usually after a crossover taper to diazepam. Where the Manual does mention gabapentin and pregabalin, in its discussion of other drugs in withdrawal, it says only that there were reports they help with sleep and anxiety, that there had been no controlled trials, that it was not clear whether these drugs themselves cause withdrawal effects, and that additional drugs are seldom needed with very slow benzodiazepine tapering. It never describes swapping to a gabapentinoid as a way out. A person who accepts a gabapentinoid in place of a benzodiazepine still has a benzodiazepine taper to complete, and now has a second taper waiting at the end of it. If a gabapentinoid is prescribed anyway, it needs its own exit plan from the first dose.
Safer alternatives for managing anxiety and insomnia
For a person whose anxiety and insomnia are benzodiazepine withdrawal symptoms, the alternative to a new drug is a slower taper: smaller steps, longer holds, and time. Those symptoms are the nervous system readjusting, and adding a second sedative delays the readjustment rather than treating it. For anxiety and sleep problems that stand on their own, the alternatives include no medication at all, regular exercise, consistent sleep habits, and the ordinary non-drug approaches a physician can discuss. None of these carries a withdrawal syndrome, and none needs an exit plan.
How to Discuss Gabapentinoid Concerns with Your Healthcare Provider
A person offered gabapentin or pregabalin, whether during a benzodiazepine taper or for any other reason, has the right to answers before starting. The questions worth asking are the ones that make the exit plan explicit:
- Why this drug, and what is the alternative, including no new medication?
- Is it being prescribed to replace the benzodiazepine or to add to it, and how will it affect the benzodiazepine taper?
- How long is it expected to be taken?
- How will it be tapered when it is stopped, and who will manage that taper?
- What are the dependence and withdrawal risks on the label, and what is the warning about combining it with a benzodiazepine?
- What symptoms mean the dose should be reviewed, and how are they reported between visits?
It helps to bring a complete list of current medications and past experience with benzodiazepines, gabapentin or pregabalin, and to ask for the prescribing information in writing. Nobody should leave the conversation without knowing how the drug will eventually be stopped.
Frequently Asked Questions About Gabapentinoids
Are gabapentin and pregabalin actually safer than benzodiazepines?
They work through a different mechanism, but they are not a safer category. Both drug classes produce tolerance, physical dependence and a withdrawal syndrome, and both can cause prolonged symptoms after stopping. Gabapentinoids can cause significant dependence at ordinary therapeutic doses. “Different” is the accurate word; “safer” is not.
Can you become dependent on gabapentin or pregabalin?
Yes. Both labels describe physical dependence and withdrawal symptoms on discontinuation, and pregabalin is a Schedule V controlled substance in the United States. Dependence can develop in anyone who takes either drug regularly. It is the same medication-caused adaptation that benzodiazepines produce, and it calls for a gradual taper.
What happens if I stop taking gabapentin or pregabalin suddenly?
Abrupt discontinuation can bring on anxiety, insomnia, nausea, sweating, tremor and, in some cases, seizures. Call emergency services for a seizure or any medical emergency. In practice, symptoms can persist for weeks or longer. Both drugs should be tapered gradually with the prescriber, at a pace set by the person’s response rather than by the calendar, in the same way a benzodiazepine is tapered.
Why are doctors prescribing gabapentinoids instead of benzodiazepines?
Partly because of well-founded concern about benzodiazepine risks, including the dependence and withdrawal warnings added to every benzodiazepine label by the United States Food and Drug Administration (FDA) in 2020. The substitution rests on the belief that gabapentinoids are the safe version of the same thing. They are not, and their risks are not always explained to the person receiving the prescription.
What medical conditions are gabapentin and pregabalin actually approved to treat?
Gabapentin is approved for postherpetic neuralgia and as adjunctive therapy for partial-onset seizures. Pregabalin is approved for neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia and spinal cord injury, for fibromyalgia, and as adjunctive therapy for partial-onset seizures. Anxiety, insomnia and most chronic pain conditions are off-label uses with limited supporting evidence.
For a person reducing a benzodiazepine, the way out is a slower taper of the drug they are already on, not a different drug. Ashton Manual Guide’s benzodiazepine taper calculator shows how a gradual, patient-paced schedule lays out over time. It is an educational planning tool, not a schedule to follow.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
