The study provides us with a deeper overview about the problem of pregabalin abuse in Jordan from the perspectives of those affected by abuse and dependence. We recognize that the limitations of the study are its small-scale nature confined to two addiction centers in one Jordanian city and that reported experiences of pregabalin abuse may also have been clouded somewhat by the poly-substance repertoires of patients in these addiction treatment centers. The study, however, despite these restrictions reiterates the complexities of pregabalin abuse within the regulatory framework of availability in Jordanian community pharmacies. Of note was the demographic profile of the participants, similar to that reported elsewhere (Johnson et al. 2000; Jensen et al. 2016). The vast majority of participants were poly-drug abusers and had previous history of substance abuse (Schwan et al. 2010; Grosshans et al. 2013). It was encouraging to note the relative short-term use of pregabalin, despite negative experiences and difficulties in cessation. Routes of administration were similar to those reported in the literature; either taking tablets whole or cutting and snorting them is an example (Carrus and Schifano 2012; Millar et al. 2013).

Given the poly-pharming experience of the participants, the use of pregabalin in self-medication from synthetic cannabinoid effects, the use of pregabalin with other substances when seeking to potentiate the intoxicating effect, and the self-medication with other substances when attempting to self-detoxify from pregabalin are of concern. Synchronizing the inhibitory and anxiolytic effects of pregabalin by mixing pregabalin with sedatives is not a new behavior among pregabalin abusers as it was mentioned in the 2010s in different studies (Schwan et al. 2010; Schifano et al. 2011; Baird et al. 2014; Grosshans et al. 2013). This is also not surprising as it has been documented that pregabalin may be effective in treating withdrawal symptoms of drugs and alcohol associated with physical dependency (Freynhagen et al. 2016). The potential risk of pregabalin abuse or misuse in patients with a history of substance abuse should also be considered (Schjerning et al. 2016). Poly-substance abuse patterns are vital in contributing to the abuse liability of pregabalin (Schwan et al. 2010; Grosshans et al. 2013). Combinations are similar to those reported in other countries such as Austria and Greece in which pregabalin was frequently co-administered with alcohol, benzodiazepines, or cannabinoids (Papazisis et al. 2013; Yazdi et al. 2015). Combining pregabalin with sedative drugs is dangerous and unpredictable (Yazdi et al. 2015) since the user may feel more sedated and relaxed when taking them. Equally, consuming two psycho-depressant drugs can contribute to exaggerated heightened effects and may lead to overdose and death (Carrus and Schifano 2012).

Of particular concern also are the combination with new designer drugs such as synthetic cannabinoids, which carry particular risks and unpleasant withdrawal experiences for users (Palamar and Barratt 2016; Van Hout and Hearne 2017), and the use with Captagon (Van Hout and Wells 2016). This is a unique result found compared with previous literature. The only substances mentioned previously in the literature to be mixed with pregabalin were natural hashish, opioid, benzodiazepine, and alcohol, and this was attributed to the claim that pregabalin potentiates the effects of these drugs, which may have a similar effect of pregabalin (Carrus and Schifano 2012; Baird et al. 2014). The mixing of pregabalin with opioids by illicit drug users to enhance or prolong the effects of opioids has also been reported (Baird et al. 2014; Loftus and Wright 2014). Our study also commented on the enhanced use of cigarettes during pregabalin-taking episodes, a synergistic effect replicated by Driot et al. (2016).

Users also reported boosting the effect of pregabalin by combining it with various sweet drinks. The literature suggests that the sweetness activates the endogenous opioid system in animals and humans by inducing a release of β-endorphin and by increasing the binding affinity for opioids (Dum et al. 1983; Getto et al. 1984). Preference for stronger sweet solutions may represent a marker of alterations in brain systems that mediate rewarding responses to a variety of hedonic stimuli, including sucrose and alcohol (Kampov-Polevoy et al. 1997).

Participants reported a lack of awareness of adverse health consequences. Although there are several treatment centers in Jordan, the awareness regarding in-depth knowledge of substance abuse is lacking among high school students in Jordan, where young people constitute the majority of the Jordanian population (Haddad et al. 2010). Nonmedical use of a prescription drug may also be seen as being more socially acceptable than the use of illicit drugs such as cocaine or heroin (Hernandez and Nelson 2010). This coupled with the perception of legality and relative ease in securing pregabalin products or alternatives in community pharmacies underscores the need for heightened pharmacovigilance and educational efforts in community pharmacies (Jaber et al. 2015). Different factors (e.g., lack of pharmacist awareness about pregabalin abuse and prospect for economic gain to income) complicate the role of pharmacists in Jordanian communities. The lack of detection in urine screening additionally facilitates abusers to continue on pregabalin. The lack of detection might be due to the variability of urinary detection times of abused drugs, and differentiating new drug use from residual drug excretion could be difficult, especially after repeated or chronic drug usage (Spigset and Westin 2013).