The recent surge in controlled gabapentinoid usage warrants serious attention. While it is prescribed with an unapproved diagnostic code at a rate of 2/3 [13], it is used for non‐medical purposes and is widely distributed and sold on black markets. This trend has propelled the transformation of these drugs into recreational substances within the past decade [14]. The current study delves into the profiles of gabapentin and pregabalin detected in substance analyses following their designation as controlled drugs in Türkiye. We focused on cases referred to the laboratory affiliated with Manisa AMATEM, where substance use is a prevalent concern, offering a unique medicolegal perspective on the issue.

According to the General Directorate of Security (2021), the number of tablets seized by security forces in Türkiye increased by approximately 15 times from 2016 to 2020, with pregabalin‐containing drugs ranking among the top three synthetic drugs (General Directorate of Security, 2021). Aligning with these observations, 21.6% (n = 2224) of all analyzed cases tested positive for gabapentinoids in our study. Furthermore, the comparison of the last 6 months of 2021 and the first 6 months of 2022 reveals a concerning rise in GP positivity as PGB increased from 15.9% (n = 769) to 21.4% (n = 1174), while GBP surged from 2.7% (n = 129) to 7.6% (n = 417). This echoes data from the Forensic Medicine Institute, responsible for a significant portion of antemortem and postmortem analyses in our country, where pregabalin‐positive cases represented 3.2% of their total caseload. Also, it is worth noting that the study mentioned above focused on the years 2017–2018, prior to GPs being designated as controlled substances [15]. Nonetheless, despite the implementation of legal regulations since then, our study covering 2021–2022 reveals alarmingly high positivity rates for gabapentinoids, which underscores a critical issue warranting further attention and proactive measures. A similar surge was also observed worldwide. For instance, the longitudinal trend study published in 2023 used pharmaceutical sales data from 65 countries and regions around the world to assess global trends in gabapentinoid consumption between 2008 and 2018. The multinational average annual percentage change of gabapentinoid consumption was +17.20%, increasing from 4.17. The study showed that despite differences in healthcare systems and culture, a consistent increase in gabapentinoid consumption is observed worldwide, with high‐income countries remaining the largest consumers [7]. Regional studies provide further evidence of this alarming escalation. In France, they observed a staggering 1.233% increase in PGB consumption and a 1.185% increase in GBP in regions without social security coverage between 2016 and 2021 [16]. Data from the French addiction vigilance network also shows a sharp rise in GPs, from 3% in 2018 to 23.8% in 2019 [17]. Scotland offers another stark example, where prescribed GBP quadrupled and PGB prescriptions increased 16‐fold between 2006 and 2016 [18].

Gabapentinoids are often used in conjunction with other addictive substances. While THC‐COOH has historically been the most frequently associated substance in Türkiye [15], our study reveals a shift, with ATS now ranking first at 46.8% prevalence in this study population. Cannabis, however, remains a significant factor, coming in second place (26.7%). The widespread availability and affordability of ATS likely contribute to their prevalence in polysubstance use. The needs of users are also a factor in the combined use of methamphetamine with gabapentinoids. Among these, we can infer from our daily experiences that gabapentinoids are used to reduce some of the effects of methamphetamine use, such as loss of appetite and insomnia, and to reduce depressive and anhedonic symptoms that occur during methamphetamine withdrawal. Despite substantial international research on the combined use of opioids and benzodiazepines, studies specifically focusing on ATS and gabapentinoid polysubstance use remain limited. However, a recent study conducted in the Aegean Region of Türkiye [19] observed similar findings to those of the current study, observing the combined use of PGB and methamphetamine. While the dramatic abuse potential of gabapentinoids among individuals with a history of opioid use disorder was demonstrated by studies [2, 4, 7], our study provides further evidence for the polysubstance use of gabapentinoids and ATS. Mirroring a pattern observed in the United States and England, the “opioid crisis” led to a shift away from opioid prescriptions in favor of gabapentinoids for neuropathic pain, which resulted in a dramatic increase in PGB and GBP prescriptions, rising 150% and 350%, respectively, over a mere 5 years [13]. However, despite their affordability and accessibility, promoting the long‐term use of gabapentinoids as a replacement for opioids or in combination with them has proven insufficient in preventing severe adverse effects like psychological/physical dependence and overdose [20, 21]. The perception of safety, a scarcity of superior alternatives, and the urgent need to address chronic pain continue to drive their use. Our study revealed a low (<1%) association between opioids and gabapentinoids. The low prevalence of opioid use disorders in our study likely reflects the nature of our hospital as a psychiatric facility where medical analgesics are not prescribed. Additionally, the patient population primarily consists of individuals seeking addiction treatment at AMATEM or on probation. The co‐administration of gabapentinoids occurred more frequently with benzodiazepines than with opioids, consistent with global trends [22, 23]. The dual role of benzodiazepines as therapeutic agents at our institution complicated the differentiation between legitimate use and potential misuse.

The decrease in the age of use of GBP and PGB and the increase in the use of these substances in judicial cases such as probation, especially in order to take advantage of the gap in the legal regulation, is also an issue that needs to be emphasized. Several factors contribute to the increasing use of gabapentinoids (GPs). Despite their controlled prescription status, GPs are excluded from mandatory five‐panel screening protocols, and their unauthorized use does not constitute a criminal offense, particularly within the probation program framework. This regulatory environment allows affected individuals to maintain their occupational and social functions while potentially posing risks to themselves and others. However, it may be a challenge to distinguish between medical use and abuse. This situation can be overcome by evaluating prescriptions. Since methadone is on the routine analysis scale in some countries but not in our country, a cost‐effective approach can be provided by replacing it with gabapentinoids.

The clinical landscape presents additional challenges. Neither the DSM‐5 nor ICD‐11 includes specific diagnostic criteria for gabapentinoid use disorder, yet patients with gabapentinoid dependence—either alone or combined with other substances comprise—more than half of all SUD diagnoses in clinical practice (personal communication). This discrepancy between diagnostic frameworks and clinical reality underscores the severity of the situation. While gabapentinoids are not included in mandatory screening protocols by the Substance Abuse and Mental Health Services Administration in the United States, similar to our national policy, the European Workplace Drug Testing Society guidelines list them as secondary substances for targeted analysis.

The exploitation of gabapentinoids by individuals under judicial supervision, particularly those seeking to evade legal restrictions, presents a serious challenge. The findings indicate that individuals aged 24–35 represent a significant portion of cases (44.8%, n = 4624). Furthermore, alarming positivity rates for gabapentinoids were observed among those within the forensic and probation systems (75.9% for PGB and 82.6% for GBP). These results highlight a concerning pattern of gabapentinoid abuse within this population. Given these findings, we strongly advocate for the inclusion of gabapentinoids in mandatory substance screening protocols as mandated by the Ministry of Health.