Medical and non‑medical gabapentinoid use in fatal drug poisonings in Norway: Linked postmortem toxicology and prescription data.

INTRODUCTION: Increasing prescribing and postmortem detection of gabapentinoids have raised concerns about their contribution to fatal poisonings, but information on medical and non-medical use remains limited. METHODS: Forensic toxicology findings from fatal drug poisonings in Norway from 2005 to 2021 were linked to prescription data. Medical use was defined as ≥ 1 dispensing of the detected gabapentinoid during the two calendar months preceding death. RESULTS: Among 5075 fatal drug poisonings, gabapentinoids were detected in 668 cases (13%). Nearly one-quarter (24%) were not captured by the standard European Union Drugs Agency (EUDA) definition of drug-induced deaths. Pregabalin detections increased from 0.7% in 2006 to 18% in 2021, while gabapentin detections increased from 0.3% in 2008 to 11% in 2021. The median number of detected substances was five, with opioids and benzodiazepines co-detected in 87% and 82% of cases, respectively. Medical use was identified in 69% of gabapentin cases and 55% of pregabalin cases. Non-medical use increased over time, particularly for pregabalin, and was associated with illicit substance use. Median postmortem concentrations were 16 mg/L for gabapentin and 8.3 mg/L for pregabalin, with concentrations reaching 1400 mg/L and 320 mg/L, respectively. Higher concentrations were associated with medical use for both substances and with suicide for pregabalin. CONCLUSIONS: Gabapentinoids were increasingly detected in fatal drug poisonings in Norway. Non-medical use became more common over time, particularly for pregabalin. Because 24% of cases were not captured by the standard EUDA definition, the contribution of gabapentinoids to drug-related mortality may be underestimated.