BACKGROUND: Prescribing epidemiology in general practice shows gabapentinoid drugs to be independently associated with unexpected, drug-related death. There is an increasing trend of gabapentinoid deaths throughout Europe and North America.

OBJECTIVES: The overall aim of this study was to assess how patient, practice and health system factors might be associated with gabapentinoid prescribing in primary care.

METHODS: Case series following a critical incident of an unexpected death in a patient prescribed a gabapentinoid drug in a single general practice. Unexpected and expected deaths in patients prescribed a gabapentinoid drug deaths over an 11-year period in a single general practice. We examined patient, prescriber and health system factors. Toxicology and post-mortem data were provided by the Coroner.

RESULTS: There were 36 deaths (four unexpected and 32 expected deaths) during the study period. Of the four patients who suffered an unexpected death, one of these patients' cause of death could be attributed to drug and alcohol toxicity. Over half of gabapentinoid prescribing ( = 19,53%) was hospital initiated, often 'off-label' ( = 6, 17%) and commonly co-prescribed with opiates ( = 15, 42%) and benzodiazepines ( = 11, 31%) to patients with high multi-morbidity.

CONCLUSIONS: Gabapentinoids are often initiated in the outpatient setting in clinically complex patients, often for 'off label' indications, with high polypharmacy. Patient, practice and health-system related factors need to be addressed in relation to gabapentinoid associated deaths and reflected in clinical practice guidelines. There is critical value in using toxicology reports from Coroner's offices in cases of unexplained gabapentinoid death in general practice.