BACKGROUND: The evidence informing the harms of gabapentin use are at risk of bias from comparing users with nonusers. OBJECTIVE: To describe the risk for fall-related outcomes in older adults starting treatment with gabapentin versus duloxetine. DESIGN: New user, active comparator study using a target trial emulation framework. SETTING: MarketScan (IBM) commercial claims between January 2014 and December 2021. PARTICIPANTS: Adults aged 65 years or older with diabetic neuropathy, postherpetic neuralgia, or fibromyalgia and without depression, anxiety, seizures, or cancer in the 365 days before cohort entry. INTERVENTION: New initiation of treatment with gabapentin or duloxetine (comparator). MEASUREMENTS: The primary outcome was the hazard of experiencing any fall-related visit in the 6 months after initiating gabapentin or duloxetine until discontinuation of treatment. Secondary outcomes were hazard of severe fall-related events defined as a fall associated with hip fracture or emergency department visit or hospitalization associated with a fall. Stabilized inverse probability of treatment weighting was used to adjust for baseline characteristics. RESULTS: Our analytic cohort included 57 086 older adults with a diagnosis of interest initiating treatment with gabapentin ( LIMITATION: Claims may contain fewer frail adults and undercount falls. CONCLUSION: Compared with incident use of duloxetine, incident use of gabapentin was not associated with increased fall-related visits. PRIMARY FUNDING SOURCE: None.