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The American Journal of Managed Care December 2019
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Benzodiazepine and Unhealthy Alcohol Use Among Adult Outpatients
Matthew E. Hirschtritt, MD, MPH; Vanessa A. Palzes, MPH; Andrea H. Kline-Simon, MS; Kurt Kroenke, MD; Cynthia I. Campbell, PhD, MPH; and Stacy A. Sterling, DrPH, MSW
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Joseph P. Newhouse, PhD; Mary Price, MA; John Hsu, MD, MBA; Bruce Landon, MD, MBA; and J. Michael McWilliams, MD, PhD
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Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership
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Benzodiazepine and Unhealthy Alcohol Use Among Adult Outpatients

Matthew E. Hirschtritt, MD, MPH; Vanessa A. Palzes, MPH; Andrea H. Kline-Simon, MS; Kurt Kroenke, MD; Cynthia I. Campbell, PhD, MPH; and Stacy A. Sterling, DrPH, MSW
Among outpatients who were screened for alcohol use, those with unhealthy alcohol use, women, and those who were older, white, and of lower socioeconomic status were more likely to use benzodiazepines.

Objectives: Concomitant excessive alcohol consumption and benzodiazepine use is associated with adverse health outcomes. We examined associations of unhealthy alcohol use and other patient characteristics with benzodiazepine use.

Study Design: A cross-sectional analysis of 2,089,525 Kaiser Permanente of Northern California outpatients screened for unhealthy alcohol use in primary care between November 1, 2014, and December 31, 2016.

Methods: We fit multivariable generalized linear models to estimate the associations between unhealthy alcohol use and benzodiazepine dispensation and, among patients who were dispensed a benzodiazepine, mean doses (in mean lorazepam-equivalent daily doses [LEDDs]) and prescription durations. We controlled for patient sex, age, race/ethnicity, estimated household income, Charlson Comorbidity Index (CCI) score, anxiety disorder, alcohol use disorder, insomnia, musculoskeletal pain, and epilepsy.

Results: In the 12 months centered around (6 months before and 6 months after) the first alcohol-screening visit, 7.5% of patients used benzodiazepines. The following characteristics were independently associated with higher rates of benzodiazepine use, higher LEDD, and longer prescription duration: older age, white race/ethnicity, lower estimated household income, higher CCI score, and the presence of an anxiety disorder, insomnia, musculoskeletal pain, or epilepsy. Women and patients with an alcohol use disorder or unhealthy alcohol use, compared with men and patients with low-risk drinking or abstinence, were more likely to use a benzodiazepine; however, their LEDDs were lower and their prescription durations were shorter.

Conclusions: Benzodiazepine use in primary care was associated with older age, female sex, white race/ethnicity, lower socioeconomic status, and unhealthy alcohol use. These findings may be applied to develop policies and interventions to promote judicious benzodiazepine use.

Am J Manag Care. 2019;25(12):e358-e365
Takeaway Points

Among patients in an integrated healthcare delivery system who were screened in primary care for unhealthy alcohol use, we examined cross-sectional benzodiazepine use patterns.
  • Unhealthy alcohol users, patients with an alcohol use disorder, and women were more likely to use benzodiazepines, but at lower doses and for shorter durations, compared with low-risk alcohol users and men.
  • Patients who were older, white, and of lower socioeconomic status were more likely to use benzodiazepines and had higher doses and prescription durations.
  • These findings may inform the development of systemwide interventions to address disproportionate benzodiazepine use among specific patient groups, especially among unhealthy alcohol users.
Benzodiazepines have been increasingly used in the United States, leading to increases in overdose mortality and healthcare utilization due to their potent sedative properties. Between 1996 and 2013, the percentage of US adults who filled a benzodiazepine prescription increased from 4.1% to 5.6%, and overdose mortality involving benzodiazepines increased from 0.58 to 3.07 per 100,000 adults.1 In a large primary care sample, 15% of patients were prescribed a benzodiazepine, one-third of whom received high-dose benzodiazepines (ie, a daily dose equivalent of ≥30 mg/day of diazepam); high-dose recipients were more likely than low-dose recipients to have multiple medical comorbidities and high healthcare utilization.2 Furthermore, between 2003 and 2015, the percentage of outpatient medical visits including a benzodiazepine prescription doubled, and more than half of these visits were to primary care physicians.3

Between 7.5% and 20% of primary care patients acknowledge unhealthy alcohol use,4,5 defined as use exceeding recommended weekly or daily limits.6 Excessive alcohol use is associated with numerous individual and societal consequences, such as development or exacerbation of medical and mental health comorbidities, decreased medication adherence, increased HIV risk behaviors, motor vehicle crashes, and interpersonal violence.7 Unhealthy alcohol use may precede development of an alcohol use disorder8 and frequently goes undetected in routine clinical care.9,10 In this context, the US Preventive Services Task Force recommends screening all adult primary care patients for unhealthy alcohol use and offering patients with unhealthy alcohol use brief behavioral counseling.11

When benzodiazepines and alcohol are used concurrently, their sedative effects significantly increase the risk of adverse events, including fatal overdose.12 In 2010, alcohol was involved in 27.2% of benzodiazepine-related visits and 21.4% of benzodiazepine-related deaths in US emergency departments.13 Long-term consequences of combined benzodiazepine and alcohol use include cardiovascular, gastrointestinal, hepatic, kidney, and neurologic injury and exacerbation of psychiatric conditions.14,15

Nationally representative survey data from 2015-2016 suggest that past-year alcohol use or an alcohol use disorder is associated with an increased risk of concurrent benzodiazepine use, misuse, and use disorder.16,17 Similarly, among Medicare beneficiaries in 2002, presence of drug or alcohol use or dependence was associated with higher odds of benzodiazepine use.18 However, to our knowledge, no health system, primary care–based studies have examined patient characteristics associated with benzodiazepine dispensation, mean dose, and prescription duration. This information may inform the development of tailored interventions to reduce exposure to benzodiazepines among patients with unhealthy alcohol use.

In this study, we examined the prevalence of benzodiazepine use and its associations with patient demographic and clinical characteristics, including unhealthy alcohol use, among Kaiser Permanente of Northern California (KPNC) adult outpatients who were screened for alcohol use in primary care clinics. We hypothesized that people drinking at unhealthy levels, compared with low-risk drinkers and abstainers, would be less likely to receive benzodiazepines and would receive prescriptions of lower doses and shorter durations. Although this contrasts with previous national trends, we postulated that the combination of recent warnings about rising benzodiazepine use in the United States, concerns about concurrent use with other substances, and a primary care initiative in our healthcare system to detect and reduce unhealthy alcohol use would sensitize clinicians to reconsider benzodiazepine prescribing in this patient subgroup.


Design, Setting, and Participants

We conducted a retrospective, cross-sectional study using electronic health record (EHR)–derived data among adult outpatients screened for alcohol use in KPNC primary care clinics. KPNC is an integrated healthcare delivery system with more than 4 million members that covers approximately 30% of the population in the served geographic areas. For these analyses, we identified KPNC members 18 years or older who were screened for unhealthy alcohol use with 1 or more completed alcohol screenings as part of an ongoing primary care–based alcohol screening and brief intervention protocol (Alcohol as a Vital Sign [AVS])19 between November 1, 2014, and December 31, 2016. We defined the study period as the 12-month period centered around (6 months before and 6 months after) each patient’s clinic visit in which the first AVS screening occurred. We excluded patients with noncontinuous KPNC coverage during the study period (eAppendix Methods [eAppendix available at]). Use of these data was approved by the institutional review boards of KPNC and the University of California, San Francisco.

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