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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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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.
Benzodiazepine Use

In the study period, 157,449 patients (7.5% of the study sample) filled a prescription for a benzodiazepine (Table 1). Patients with unhealthy alcohol use had slightly higher odds of using benzodiazepines compared with patients with low-risk alcohol use (AOR, 1.15; 95% CI, 1.12-1.19) (Table 2). From the same multivariable analysis, women had 64% higher odds of using a benzodiazepine compared with men (AOR, 1.64; 95% CI, 1.62-1.66). Conversely, nonwhite patients had significantly lower odds of using benzodiazepines compared with white patients. Among racial/ethnic groups, Asian patients were the least likely to use benzodiazepines, with an AOR of 0.38 (95% CI, 0.37-0.38), representing 62% lower odds of using benzodiazepines compared with white patients. Older patients had significantly higher odds of using benzodiazepines compared with younger patients aged 18 to 39 years, with AORs of 1.82 (95% CI, 1.79-1.84) and 1.77 (95% CI, 1.73-1.80) for patients aged 40 to 65 and older than 65 years, respectively. Anxiety disorders, insomnia, musculoskeletal pain, epilepsy, and alcohol use disorder were all significantly associated with benzodiazepine use.

Mean Daily Dose and Duration of Benzodiazepine Prescriptions

Among patients with benzodiazepine prescriptions during the study period, the mean (SD) LEDD was 0.58 (1.51) mg/day and mean (SD) duration was 87.9 (114.0) days. Patients with unhealthy alcohol use had 40% lower LEDDs (ARR, 0.60; 95% CI, 0.55-0.66) and 18% shorter durations (ARR, 0.82; 95% CI, 0.80-0.84) compared with patients with safe alcohol use (Table 3). Women had ARRs of 0.85 (95% CI, 0.83-0.87) and 0.92 (95% CI, 0.90-0.93), representing a 15% lower LEDD and an 8% shorter duration of benzodiazepine prescriptions, respectively, compared with men. Asian patients had the lowest LEDD and shortest prescription durations of any racial/ethnic group compared with white patients. Whereas LEDD was highest among patients aged 40 to 65 years compared with patients aged 18 to 39 years (ARR, 1.49; 95% CI, 1.43-1.55), prescription durations were the longest among patients 65 years or older compared with patients aged 18 to 39 years (ARR, 2.04; 95% CI, 2.00-2.08). Higher LEDD and longer prescription durations were also significantly associated with low (compared with high) Census-derived estimated household income and the presence of an anxiety disorder, insomnia, musculoskeletal pain, and epilepsy.

DISCUSSION

This study is the first to our knowledge to examine the association of unhealthy alcohol use with benzodiazepine use, dosage, and prescription duration in a large primary care sample. Notably, 7.5% of patients in this cohort were dispensed a benzodiazepine in a 12-month period.1,27 In addition, women, older adults, and white patients were more likely to use benzodiazepines.

The rate of unhealthy alcohol use of 4.0% in our sample is lower than estimates from other health maintenance organization–based primary care samples (7.5%-20%)4,5 but is within the range estimated in population-based survey samples (0.3%-20%).27 This discrepancy may be attributable to different populations, years of data collection, and definitions of unhealthy alcohol use. Similarly, the prevalence of filled benzodiazepine prescriptions in our sample (7.5%) is consistent with a cross-sectional analysis of US retail pharmacies (5.2% of adults filled a prescription for a benzodiazepine in 2008)28 and with data from the Medical Expenditure Panel Survey (the prevalence of filled benzodiazepine prescriptions between 1996 and 2013 among noninstitutionalized adults increased from 4.1% to 5.6%).1 However, among adults in a primary care practice–based research network in 2011 and 2012, 15% of patients were prescribed a benzodiazepine.2 This larger percentage may reflect ordered prescriptions instead of filled prescriptions; the number of ordered prescriptions is likely to be greater than the corresponding number of filled prescriptions.29

Comparing our results regarding the concomitant use of benzodiazepines and alcohol with other samples is challenging given the methodologic heterogeneity among previous studies. For instance, among psychiatric outpatients (n = 93), roughly 40% used a benzodiazepine and simultaneously consumed alcohol; furthermore, alcohol use severity was associated with higher odds of benzodiazepine use (OR, 2.4; 95% CI, 1.3-4.2).30 In a study examining nationally representative survey data from 1999 to 2002, Jalbert and colleagues31 found that 8% to 10% of adult respondents reported both benzodiazepine and unhealthy alcohol use. Consistent with our findings, Kroll and colleagues2 examined data from a large primary care sample and found that patients with a diagnosis of alcohol abuse (compared with those without) had higher odds of benzodiazepine use (OR, 1.5; 95% CI, 1.3-1.7). In the emergency department setting, Jones and colleagues32 found that 27.2% of benzodiazepine-related visits involved alcohol. However, in smaller studies involving older patients33 and college students,34 the prevalence of concomitant benzodiazepine and unhealthy alcohol use (approximately 3% in these 2 samples) was significantly lower than what we found in this sample.

Clearly, previous analyses of concomitant alcohol and benzodiazepine use vary widely in their study populations, periods, and definitions of unhealthy alcohol consumption and benzodiazepine use. However, in general, the existing literature supports our conclusion that unhealthy alcohol use is associated with a greater likelihood of concomitant benzodiazepine use.


 
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