Opioids and Other Central Nervous System–Active Polypharmacy in Older Adults in the United States

Abstract

Background/Objectives Central Nervous System (CNS)-active medication polypharmacy, defined by the Beers Criteria as ≥3 CNS-active medications, poses significant risks for older adults. Among adults ages ≥65 seen in U.S. outpatient medical practice, we determined patterns and trends in contributions to CNS polypharmacy of each medication class. Design The National Ambulatory Medical Care Survey (2004–2013). Setting U.S. outpatient medical care. Participants Visits by older adults to outpatient physicians (n=97,910). Exposure Patient visits including ≥3 CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. Measurements We determined the proportion of CNS polypharmacy contributed by each medication class during 2011–2013 and then used logistic regression to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy. Results Among recent CNS polypharmacy visits, 76.2% included opioids and 61.8% included benzodiazepines. Approximately two-thirds (66.0%) of the polypharmacy visits with benzodiazepines included opioids and approximately half (53.3%) of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (CI 1.23–1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (AOR 2.15 [CI 1.19–3.91], p=0.01), while the corresponding proportion that included benzodiazepines fell. Among the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, while TCAs decreased. Conclusions Among older adults, the recent national increase in CNS polypharmacy appears to be largely driven by opioid use. Although concomitant use of opioids and benzodiazepines is associated with increased mortality, they are the most common contributors to CNS polypharmacy in older adults.

Self‐Reported Prescription Drug Use for Pain and for Sleep and Incident Frailty

“…However, increased drug use among frail individuals suggests a complex bidirectional relationship, most apparent in cross‐sectional analyses . Although clinical practice guidelines discourage co‐prescribing opioids and benzodiazepines due to the risks of dizziness, falls, dependence, respiratory depression, and death, this combination is often co‐prescribed and co‐used in the United States . Nonopioid analgesic and nonbenzodiazepine sedative‐hypnotics are also associated with increased risks of adverse events, geriatric syndromes, and death .…”

“…24 Although clinical practice guidelines discourage co-prescribing opioids and benzodiazepines due to the risks of dizziness, falls, dependence, respiratory depression, and death, 26 this combination is often co-prescribed and co-used in the United States. 27 Nonopioid analgesic and nonbenzodiazepine sedative-hypnotics are also associated with increased risks of adverse events, geriatric syndromes, and death. 28 However, association analyses of prescription drug use for pain and for sleep and incident frailty have not been published.…”

Update on Medication Use Quality and Safety in Older Adults, 2017

“…Unfortunately, other than the use of opioids, the contribution of individual therapeutic classes to CNS polypharmacy cannot be determined. Readers interested in learning more about this are referred to 2 additional publications by the same group of authors using the same data sources . Because of the nature of the data, the unit of analysis is not the percentage of the U.S. population of older adults with evidence of CNS polypharmacy but the percentage of outpatient visits.…”

“…Readers interested in learning more about this are referred to 2 additional publications by the same group of authors using the same data sources. 7,8 Because of the nature of the data, the unit of analysis is not the percentage of the U.S. population of older adults with evidence of CNS polypharmacy but the percentage of outpatient visits. A population-based cohort study reported that the 4.3% were taking 2 or more CNS active medications in 2002-03.…”

Prevalence of depression and receipt of antidepressant pharmacotherapy among patients with Parkinson’s disease: a national assessment of US office-based physician visits

“…24 NAMCS data are publicly available and widely used as a source for numerous assessments of medical care and prescribed medications in ambulatory settings in the US, including studies of psychiatric disorders and treatments. [25][26][27][28][29][30][31][32][33] The survey uses a stratified probability sampling procedure comprising multiple stages: first, selection by geographic area (eg, counties or county groups); second, within each geographic area by physician name, stratified by physician specialty; and third, by week, with each sampled physician randomly assigned to 1 of 52 weeks of data collection each year. 22,23 Finally, from each physician and week, a sample of office visits is chosen at random.…”