Combining Sleeping Pills and Opioids Common Among Alzheimer’s Patients, Study Reports

Patricia Inacio, PhD avatar

by Patricia Inacio, PhD |

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Roughly 20 percent of Alzheimer’s disease patients in Finland combine sleeping pills (benzodiazepines) with strong painkillers (opioids), a practice that has been associated with serious risks, a study shows.

These findings highlight the need for therapeutic strategies that reduce the unnecessary co-use of these compounds, according to the authors of the study.

The study, “Concomitant use of benzodiazepines and opioids in community‐dwelling older people with or without Alzheimer’s disease – A nationwide register‐based study in Finland,” was published in the International Journal of Geriatric Psychiatry.

According to recent estimates, the use of benzodiazepines — psychoactive medicines prescribed mainly to treat anxiety, seizures, and insomnia — is rising among older people, despite recommendations from the American Geriatrics Society (AGS) to avoid the use of benzodiazepines in older patients.

Examples of benzodiazepines include Valium (diazepam) and Xanax (alprazolam), among others.

Among older patients, an estimated 30 percent of those diagnosed with Alzheimer’s disease have been reported to take benzodiazepines, accounting for one of the largest groups of users.

Benzodiazepines are approved for only short-term use, up to four weeks maximum, in older people due to treatment-associated risks, such as sedation, dependence, falls, and fractures.

Combining benzodiazepines with opioid analgesics (painkillers), such as morphine or oxycodone (sold as Percocet, among other names), has been reported to increase these risks. Nonetheless, the use of both medicines is on the rise.

“The concomitant use of BZDRs [benzodiazepines] and opioids in an older population, in which this combination is generally contraindicated, represents a public health issue that is associated with several risks,” the researchers wrote.

Few studies have investigated the use of benzodiazepine and opioids at the same time, especially in vulnerable older persons and Alzheimer’s disease patients.

Researchers at the University of Eastern Finland evaluated the prevalence of the combined use of benzodiazepines and opioid among older people, paying close attention to those diagnosed with Alzheimer’s disease.

They also aimed to identify the factors associated with the co-use of the medicines, and the most commonly used combinations of benzodiazepines and opioids.

Researchers analyzed data from the Medication Use and Alzheimer’s disease (MEDALZ) study, which includes all community-dwelling Finnish citizens newly diagnosed with Alzheimer’s disease during a six-year period (from 2005 to 2011). The study includes 70,718 patients. Researchers performed the same analysis in matched controls (without Alzheimer’s disease).

After excluding participants who were hospitalized during the study, the final analysis included 69,353 Alzheimer’s disease patients and the same number of controls.

The participants’ mean age was 80, and 65.1% of them were women.

Benzodiazepines and related medicines were used by 41.1% of patients with Alzheimer’s compared with 35.3% of the controls.

Among benzodiazepine users, 1 in 5 Alzheimer’s patients were also taking an opioid medication (21%), but controls were actually more likely to be prescribed opioids (31.6%).

“The lower prevalence of opioid use among those with AD [Alzheimer’s disease] may reflect the difficulty of pain assessment and treatment in this patient group,” the researchers wrote.

“On the other hand, the lower prevalence of opioid use may indicate the clinical reality of the benefits of reducing sedative ADRs in vulnerable persons with AD,” they added.

Prolonged use of both benzodiazepines and opioids (for more than 90 days) was also more common among controls (16.2%) than Alzheimer’s patients (10.4%).

The same was seen for shorter periods of co-use (from 1 to 89 days), with a higher prevalence among controls (15.6%) than Alzheimer’s patients (10.6%).

Factors associated with the co-use of benzodiazepines and opioids included female sex, low socioeconomic position, and coexisting conditions such as lung diseases (asthma and chronic obstructive pulmonary disease), osteoporosis, and previous hip fracture.

Since the combined use of benzodiazepines and opioids is reported to reduce respiratory function and increase the risk of pneumonia, these findings pose a cause for concern, the researchers believe.

Additionally, a history of substance abuse or long-term benzodiazepine use was also a risk factor linked to higher co-use of benzodiazepines and opioids.

The specific combinations of benzodiazepines and opioids prescribed differed between participants with and without Alzheimer’s disease.

The most commonly combined prescription for Alzheimer’s patients included benzodiazepines with weak opioids, while controls were more likely to be prescribed a Z-drug with a weak opioid.

Z-drugs, which include Lunesta (eszopiclone), Ambien (zolpidem), and Sonata (zolpidem and zaleplon), are non- benzodiazepine medicines that share a similar mode of action to benzodiazepines.

However, Alzheimer’s disease patients using benzodiazepines were more often prescribed stronger opioids than controls.

“Concomitant use of drugs that act on the central nervous system in an older population is concerning, as the use of these drugs has been associated with serious risks, especially in frail individuals with AD [Alzheimer’s disease], Niina Karttunen, from the University of Eastern Finland and the study’s lead author, said in a press release. “Unnecessary co-use of these drugs should be avoided, as the benefits rarely outweigh the risks.”