Combining opioid painkillers with certain other brain-affecting drugs such as benzodiazepine tranquilizers is of particular concern, recently receiving the strongest possible warning from the U.S. Food and Drug Administration due to an increased risk of death from combined use.
Publishing in JAMA Internal Medicine, (link is external)the team from the University of Michigan and VA Ann Arbor Healthcare System reports findings from their analysis of data collected from a representative sample of doctors’ offices between 2004 and 2013 by the Centers for Disease Control and Prevention.
While only 0.6 percent of doctor visits by people over the age of 65 involved three or more CNS-affecting drugs in 2004, the number had risen to 1.4 percent in 2013. If that percentage is applied to the entire U.S. senior population, that means 3.68 million doctor visits a year involve seniors taking three or more CNS drugs.
Dr. Donovan Maust
Also concerning: nearly half of seniors taking these drug combinations did not appear to have a formal diagnosis of a mental health condition, insomnia or pain condition – the three chief types of issues they’re usually prescribed for.
“We hope that the newer prescribing guidelines for older adults encourage providers and patients to reconsider the potential risks and benefits from these combinations,” he says.
In 2015, the American Geriatrics Society updated its guideline for the use of prescription drugs in older people, called the 2015 Beers Criteria (link is external).
Some of the CNS medication groups have been on the Beers Criteria since it was first published in 1997, but this update is the first to raise concern about CNS polypharmacy as potentially inappropriate.
Other work on CNS drugs alone or in combination
Maust, who is an assistant professor of psychiatry at the U-M Medical School, also recently published two other papers on the use of CNS drugs in older people with colleagues from U-M and VAAHS.
In the December issue of the Journal of the American Geriatrics Society, (link is external) they reported that 5.6 percent of doctor visits by people aged 65 or older included a prescription for a benzodiazepine tranquilizer in 2010.
More than a quarter of those visits also included a prescription for an antidepressant, and 10 percent included a prescription for an opioid drug. Only 16 percent of those who were continuing to receive a benzodiazepine prescription had a diagnosis of a mental health condition. Almost none were referred to psychotherapy.
The data for this study came from the same source as the JAMA Internal Medicine study, the CDC’s National Ambulatory Medical Care Survey, though it focused on the years 2007 through 2010.
“Prescribing of benzodiazepines to older adults continues despite decades of evidence showing safety concerns, effective alternative treatments, and effective methods for tapering even chronic users,” says Maust.
Meanwhile, in a paper published online-first in Psychiatric Services (link is external) in January, they report that more than half of 231 older patients who had been prescribed an antidepressant for depression by their primary care doctor for depression (as opposed to off-label use for sleep, for example) did not actually meet the criteria for Major Depressive Disorder.
The patients were participating in a randomized controlled trial aimed at improving depression outcomes and are not considered a representative sample of older Americans, but Maust and his colleagues note that their findings could indicate an over-prescribing trend.
Maust and his colleague Helen Kales, M.D. also wrote an invited commentary in JAMA Internal Medicine (link is external) in January, about the use of CNS drugs to “medicate distress” in older people.
In addition to Maust and Kales, the authors of the JAMA Internal Medicine research letter are Lauren B. Gerlach, D.O., Anastasia Gibson, and Frederic Blow, Ph.D. of U-M, and Mark Olfson, M.D., M.P.H. of Columbia University and the New York State Psychiatric Institute. Ilse Wiechers, M.D., M.P.P., M.H.S., of Yale University co-authored the benzodiazepine study.
Maust, Kales and Blow are members of the U-M Institute for Healthcare Policy and Innovation and the VA Center for Clinical Management Research. Blow is the director of the U-M Addiction Center and Kales directs the Program for Positive Aging. The study was supported by a National Institute on Aging Beeson Career Development Award (NIA K08AG048321, AFAR, The John A. Hartford Foundation, and The Atlantic Philanthropies)
Reference: JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9225 (link is external)