Do Spanish pa ien s d ink alcohol while unde going ea men
wi h benzodiazepines?
M. Ca men Del Rı
´o, Ca los P ada, F. Ja ie Al a ez*
D ugs and Alcohol Resea ch G oup, Depa men o Pha macology and The apeu ics, Facul y o Medicine, Uni e si y o Valladolid, 47005 Valladolid, Spain
Recei ed 27 Ap il 2001; ecei ed in e ised o m 1 Augus 2001; accep ed 6 Sep embe 2001
Abs ac
In his s udy, we analyzed pa e ns o combined benzodiazepines and alcohol use among he Spanish gene al popula ion o e he age o
16 yea s. The s udy was based on in o ma ion om he 1997 Spanish Na ional Household Heal h Su ey. A o al o 6,396 pe sons o e 16 yea s
o age, a ep esen a i e sample o nonins i u ionalized Spania ds, we e su eyed. One pe cen o he popula ion a e consume s o
benzodiazepines and daily d inke s o alcohol; undamen ally, hese consume s a e men, o whom 15.4% d ink alcohol a a high le el
( > 50 uni s/week). Findings show he equency o concu en use o benzodiazepines and alcohol by he Spanish popula ion. D2002 Else ie
Science Inc. All igh s ese ed.
Keywo ds: Alcohol–d ug in e ac ion; Alcohol; Benzodiazepines; D ug u iliza ion
1. In oduc ion
Benzodiazepines a e widely p esc ibed because o bo h
hei e ec i eness and hei sa e y in he ea men o mul iple
psychia ic and physical diseases. Bu , despi e hei being
sa e d ugs, one o he g ea es isks is ha ad e se e ec s may
be p oduced when aking benzodiazepines owing o hei
in e ac ion wi h o he subs ances—pa icula ly wi h psycho-
ac i e medica ion and alcohol. Ad e se d ug in e ac ions a e
an impo an clinical p oblem, and i is well known ha
se e al di e en mechanisms a e implica ed in hei pa ho-
genesis. In ega d o benzodiazepines, alcohol in e e es bo h
a he pha macokine ic and a he pha macodynamic le el,
which means ha he occu ence o ad e se e ec s is mo e
equen (Ha is e al., 1998; Tanaka & Misawa, 1998).
Benzodiazepines a e widely aken in Spain, mo e com-
monly by women and he elde ly (Del Rı
´o & Al a ez, 1996;
Rayo
´n e al., 1996). Addi ionally, he aking o hypno ic and
anxioly ic benzodiazepines has inc eased conside ably in
he pas 10 yea s, compa ed wi h he dec ease in consump-
ion in o he Wes e n coun ies, such as he No dic coun-
ies, he Uni ed Kingdom, and he Uni ed S a es (Rayo
´n
e al., 1996; Tille , 1994). Mo eo e , in Spain, d inking
alcohol is a social habi , and he e a e many who d ink
egula ly (Del Rı
´o e al., 1995).
In o ma ion ela ing o he use o benzodiazepines and
alcohol oge he is scan , and he aim o his s udy was o
analyze pa e ns o combined benzodiazepines and alcohol
use among he Spania ds.
2. Me hods
The s udy was based on in o ma ion om he 1997
Spanish Na ional Household Heal h Su ey, unde aken by
he Minis y o Heal h and Consump ion (Minis e io de
Sanidad y Consumo, 2000) o ob ain da a on aspec s ela ing
o heal h and he use o heal h esou ces. The p ocedu es
ollowed we e in acco dance wi h he e hical s anda ds o
he commi ee esponsible o human expe imen a ion ( he
E hics Commi ee o he Facul y o Medicine) and wi h he
Helsinki Decla a ion o 1975, as e ised in 1983.
A su ey o 6,396 pe sons o e 16 yea s o age, a
ep esen a i e sample o nonins i u ionalized Spania ds,
was ca ied ou . The sample was s a i ied: i s , by Spanish
communi ies; second, in se en s ages, by numbe o inhab-
i an s; hi d, by ci ies in each o he communi ies; and,
inally, by sex (3,102 males, 3,294 emales) and age (in
0741-8329/02/$ – see on ma e D2002 Else ie Science Inc. All igh s ese ed.
PII: S0741-8329(01)00195-1
* Co esponding au ho . Tel.: +34-983-423077; ax: +34-983-423022.
E-mail add ess: [email p o ec ed] (F.J. Al a ez).
Edi o : S. Bo g
Alcohol 26 (2002) 31–34
yea s) (1,353, age 16–25; 1,227, age 26–35; 1,012, age
36–45; 853, age 46–55; 927, age 56–65; 673, age 66–75;
352, age >75).
Those su eyed we e asked whe he hey had aken
benzodiazepines in he 2-week pe iod be o e he in e iew.
In ega d o alcohol, hey we e asked whe he hey had had
any ype o alcoholic be e age in he p eceding 2 weeks
and, i he answe was a i ma i e, how o en, he numbe o
alcoholic d inks consumed on each occasion, and he ype
(wine, bee , o spi i s). Daily d inke s we e conside ed o be
hose who spoke o ha ing a leas one d ink a day. The
amoun o alcohol consumed was exp essed in g ams o
absolu e alcohol consumed pe day, in acco dance wi h he
alcohol con en o Spanish d inks and he olume o in ake
o each o he di e en d inks.
To acili a e he egis a ion and moni o ing o alcohol
consump ion and o p o ide compa able da a, he use o a
d ink-uni sys em is ecommended. A uni is he alcohol
con en in de ined olumes o di e en be e ages wi h a
s anda d s eng h ( he s anda d d ink uni o Spain has been
de ined as 10 g ams o pu e alcohol) (Rod iguez-Ma os
e al., 1999). D inke s we e classi ied acco ding o hei
consump ion le el: low consump ion (men, 21 uni s/week,
and women, 14 uni s/week); mode a e consump ion (men,
22–50 uni s/week, and women, 15-35 uni s/week); high
consump ion (men, >50 uni s/week, and women, >35 uni s/
week) (Del Rı
´o e al., 1995). The ques ionnai es we e
adminis e ed by ained in e iewe s.
S a is ical analysis was unde aken wi h he use o SAS
so wa e e sion 6.07. F equencies we e compa ed by
u ilizing c
2
analysis. Values o Pless han o equal o .05
we e conside ed o be signi ican di e ences.
3. Resul s
O he pa icipa ing adul popula ion, 6.4% (males, 4.1%;
emales, 8.5%; c
2
= 50.86, d =1;P< .0001) had aken
benzodiazepines in he 2 weeks be o e he su ey, and use
inc eased wi h inc easing age: om 1.4% in he g oup
16- o-25 yea s o age o 15.9% in he g oup olde han
75 yea s o age (Fig. 1). In addi ion, 23.7% (males, 33%;
emales, 10.9%; c
2
= 613.99, d =1;P< .0001) o he
popula ion d ank alcohol on a daily basis.
When use o benzodiazepines and consump ion o alco-
hol we e analyzed join ly, 16% we e seen o be daily
d inke s (1% o all hose su eyed), mo e commonly among
men (30.5%) han among women (9.3%; c
2
= 29.25, d =1;
P< .0001) (Table 1). Consump ion inc eased wi h inc eas-
ing age o he popula ion, om 0% in he 16- o-25 yea s
age g oup o 12.1% in he 26–35 yea s age g oup o a
maximum o 23% in he 56- o-65 yea s age g oup, a e
which i wen down (Fig. 1). Mean alcohol consump ion
among hose aking benzodiazepines and d inking daily was
35.99 ± 28.67 g/day: 44.28 ± 44.22 g/day o men and
17.65 ± 9.19 g/day o women. In e ms o benzodiazepine
use and daily alcohol consump ion, 58.5% d ank a a low
le el, 32.3% d ank a a mode a e le el, and 9.2% d ank a a
high le el. Di e ences acco ding o sex also we e e iden
(c
2
= 9.98, d =2,P< .01); women d ank alcohol a a low
le el (80.8%) mo e o en han men (43.6%), whe eas men
consumed alcohol a mode a e (41.0%) and high (15.4%)
le els mo e equen ly han women (19.2% and 0%,
espec i ely) (Table 1).
The e we e mo e daily consume s o alcohol (24.2%)
among hose no aking benzodiazepines han among hose
aking hem (16%, c
2
=14.31, d =1,P< .0001).
Ne e heless, he dis ibu ion o d inke s acco ding o hei
le el o consump ion did no di e , ei he among hose who
ook benzodiazepines o hose who did no ake hem
(c
2
= 1.73, d =2,P> .05).
4. Discussion
Acco ding o ou s udy esul s, 6.4% o he Spanish
popula ion ake benzodiazepines, especially emales and
Fig. 1. Alcohol consump ion among hose aking benzodiazepines.
Table 1
The use o benzodiazepines and alcohol among he Spanish popula ion
To al sample
To al
(n= 6396) %
Males
(n= 3102) %
Females
(n= 3294) %
Take benzodiazepines 6.4 4.1 8.5
D ink daily 23.7 33.0 10.9
Take benzodiazepines +
d ink daily
1.0 1.3 0.8
Popula ion aking benzodiazepines
To al
(n= 407) %
Males
(n= 127) %
Females
(n= 280) %
Daily d inke s 16 30.5 9.3
Consump ion le el
Low 58.5 43.6 80.8
Mode a e 32.3 41.0 19.2
High 9.2 15.4 0
M.C. Del Rı
´o e al. / Alcohol 26 (2002) 31–3432
he elde ly. In addi ion, 1% o he popula ion a e consume s
o benzodiazepines and daily d inke s o alcohol; un-
damen ally, hey a e men, o whom 15.4% d ink alcohol a
a high le el (>50 uni s/week). Ou indings also indica e ha
alcohol consump ion is mo e common among people no
aking benzodiazepines han among hose who do ake hem.
In ou s udy, we obse ed a lowe a e o benzodiazepine
use han ha in o he , nea by coun ies, such as Finland
(Joukamaa e al., 1995), I aly (Mag ini e al., 1996), and he
Ne he lands ( an de Waals e al., 1993; an Hul en e al.,
1998), bu a clea ly highe a e han ha o he Uni ed
Kingdom (Ohayon e al., 1998) and he Uni ed S a es
(Simon e al., 1996), al hough di e ences among di e en
ypes o popula ions ha e o be aken in o conside a ion.
Wi h ega d o alcohol consump ion among hose who ake
benzodiazepines, 15.4% consume alcohol a a high le el. In
o he s udies, a high a e o alcohol dependence was ound
among hose who ake high doses o benzodiazepines
(Lekka e al., 1997).
In he p esen s udy, benzodiazepines we e mo e e-
quen ly used by women han by men, as p e iously epo ed
(Mag ini e al., 1996; Rayo´n e al., 1996; an Hul en e al.,
1998). In addi ion, benzodiazepine use oge he wi h alcohol
consump ion we e analyzed. Men ook benzodiazepines
wi h alcohol mo e equen ly han did women, as obse ed
in p e ious s udies, which co ela es wi h he ac ha
alcohol consump ion is mo e common among men han
women (Del Rı
´o e al., 1995).
Pha macokine ic and pha macodynamic in e ac ions
be ween alcohol and benzodiazepines can ha e signi ican
clinical implica ions, such as he impai men o many mo o ,
senso y, and neu ological unc ions, wi h a g ea e isk o
seda ion and, consequen ly, a g ea e isk o acciden s,
including oad, wo k, and possible sudden dea h (Ba bone
e al., 1998; Neu el, 1998; Tanaka & Misawa, 1998). These
side e ec s can impai he quali y o li e and ha e led o a
c i ical discussion abou he p ac ice o p esc ibing benzo-
diazepines and he in o ma ion p o ided by physicians
(Gu ie ez-Lobos e al., 2001). Ou indings do no pe mi
us o es ablish whe he in e ac ions ake place be ween
benzodiazepines and alcohol bu allow us o p esume ha
hey did in some cases. To p e en d ug–e hanol in e ac-
ions, physicians should pay mo e a en ion o his possible
occu ence (Del Rı
´o e al., 1996).
Eu opean Union egula ions (Di ec i e 92/27/CEE) and
Spanish legisla ion (Royal Dec ee 2.236/93, Decembe 17)
es ablish no ms o labeling and package inse s o medi-
cines used by human beings and de ine he sec ions o be
included. Sec ion 4.5 e e s speci ically o he in e ac ions
wi h o he d ugs, including alcohol. The e o e, he package
inse s and Summa y o P oduc Cha ac e is ics mus p o-
ide in o ma ion on he possible side e ec s o hese
subs ances as well as hei possible in e ac ions wi h o he s,
including alcohol. In Spain, wa ning is gi en o all benzo-
diazepines in ega d o hei in e ac ions wi h alcohol. Bu ,
apa om his in o ma ion in he package inse s, i is e y
impo an o a physician p esc ibing a benzodiazepine o
ask he pa ien abou his o he habi s ela ing o alcohol
consump ion and o in o m and wa n he pa ien o he
possible isks when aking he benzodiazepine oge he
wi h alcohol.
In acco dance wi h he Spanish egula ion, benzodiaze-
pines mus be p esc ibed by a physician, bu he e is no
speci ic egula ion o benzodiazepine p esc ip ion. A
s ic e and speci ic egula ion ega ding benzodiazepine
p esc ip ion has been in oduced in o he coun ies (Wein-
aub e al., 1991), wi h a iew o encou aging mo e a ional
p esc ip ion o hese d ugs.
The bene icial e ec s o benzodiazepine ea men o
ce ain diso de s (anxie y diso de , panic diso de , sleep
diso de ) ha e been clea ly shown. Any benzodiazepine
p esc ip ion should be p eceded by ca e ul diagnos ic e alu-
a ion and conside a ion o he po en ial isks and bene i s o
al e na i e ea men op ions, mainly i he e is a his o y o
alcohol o o he d ug abuse (Pos e nak & Muelle , 2001).
Thus, app op ia e educa ion is necessa y o bo h he pa ien
and he physician, pe haps o malized in p ac ice guidelines,
ins ead o speci ic egula ions ha can es ic clinical judg-
men and lead o less desi able al e na i es (Glass, 1991).
Ne e heless, i is essen ial o esea ch p esc ip ion
pa e ns and how benzodiazepines a e aken in Spain o
p o ide guidelines o egula o y decisions, wi h a iew o
implemen ing a mo e app op ia e and a ional use o
such d ugs in he u u e (Del Rı
´o & Al a ez, 1996; Rayo´n
e al., 1996).
Acknowledgmen s
We hank he Minis e io de Sanidad y Consumo o
p o iding us wi h he 1997 Spanish Na ional Household
Heal h Su ey compu e ized da abase. Suppo o his
s udy was p o ided by he Na ional Plan on D ugs
(Delegacio
´n del Gobie no pa a el Plan Nacional sob e
D ogas), Home O ice (Minis e io del In e io ), Mad id,
Spain, as well as by he Conseje ı
´a de Sanidad y Bienes a
Social, Jun a de Cas illa y Leo
´n, Valladolid, Spain.
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