Do Spanish patients drink alcohol while undergoing treatment with benzodiazepines?

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. 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