Opioids and other CNS-active polypharmacy among 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.