Concurrent use of alcohol and sedatives in Finnish general population

ABSTRACT Background The epidemiology of independent use of sedatives or alcohol is well reported in previous research. However, the epidemiology of concurrent use of sedatives and alcohol is vastly understudied despite the unpredictable interactions associated with it. Objectives Our aim was to study the prevalence of concurrent use of alcohol and sedatives and further examine the use of sedatives in some subgroups of people with alcohol use. Methods A mailed questionnaire was sent to a randomly chosen representative sample of a Finnish population (n = 5000). The main outcome measure was the prevalence of the use of sedatives in five subgroups of people with alcohol use in the previous week. Results Of the participants, 7.8% (142/1818) reported use of both alcohol and sedatives in the previous week. Among the people with sedative use, 67.0% (142/212) reported at least some alcohol use, and 9.9. % (21/212) reported high use of at least 21 units of alcohol in the previous 7 days. The prevalence of sedative use was highest among those who had used at least 21 units of alcohol in the previous 7 days (19.4%). Conclusion The use of sedatives was especially common among those who reported having used large amounts of alcohol.


Introduction
Benzodiazepines and non-benzodiazepine hypnotics are sedatives prescribed for various psychiatric and somatic conditions, making them one of the most prescribed psychotropic medications worldwide (Janhsen et al., 2015).Prescription of these medicines has increased significantly, even though their use has been associated with several public health concerns, such as increased benzodiazepine-related overdose deaths (Bachhuber et al., 2016;Votaw et al., 2019b).For example, in Finland nearly 10% of the adult population were using sedatives, and 4% were people with long-term use in 2014 (T.Kurko et al., 2018).Another Finnish study reported that 39.4% of those who initiated benzodiazepine medication from 2006 to 2015 continued using these medications in the long term (Taipale et al., 2020).The most common definition of long-term sedative use is 6 months during a year, but it varies between studies (T. A. T. Kurko et al., 2015).
Concurrent use of alcohol and sedatives may be problematic for various reasons.They share similar pharmacological properties and present similar sedative and intoxicating effects (Hollister, 1990).Thus, their concurrent use introduces potential unpredictable interactions that can even be fatal (Calhoun et al., 1996;Dåderman & Lidberg, 1999;Perera et al., 1987).Sedative use itself has been associated with multiple psychological and physical adverse effects, varying from memory disruption to risks of accidents (Lader, 1999).Risk of dependence also increases on long-term use of sedatives (Lader, 1999).
Previous literature introduces an abundance of studies on the epidemiology of independent alcohol or sedative use, but only a few studies have examined the epidemiology of concurrent use of sedatives and alcohol in the general population (Del Río et al., 2002;Veldhuizen et al., 2009).A great deal of the earlier studies are also focused on a particular clinically relevant sub-group, such as elders (Ilomäki et al., 2013) or people with misuse of alcohol or sedatives (Votaw et al. (2019a), Votaw et al. (2019b).
Despite the risks associated with the concurrent use of sedatives and alcohol, the epidemiology of this phenomenon in the general population has been vastly understudied.Using a sample from a Finnish general population, our aim was to study the prevalence of concurrent use of alcohol and sedatives and further examine the use of sedatives among some subgroups of people with alcohol use.

Participants
This study uses data from the Regional Health and Well-being Study conducted in 2010 in Finland, designed to obtain data on aspects relating to health and the use of health resources (Härkänen et al., 2014).The study utilized a nationally representative sample of Finland (n = 5,000), and the study participants were recruited randomly from the Population Register Center.A mailed questionnaire was sent to participants over 20 years of age with the option to submit it by mail or via an CONTACT Mauri Aalto mauri.aalto@tuni.fiFaculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Psychiatry, South Ostrobothnia Hospital District, Seinäjoki, Finland internet platform.Three versions of the questionnaire were prepared for the age groups of 20-54, 55-74 and 75 or older in four languages: Finnish, Swedish, Russian and English.The overall response rate to the questionnaire was 48%.The study participants in the final sample represented all age groups.

Use of alcohol
The participants were asked how many glasses, bottles or restaurant servings of various types of alcoholic beverages they had used over the past 7 days.The question was asked separately for four alcoholic beverage categories: "Medium strength beer, medium cider or long drinks (alcohol content 2.9% to 4.7%)"; "stronger beer, strong cider or long drinks (alcohol content over 4.7%)"; "wine"; and "spirits or other strong drinks."The participants were requested to respond "0" if they had not used any alcohol of the type indicated.Using the Finnish standard for drinks, a bottle (33 cl) of beer, cider or long drink; a glass of wine (12 cl) or a drink of strong alcohol (4cl) corresponds to one unit or approximately 12 g of pure alcohol.

Use of sedatives
The participants were asked whether they had used sedatives or hypnotics during the past 7 days.No further names or visual depictions of these medications were given.The response options were "No," "yes, other than prescribed medication" and "yes, prescribed medication."The two latter categories were pooled as "yes" due to sample size.

Statistical analysis
A stratified random sampling design was applied.The probability of being picked was set twice as high in the oldest group (75 or older) in order to correct for the relatively low response rate of the group.The response rates were corrected using the weight factors produced by the Inverse Probability Weighting (IPW) method.
The main outcome measure was the prevalence of sedative use by five categories of alcohol consumption in the previous week.The categories were determined based on alcohol consumption as 0; 0.1-6.9;7-13.9;14-20.9;and 21 or more units of alcohol.The prevalence of alcohol use and the prevalence of concurrent use of alcohol and sedatives were reported as mean values of alcohol use by sex.The confidence interval (CI) was set at 95%.Post hoc analysis was also conducted to determine whether there were participants with severe alcohol use disorder among the study population.Questionnaire data on self-reported attendance at a detoxification program during the previous 12 months was used for this purpose.Statistical analysis was conducted with PASW Statistics 18 software, using Complex Samples commands.

Results
Of the sample population, 33.9% (1695/5000) had answered the questions relevant to this study.Of the participants, 749 were men and 946 women.After the weighted correction, the total number of participants was 1818, of whom 895 were men and 923 women.The weight-corrected value was used in the following results.
Of the participants, 76.3% (1387/1818) had used alcohol in the previous week.The corresponding proportions were 80.6% (721/895) for men and 72.2% (666/923) for women.Those who had used alcohol reported an average of 8.1 (95% CI 7.4-8.8)units of alcohol.The results were 10.5 (95% CI 9.2-11.8)units of alcohol for men and 5.5 (95% CI 5.0-5.9)for women.A more detailed description of alcohol use in the sample population is presented in Table 1.Of the participants, 11.7% (212/1818) reported having used sedatives in the previous week.The corresponding proportions were 9.5% (85/895) for men and 13.8% (128/923) for women.More detailed prevalence data on the use of alcohol and sedatives is presented in Table 2.
Of the participants, 7.8% (142/1818) reported use of both alcohol and sedatives in the previous week.The proportions were 6.7% (60/895) for men and 8.9% (82/923) for women.Of the participants reporting use of sedatives, 67.0% (142/212) reported any alcohol use in the previous 7 days.The corresponding proportions were 70.6% (60/85) for men and 64.6% (82/127) for women.Within this group, 29.5% (62/212) reported having used at least seven units; 15.4% (33/212) at least 14 units and 9.9% (21/ 212) at least 21 units of alcohol in a week.Of the participants, 0.8% (21/1818) reported having used sedatives and at least 21 units of alcohol in the previous week.A more detailed description of alcohol use among people with sedative use is presented in Table 3.
The prevalence of the use of sedatives in the five subgroups by alcohol units is presented in Table 4.The prevalence was highest among those who had used at least 21 units of alcohol (19.4%, 21/108) in the previous 7 days.The corresponding proportions were 14.0% (12/86) for men and 39.1% for women (9/23).The prevalence of the use of sedatives was the second highest among those who had not used any alcohol (16.2%, 70/431) and lowest among those who had used 7-14 units of alcohol (9.0%, 29/321) in the previous 7 days.
Severe alcohol disorders were rare among this study population as only one participant reported attendance at a detoxification program.

Discussion
The concurrent use of alcohol and sedatives was common in the general population (7.8%) and even more common among those who used alcohol at least 21 units in a week (19.4%).
One-tenth of those with sedative use reported alcohol use of at least 21 units in a week.These are concerning findings because even lesser amount of alcohol use might be a risk when used concurrently with sedatives (Hollister, 1990).
We also found that the rate of sedative use among women compared to men was pronounced in the subgroup of highest alcohol use in our study.This may relate to overall higher prevalence of sedative use in women, which may be explained by higher prevalence of anxiety disorders (Martin, 2003).Some of our findings are aligned with previous literature (Del Río et al., 2002;Veldhuizen et al., 2009).Sedatives were more frequently used by women, and alcohol was more frequently used by men.Similar to previous studies, the prevalence of any alcohol use was lower in people who use sedatives.The Canadian study presented that even heavy drinking was less frequent among those who use sedatives (Veldhuizen et al., 2009).However, our study suggests that the prevalence of sedative use may increase a certain number of alcohol units.It should be noted that prevalence figures between studies are not directly comparable due to different methodological approaches.
There are several reasons, which might explain concurrent use being more prevalent among those who drink.Alcohol use has been associated with an increased risk of depression and anxiety disorders (Haynes et al., 2005).Those who use alcohol may experience more severe symptoms of depression and anxiety and therefore may use sedatives in an attempt to better cope with them.Similarly, sedatives may be used in an attempt to relieve possible symptoms caused by alcohol, e.g., withdrawal symptoms.Among people with non-medical use of sedatives, the most common motives for simultaneous alcohol use were to relieve stress, to sleep and to change mood (Nattala et al., 2012).Previous studies have suggested that index dependence increases the risk of another dependence (McGrath et al., 2020).Thus, dual dependence of alcohol and sedatives might also partly explain our findings of higher prevalence of sedative use among those who report using high doses of alcohol.
The sample used in this study is part of a large national data collection, which renders it representative of the general Finnish population.The results are thus generalizable at least in most western countries with similar trends in alcohol and sedative use.In sensitive matters such as alcohol use, it is suggested that a self-reported questionnaire, which was used in the present study, may reflect participants' real behavior better than an interviewed survey (Hochstim, 1967).The questions about medication use and drinking were dispersed across the questionnaire, which probably decreased the effect of social desirability bias related to the simultaneous use of alcohol and medication.
The response rate was relatively low, which is typical for mailed questionnaires.It is likely that the concurrent use of alcohol and sedatives was higher among individuals who did not participate.Only one participant reported attending a detoxification program, indicating that individuals with an alcohol use disorder may be underrepresented in the sample.If so, the results might underestimate the prevalence of concurrent use of alcohol and sedatives.A similar effect would occur if the self-reported use of alcohol was underestimated, which is possible.Due to limitations in the questionnaire, it was not possible to determine if the use of sedatives occurred simultaneously with the use of alcohol.Less than five reported other than prescribed use of sedatives in the past 7 days.Therefore, it was not possible to separate prescription use and misuse of sedatives from this data.Relative weakness of the questionnaire was that it did not include examples of sedative or hypnotic medicines.Thus, it is possible that the participants may have reported other medication as sedatives.However, we estimate that in Finland sedatives are widely understood to refer to benzodiazepines by general public.
As a conclusion, the concurrent use of alcohol and sedatives is common.Subsequent studies should examine if this is explained by sociodemographic or psychosocial factors.Based on our findings, it is important to assess patients' alcohol use before prescribing sedatives.ATH study is a cross-sectional study, and it has been conducted annually starting from 2010.ATH study was approved by the Coordinating Ethics Committee of Finnish Institute for Health and Welfare (THL) in 2010 (approval number THL107/6.01.00/2010).

Funding
For this study, JP has received funding from the South Ostrobothnia Hospital District.For this study, AM has received funding from the Emil Aaltonen Foundation, South Ostrobothnia Hospital District and The Finnish Foundation for Alcohol Studies.The funders had no role in the design or conduct of the study; in the collection, management, analysis, or interpretation of the data; in the preparation, review or approval of the manuscript; or in the decision to submit the manuscript for publication; Etelä-Pohjanmaan Sairaanhoitopiiri [6000 euros].

Table 1 .
Prevalence of alcohol use by units of alcohol in the previous 7 days in the sample population (n = 1818).

Table 2 .
Prevalence of the use of alcohol and sedatives in the sample population (n = 1818) in the previous 7 days.

Table 3 .
Prevalence of alcohol use by units of alcohol in the previous 7 days among the people with sedative use (n = 212).

Table 4 .
Prevalence of the use of sedatives in subgroups by alcohol units in the previous 7 days in the sample population (N = 1818).