Introduction

Concurrent alcohol and medication use can result in significant problems especially in mid to later life (50 years and over)[1]. When alcohol is combined with nonsteroidal anti-inflammatory drugs it can cause stomach bleeding, gastric inflammation and liver damage[2]. Alcohol also enhances the sedative effects of antidepressants, antihistamines, barbiturates, muscle relaxants, benzodiazepines and opioids. This can have serious consequences such as falls, accidents and even death[2].

Older people are more likely to be at risk of alcohol-related adverse drug reactions because they are more likely to use multiple alcohol-interactive drugs[2]. The average person aged 50 years and over takes at least four medications a day[3]. In addition, alcohol consumption has recently increased among older age groups in many developed countries including the United States, Australia, and many parts of the European Union[4–7]. In the UK, older people tend to drink more frequently than younger people[8] with 17% of people aged over 50 drinking alcohol four or more times each week[9]. In addition, while older people might consume less alcohol overall than younger people[8], 17% of people aged over 50 are at increasing risk and 3% are at high risk of developing alcohol use disorders or dependence[9].

Research has shown that adults in mid to later life consume alcohol for a number of different reasons which can be categorised as either positive or negative reinforcement[10]. While stressful life events, such as bereavement or retirement, may trigger late-onset drinking in some, this is not the case for all[11, 12]. Alcohol use has been associated with self-medication for both physical and mental health problems as well as insomnia and has also been linked to boredom, loneliness, isolation and homelessness[11]. However, the direction of causality in the relationship between alcohol use and many of these factors is often in doubt[10]. Older people also report consuming alcohol for positive reasons such as enjoyment and socialisation[11, 13–14].

A number of systematic reviews and quantitative studies have shown that combined alcohol and medication use is common in older people[15–23]. A survey of Irish adults aged 60 years and over has shown that 60% of people using alcohol-interactive drugs also reported alcohol use[24]. A similar study of older adults aged 65 years and over in Finland reported 63% of those taking medication also used alcohol[22]. In the United States research has reported rates of combined alcohol and alcohol-interactive drug use ranging from 19% to 78% in older people aged 65 years and over[2, 23].

Alongside concurrent alcohol and medication use, alcohol itself is often used instead of medication for a number of health-related conditions[25, 26]. The extent of drinking for medicinal purposes has been quantified in a small number of studies in the United States, Canada and Finland[25–28]. Research in Finland, of people aged over 75 years, revealed that 40% reported using alcohol for medicinal purposes. The main reasons cited were heart and vascular disorders (38%), sleep disorders (26%) and mental health problems (23%)[26]. Chronic pain has also been associated with the use of alcohol in older people[27, 28]. Research, mainly from the United States, has revealed associations between problem drinkers and severity of pain[27], and suggests that those older individuals who have more painful medical conditions also have more frequent drinking problems[28].

However, whilst there is reasonable quantitative evidence on the prevalence of concurrent alcohol and medication use, and drinking for medicinal purposes in mid to later life, there is a lack of understanding of the views and experiences of older people themselves on this issue. Moreover, previous studies have been based outside the UK, despite the fact that evidence suggests the UK has both an aging population and high rates of heavy drinking amongst this population group. This lack of both qualitative and quantitative research in the UK and the limits of generalising research from other cultural contexts, means there is a real need for UK-based research in this area. This paper reports the first UK-based, qualitative study examining experiences of and attitudes to concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life.

Methods

The study involved qualitative interviews and focus groups with a purposive sample of people aged 50 years and over. Ethical approval was issued by Newcastle University Research Ethics Committee (application no. 000224/2009). Participants provided written informed consent to participate in this study and for data to be published. In line with the terms of consent to which participants agreed, the data are not publicly available.

From an epistemological stance (the set of assumptions that help explain the nature of the world)[29] this research is situated within the interpretivist paradigm. Interpretivism is associated with the understanding of complex and often changing entities. Interpretivists assert that there is no such thing as a single objective reality. Rather, there are multiple constructed realities, because different people are likely to experience the world in differing ways. The interpretivist approach delivers a contextualised, rich, detailed account of human experiences[30]. In order to gain this depth of understanding, a range of qualitative methods were employed. We combined one-to-one interviews with focus groups in order to compare individual accounts with perspective that have been socially negotiated. Triangulation of data from these two sources was intended to situate the individual beliefs within the social discourse likely to have shaped their production.

Twenty-four qualitative interviews (12 men, 12 women) were conducted between 19/11/09 and 15/03/10. Sample size was determined by reaching data saturation where the research team deemed no new themes to have emerged in three consecutive interviews[31]. Purposive sampling (a non-random method of ensuring that particular categories of cases within a sampling universe are represented in the final sample)[32] aimed to recruit both sexes and represent a broad range of ages and self-reported drinking practices. This sampling approach was intended to reflect those who might request help or support from Age UK, the UK’s leading charity for older people (http://www.ageuk.org.uk/). Age UK provides services and support at a national and local level to “inspire, enable and support anyone over the age of 50 years”[33].

Three branches of Age UK and two services for alcohol problems, covering a wide geographical area, distributed research information leaflets to clients aged 50 and over with experience of drinking alcohol. Staff from the recruiting organisations invited clients to consider participating in an interview, answered any questions they had about the research and asked those who were interested to complete a consent form.

All potential participants were contacted by telephone by one of the authors (GW) to arrange an interview. As the initial sample appeared to consist of a large proportion of participants who described themselves as recovering dependent drinkers, strategic ‘snowballing’ was used to add further interviewees. This involved existing study participants recruiting future participants, who were not using services and therefore not recovering dependent drinkers, from among their acquaintances. In total, nine participants were recruited via Age UK, 13 via services for alcohol problems and two via strategic snowballing. Considerable diversity was ultimately achieved in terms of gender, age, social situation and level of alcohol consumption (see Table 1).

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Table 1. Interviewee characteristics.

https://doi.org/10.1371/journal.pone.0205956.t001

Three focus groups were facilitated between 15/03/10 and 19/10/10. Staff at the three branches of Age UK distributed research information leaflets to members with experience of drinking alcohol, inviting them to consider participating in a focus group. Staff answered any questions they had about the research and asked those who were interested to complete a consent form. The first group comprised 9 participants (1 man, 8 women, ages 79–95); the second group comprised 12 participants (5 men, 7 women, ages 50–85) and the third comprised 6 participants (all women, ages 51–76). Participants in each focus group were known to each other through their membership of Age UK. To encourage participation, focus group participants were not required to disclose personal details other than age and date of birth; these data were gathered on consent forms. At the groups, participants were invited by the facilitator (GW) to offer views in general rather than recounting personal experiences in front of others.

Interviews and focus groups were conducted by GW, a male, experienced post-doctoral researcher, lasted between 40 and 150 minutes, and took place either at individual respondent’s homes or the offices of participating organisations. The research team prepared topic guides (see supplementary files) to initiate or return discussion to the research topics; drinking in later life, experiences of service use and support, and how support could be improved. In addition, participants were specifically asked whether they were taking any prescription medications, whether this was affected by alcohol and if so how, and whether their doctor had discussed this with them. The interviewer was not previously known to participants and introduced himself as a researcher with an interest in alcohol use in later life. Interview and focus group data were audio recorded, transcribed verbatim, anonymised and loaded into NVivo qualitative software, version 10[34]. Data were analysed using a grounded approach[35–36] which operates well within the interpretivist paradigm and starts with the qualitative data collected. As the data are reviewed, repeated concepts become apparent. As more data are collected and re-reviewed, these concepts can be grouped into themes. The original position of Strauss and Corbin[35] was one of an objective researcher who tries to represent an external reality as accurately as possible. Analysis involved repeatedly reading transcripts and identifying emerging themes; early analysis informed later interviews and focus groups. Authors were aware that the interviewer was part of the research process and, along with those being researched, brought with him concepts, ideas, theories, values and experiences. Therefore themes were refined through discussion amongst all the authors with consideration of divergent cases in order to provide a full account of the data that recognises and explores how demographic factors will have shaped participants’ views. Focus group data were used to triangulate findings from individual interviews. In the results section below we report findings from individual interviews, then consider how the focus group data inform or challenge these themes. The original study aimed to elucidate the views of older individuals about alcohol consumption, health, and well-being in order to inform future targeted prevention in this group [11, 37]. This paper is not exhaustive in its presentation of the analysis; rather it focuses on specific themes (with each subheading representing a distinct theme) which emerged from the data relating to alcohol and medication.

Results

Four distinct themes emerged from the data: drinking and using medication regardless of potential consequences; health professionals being unaware of alcohol use; reducing or stopping alcohol consumption because of medication; and using alcohol to self-medicate. Each of these themes will be discussed below.

Discussion

Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Older people in this study also self-medicated, regularly using alcohol to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study tended to report using alcohol to cope with mental health problems while men were more likely to describe reducing alcohol consumption as a consequence of being prescribed medication.

Other research has shown that depression, anxiety and other mental health problems are commonly seen in older individuals with alcohol dependence[38], with many older adults who develop depressive symptoms having a higher likelihood for day drinking[39]. One study revealed that while older people commonly drank alcohol to enhance positive daily experiences, they also drank to mask negative experiences. The study also reported that women had a tendency to drink more alcohol when stressed compared to men[40], which is consistent with findings from this study. Another interview-based study with community-dwelling older people reported that 23% cited using alcohol to deal with mental health problems[26].

However, the relationship between substance use disorders and mental health problems such as depression and anxiety is complex and the direction of causality is often in doubt. For example, does increased alcohol intake result from ‘self-medication’ in depression, or is the depression secondary to high levels of consumption? Davidson[41] reported that depression and alcohol dependence are frequently found to co-exist but the relationship between these disorders required further elucidation. His study tested several hypotheses related to the relevance of whether a diagnosis of depression was made before admission or after detoxification in an episode for those with alcohol dependence. For the episode of drinking which led to admission, a diagnosis of major depression was found in the majority of patients (67%). Once detoxification from alcohol took place, only a minority (13%) met criteria for major depression. He suggested therefore that depression is largely associated with the episode of drinking which led to admission in patients who are dependent on alcohol and may be due to the effect of chronic alcohol intoxication[41]. Alcohol consumption has also been linked to pain, with the majority of older adults who report drinking problems also reporting severe pain[34]. The “self-medication” hypothesis states that alcohol consumption is increased to combat rising levels of pain and has also been positively identified in younger adults[42]. Older problem drinkers in one study reported more severe pain, more disruption of daily activities due to pain, and more frequent use of alcohol to manage pain than older non-problem drinkers[27]. Other interview-based research has reported that 40% of older people used alcohol for medicinal purposes. This was equally common in women, and the most common reasons for use were reported to be heart and vascular disorders (38%) and sleep disorders (26%)[26]. The use of alcohol in aiding sleep was also reported by Sproule et al., revealing that 6% of older people chose alcohol as a non-prescriptive medication to help them sleep[25].

Findings from this study are consistent with the quantitative literature which suggests that the extent of combined alcohol and medication use among older people is widespread[2, 23]. However, this study further highlights that many people combine alcohol and medication despite knowing the potential consequences. Nevertheless, some participants in this study were unaware of the consequences of combining alcohol with their medication as they reported that their family doctors had never enquired about their use of alcohol. This is not surprising given that even when family doctors are encouraged to screen for alcohol problems they may both under-detect alcohol use disorders among older patients[43] and under-deliver health-promoting advice to them[44]. Furthermore, nurses report avoiding engagement with older people about alcohol use as they worry about depriving them of the social benefits of drinking[45–46].

Findings from this study are also consistent with the literature revealing that older people often use alcohol to self-medicate[25, 26] to manage pain[27, 28], aid sleep[25, 26] and to cope with mental health problems[26]. However, the qualitative nature of this study revealed that some older people continue to use alcohol to self-medicate even when they are skeptical of its medicinal properties. This study did indicate however that some older individuals will view being prescribed medication as a reason to reduce or stop their alcohol consumption, particularly when instructed by their family doctor to do so, through fear or experience of the adverse reactions. A large quantitative survey in the US found individuals who initiated antipsychotic and antineoplastic therapies were most likely to quit drinking[16]. However, some older individuals in this study rationalise their continued drinking and medication use on the grounds that they do not experience noticeable side effects.

This research contributes the first qualitative data regarding alcohol and medication use in mid to later life in the UK. The sample was restricted to a single region of the UK and with some characteristics of the sample over-represented (e.g. women and recovering dependent drinkers). Whilst attempts were made to recruit other types of drinkers we found higher-than-expected levels of enthusiasm among the treatment sample who appeared keen to share their experiences. In keeping with the assumptions of qualitative research, participant views expressed in interviews are recognised as having been intrinsically shaped by social influences. The specific use of focus groups to assess socially-negotiated versions of drinking in later life, and therefore what beliefs and attitudes might be seen as socially desirable in the social milieu of the individual interviewees, is a strength of this research. However, two of the focus groups contained participants from a broad age range, and given that focus groups are sensitive to power and social group dynamics, this might have affected participants’ willingness to express their views.

Triangulation of data appeared effective as similar themes arose from both interviews and focus groups although participants in the focus groups spoke of issues with alcohol and medication use as being experienced by family and friends rather than themselves. This lack of personal experience could however simply have been a consequence of recruiting focus group participants only via Age UK. As a result, focus group participants were more likely, than interview participants, to be moderate drinkers and this must be acknowledged as a limitation to triangulation. The negotiated social norm relating to combined alcohol and medication use was that it was not an acceptable form of behaviour, unlike using alcohol to self-medicate which was endorsed. This might be explained, at least in part, by the concept of ‘healthism’ or the imperative of health, which proposes an individual’s pursuit of health is a valuable activity that responsible individuals undertake [47]. When individuals engage in healthy practices they may feel good about themselves but when they fail to do so they may feel distressed or stigmatised (e.g. heavy alcohol consumption). Given that self-medication is a practice that is commonly engaged in and to some extent considered a normal way of attempting to address ailments it may be that using alcohol to self-medicate was an extension of these broader societal norms [48, 49]. Further qualitative research should explore these important findings in other geographical locations of the UK and internationally and with greater representation from male participants.

Conclusion

There is a complex relationship between alcohol and medication use which is multi-faceted and related to other issues such as mental health. Our data revealed two main groups of participants. The first group was those participants who used alcohol with, or instead of, their medication. This group was knowledgeable about the contraindications but did not seem overly concerned about the potential risk. It is important therefore that health professionals including family doctors, community nurses, and pharmacists consider older patients’ alcohol consumption prior to prescribing or dispensing medication. Health professionals should also monitor older people who have been prescribed alcohol-interactive medication, for subsequent drinking[50]. Ultimately, health professionals need to address the underlying reasons for alcohol use such as mental health, pain, insomnia or dependence. The second group of participants was those who were unaware of alcohol-related adverse drug reactions and who would have benefitted from being informed of the dangers of concurrent alcohol and medication use. Overall evidence based guidelines regarding alcohol use in mid to later life are needed, especially in the UK, to support health professionals.

Acknowledgments

We are most grateful and extend our sincere thanks to all the people who took part in the study.