Mohammed Gharbia, James Larkin, Tom Fahey, Frank Moriarty
Medication review is a core component of multifactorial falls prevention in older adults (1). The 2023 Beers Criteria advise avoiding opioid-gabapentinoid combinations because of severe sedation-related adverse events, and avoiding combinations of three or more CNS-active medicines because of increased falls and fracture risk (2). STOPPFall similarly identifies opioids, benzodiazepine receptor agonists (BZRAs) and several antidepressant classes as fall-risk-increasing medicines (3). Adverse drug reactions are an important cause of hospital admission in older people, with non-steroidal anti-inflammatory drugs (NSAIDs) among commonly implicated medicines (4,5). Many of the classes considered in this study may be used in pain management, either as analgesics or as potential adjuvant treatments, although several also have important non-pain indications. Evidence on opioid-gabapentinoid combinations is clinically concerning but not uniform. Among older US Medicare beneficiaries, adding a gabapentinoid to established opioid therapy was associated with a higher rate of fall-related injury (adjusted hazard ratio 1.69, 95% confidence interval 1.17-2.44), whereas simultaneous initiation was not (6). In a separate study of older adults receiving chronic opioid therapy, concurrent gabapentin was associated with higher odds of a fall than opioid monotherapy (adjusted odds ratio 1.73, 95% confidence interval 1.08-2.78) (7). Other claims-based studies have examined opioid-gabapentinoid and broader opioid-related medication combinations in relation to falls and fractures (8,9). Evidence for gabapentinoids and fracture outcomes also differs by study design and comparator. Recent gabapentinoid dispensing was associated with higher odds of hip fracture in an Australian case-case-time-control study, particularly among people with frailty or chronic kidney disease (10). A UK linked primary-care study found a modest association between current gabapentinoid use and fractures in people with inflammatory arthritis (11). An active-comparator study, however, found no increase in fall-related healthcare visits after gabapentin initiation compared with duloxetine (12). Together, these findings show that population, exposure timing, comparator choice and confounding control influence the estimated association (10-12). The study is also relevant to Irish prescribing. Strong opioid prescribing increased between 2010 and 2019, particularly in older adults (13). Gabapentin and pregabalin prescribing increased from 2010 to 2020, alongside increases in law-enforcement seizures of pregabalin and postmortem gabapentinoid detections; these ecological trends signal safety concerns but do not establish causal relationships between prescribing and the other population-level indicators (14). Analgesic dispensing rates in Ireland were generally higher and increased for several classes between 2014 and 2022, whereas rates for many classes declined in England (15). A 2025 Irish multiagency report highlighted concerns about overprescribing, dependence, access to treatment supports and incomplete visibility of public and private BZRA and gabapentinoid prescribing (16). The Medication Reconciliation (MedRec) data resource links GP prescribing and clinical records with hospital discharge information from 44 Irish general practices (17-20). Previous MedRec studies have examined prescribing around fall-related hospitalisation and continuation after hospital initiation of BZRAs and opioids (17-19). This study extends this work by examining recent analgesic and CNS-active medication combinations in relation to all-cause and fall-related hospitalisation among older adults.