Hypnotics in the News

Jonathan Gabe, Katie Coveney and Simon WilliamsPrescriptions and Proscriptions: Moralising Sleeping Pills

IntroductionPharmaceuticalisation of insomnia contentiousInvolves sleep being redefined as medical problem requiring medical solution sleeping pillsSleeping pills bad press side effects addiction mortality risksUK NICE recommendations hypnotics only for severe insomnia (disabling/ extreme distress)- Lowest dose, short periodsYet long term prescribing still common in the UK

The Sociology of Hypnotics/Prescribed Medicines (1/3)Sociological research on patient experience generally quite old Gabe et al 1982,1984 1986Focus older benzodiazepines (Mogadon) rather then newer Z drugsFound prescribing and use moralised- Patients feel need to convince doctor sleep difficulties serious- Consultation a last resort after trying to manage themselves /use an `evil necessity Recent applied research in UK suggests - 20% users want to stop.- 50% tried to stop

Sociology of Hypnotics/Prescribed Medicines (2/3)More recent studies of medicines use in general found: - users increasingly knowledgeable/reflexive- assess the risks /benefits- make informed choices with doctor- alter frequency/size of dose (Pound et al 2005)- draw on a range of therapies (including CAM) Personal medication practices influenced by - practical concerns over meds use - congruence with world view - observation and experimentation.

Sociology of Hypnotics/Prescribed Medicines (3/3)Recent study of older peoples decision about sleep meds (Venn & Arber 2012) - poor sleep often not seen as health problem- sleep meds seen as morally inappropriate `unnatural interference with natural state- sleeping pills associated with addiction + loss of control - BUT only few had taken sleeping pills - these felt ambivalent about taking / tried to control use (timing/frequency/ dosageIn sum act of taking meds in daily life highly moralised

MethodsAim explore ways in which use/ non use of prescribed hypnotics understood / negotiated in daily lifeESRC study of sleep & wakefulness medicines19 Focus groups - 84 participants likely to have range of views / experience of sleep management Primary care patients/ patients with `sleep disorder / shift workers/ students/ parents of young children/ retiredAsked how managed sleep problems + what thought appropriate role for medications.Focus 49 participants who said had/were using sleeping pills.FindingsParticipants depicted selves / relationships with hypnotics in range of ways6 user identities:The Deserving PatientThe Responsible PatientThe Compliant PatientThe AddictThe Sinful UserThe Noble Non User Each identity constructed through intersecting discourses Ambivalence/Reflexivity/Addiction & Loss of ControlThe Deserving Patient (1/2)Participants who had used sleeping pills took turns to tell story- explain / justify use.Other members of group listened/ occasionally expressing empathy / rarely challenged.

PC FG M 2`The reason I had [sleeping pills] was because I had a bad accident several years ago and the particular hospital I was in said something to help you sleep and when you come out just go and see your doctor for a prescription and continue. Simple as that..

PC FG F1`With me it was I didnt sleep at the time my husband died... I struggled along for a number of years.. But various problems that I had, not really coping all that well. Doctor gave me a prescription. He said take one of these every second day and see how you go. Well it was lovely, but I was back within three days can I have some more. So it has gone on from then really.

Deserving patient (2/2)All presented themselves as deserving a pharma solutionWere in need of sleeping pills so morally justified.Had enduring health / social problems contributed to poor sleepSA FG F1`Not sleeping? Well ..all the doctors said it was because of the stressful life I had, and I had as I say a very sick child and my husband was away a lot, and a very, very stressful job, and so I went to a doctor and I just said, you know I need something to get me to sleep so they gave me some tablets.Narrative functioned to legitimate pill use a deserving patient in need, recognised by doctorsThe Responsible User (1/2)Respondents also often presented themselves as vigilant in self monitoring use of pills.Image of themselves as responsible users used meds appropriately / were knowledgeable about use and effects.Concerned about becoming dependent took steps to avoid / reduce dose in discussion with doctor or outside of medical authority.RFG3 F3 `What frightens me.. I had a hip operation and I have to take some medication to get me to sleep at night because of the pain. The trouble is, after a few nights youre beginning to rely on it. And thats frightening. And so you have to be self controlling, and try and control the drug and gradually lessen it.RFG2 F2 `Thats why you cut it down if you can.

The Responsible User (2/2)Where only one person in the group had used sleeping pills - could find self challenged

Forced to justify/ explain demonstrate deserving / responsible

Overall responsible user ambivalent about use of sleeping tablets, tried to minimise use, modified drug use outside medical authority, substituted meds with non pharma alternatives at times

The Addict (1/3)The type of user participants did NOT want to become.Addiction associated with escalating use / loss of control over use of meds/self.Long term users in particular tried to distance identity from that of an addict because deserving / responsibleSeemed reluctant to say anything that might suggest `addictedAcknowledging long term use & need meant felt ambivalent about user identity:

The Addict (2/3)

PCFG M1`I remember vaguely talking about sort of getting addicted and I think he (GP) said you know, you want to make sure youre not taking them too often.. But I am almost of the philosophy that if he doesnt say anything that is OK. And I find it very comforting that Ive got them there for when I need them, you know. But I do very much try and watch it myself.Moderator: Is addiction an issue in your mind?M1: No, I mean it is an issue in the fact that I dont want to become addicted, but I honestly dont think I am addicted.. Theres the occasion Ive forgotten about them and absolutely got worried.. But it hasnt been a disaster.. If I was addicted it really would cause problems.

The Addict (3/3)As this quote shows, some said been told by GP to reduce/withdraw meds while still prescribing.Conveys impression long term use `wrong and users could be addictsBUT prescription continues to legitimate need Result - divided emotions guilt / embarrassment at use, alongside having legitimate need.Risk of addiction managed by saying reduced use if worried

The Sinful User (1/3)Admitted to morally dubious practices- being naughty, sinfulSharing tablets, stock pilling, getting round medical authorityOften when doctor wouldnt prescribe.Able to forgive selves as in needStill deserving and responsiblePCFGM3: I have sinned occasionally, when there has been a big day, a long travelling day..F1: I think we all know the dangers of being over sedated.. But occasionally if you have to take an extra one.. You have just got to forgive yourself and get on with your life.

The Sinful User (2/3)Sharing in retirement homeNot able to get from doctor any moreClearly secretive about itKnew not appropriate but running outRFG1Moderator: Have you ever shared them with each other?F4: When we run outF2: Be careful what you say (F4). She is inclined to slide me a few Temazepam.F4: If she was running out, Id say have some of mine.F7: See you shouldnt say thatF4: But we are running out of our prescription. The Sinful User (3/3)In sum Some mentioned more morally dubious practices unsanctioned by doctors.

Sinful but forgivable because of need.

Yet tried to maintain image of responsible/ reflexive user

The Noble Non User (1/3)Prevalent theme among non users/ ex usersRejection of pharmaceuticalisation of sleep something should be able to deal with oneselfUsing hypnotics is giving in / `taking the easy route/ against world view.

AmbFG2 F2Moderator What have you used to sleep?F2 Nothing. Im quite a natural.. I like the natural complementary side of .. I dont particularly like the allopathic way of treating your body. So I definitely would never go to the doctor and say Can I have some Zoplicone please and I would never think about taking anything orally to make me either stay awake or go to sleep.The Noble Non user (2/3)Some had used pills in the past but disliked side effects / not used since.RF G3 M1`50 years ago I was admitted to hospital and was in a lot of pain. So I was given prescribed sleeping pills which I took for two nights and woke up with a hangover. I was asked by the consultant why I wasnt taking my medication, because I refused to take it. He agreed because I was adamant I didnt want the hangover in the morning. And Ive never had any aid to sleep in the form of a sleeping tablet since that one occasion.

The Noble Non User (3/3)In sum noble non users gave different reasons for rejecting / resting pharmaceuticalisation of sleep - against world view- something should be able to deal with oneselfpast experiencing of taking.Not shown here but some could still see the need for use in certain circumstances.

Conclusion (1/5)Identity central to medication use emerges from uncertainties faced when illIdentified a variety of pill user identities Focused on 5 - Deserving Patient - The Responsible User - The Addict- The Sinful User- The Noble Non UserEach identity constructed through intersection of various discourses - Ambivalence, Reflexivity, Addiction & Loss of Control.Ambivalence (2/5)Across all focus groups even those most anti- medsAnti med group could still see the need in certain circumstances. Deserving patients aware of unpleasant side effects/ doubts about efficacy. Needed but didnt want.Reflects late modern culture previous certainties undermined / moral absolutism challenged.

Reflexivity (3/5)Older participants more experienced users more experiential knowledge.But little difference between age groups about asserting responsibility for health / meds useAll presented selves as reflexive consumers of meds - questioning medical authority / altering treatment / resisting useMedical knowledge not privileged but can be re-worked - based on relations with meds in daily life hybridising practices

Addiction and Loss of Control (4/5)Taking sleeping pills highly moralised in part because of association with addiction/stigma.Reinforced by nature of sleep as something to manage without medsGeneral avoidance of being seen as an addict users resisted those who constructed them as one.Described strategies of self surveillance / self governance to protect selves from becoming an addict.Part of attempt to present self as `in control whether took, how many, how often, can stop

Implications for Pharmaceuticalisation (5/5)Evidence of how pharmaceuticalisation / depharma shape cognitive / cultural framing of sleep problems.Pharma treatments seen as far from perfectMedical community generally critical of use feeds moralisation of issue.Evidence suggests pragmatic decision making about use of pills what works whats appropriate/acceptable.Illustrative of resistance and need.Even long term users reflexivePharmaceuticalisation of sleep not linear but in state of flux/ uncertain future