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Jonathan Gabe, Katie Coveney and Simon Williams Prescriptions and Proscriptions: Moralising Sleeping Pills.

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Presentation on theme: "Jonathan Gabe, Katie Coveney and Simon Williams Prescriptions and Proscriptions: Moralising Sleeping Pills."— Presentation transcript:

1 Jonathan Gabe, Katie Coveney and Simon Williams Prescriptions and Proscriptions: Moralising Sleeping Pills

2 Introduction Pharmaceuticalisation of insomnia contentious Involves sleep being redefined as medical problem requiring medical solution – sleeping pills Sleeping pills – bad press – side effects – addiction – mortality risks UK NICE recommendations – hypnotics only for severe insomnia (disabling/ extreme distress) - Lowest dose, short periods Yet long term prescribing still common in the UK

3 The Sociology of Hypnotics/Prescribed Medicines (1/3) Sociological research on patient experience generally quite old – Gabe et al 1982,1984 1986 Focus older benzodiazepines (Mogadon) rather then newer Z drugs Found 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

4 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.

5 Sociology of Hypnotics/Prescribed Medicines (3/3) Recent study of older people’s 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/ dosage In sum act of taking meds in daily life highly moralised

6 Methods Aim – explore ways in which use/ non use of prescribed hypnotics understood / negotiated in daily life ESRC study of sleep & wakefulness medicines 19 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/ retired Asked how managed sleep problems + what thought appropriate role for medications. Focus – 49 participants who said had/were using sleeping pills.

7 Findings Participants depicted selves / relationships with hypnotics in range of ways 6 user identities: 1. The Deserving Patient 2. The Responsible Patient 3. The Compliant Patient 4. The Addict 5. The Sinful User 6. The Noble Non User Each identity constructed through intersecting discourses – Ambivalence/Reflexivity/Addiction & Loss of Control

8 The 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 didn’t 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.

9 Deserving patient (2/2) All presented themselves as deserving a pharma solution Were in need of sleeping pills – so morally justified. Had enduring health / social problems contributed to poor sleep SA 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 doctors

10 The 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 you’re beginning to rely on it. And that’s frightening. And so you have to be self controlling, and try and control the drug and gradually lessen it. RFG2 F2 `That’s why you cut it down if you can’.

11 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

12 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 / responsible Seemed reluctant to say anything that might suggest `addicted’ Acknowledging long term use & need meant felt ambivalent about user identity:

13 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 you’re not taking them too often..” But I am almost of the philosophy that if he doesn’t say anything that is OK. And I find it very comforting that I’ve 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 don’t want to become addicted, but I honestly don’t think I am addicted.. There’s the occasion I’ve forgotten about them and absolutely got worried.. But it hasn’t been a disaster.. If I was addicted it really would cause problems.’

14 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 addicts BUT 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

15 The Sinful User (1/3) Admitted to ‘morally dubious practices - being ‘naughty’, ‘sinful’ Sharing tablets, stock pilling, getting round medical authority Often when doctor wouldn’t prescribe. Able to forgive selves as ‘in need’ Still deserving and responsible PCFG M3: 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.

16 The Sinful User (2/3) Sharing in retirement home Not able to get from doctor any more Clearly secretive about it Knew not appropriate but running out RFG1 Moderator: Have you ever shared them with each other? F4: When we run out F2: Be careful what you say (F4). She is inclined to slide me a few Temazepam. F4: If she was running out, I’d say “have some of mine”. F7: See you shouldn’t say that F4: But we are running out of our prescription.

17 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

18 The Noble Non User (1/3) Prevalent theme among non users/ ex users Rejection of pharmaceuticalisation of sleep – something should be able to deal with oneself Using hypnotics is ‘giving in’ / `taking the easy route’/ against world view. AmbFG2 F2 Moderator – What have you used to sleep? F2 – Nothing. I’m quite a natural.. I like the natural complementary side of.. I don’t 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.

19 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 wasn’t taking my medication, because I refused to take it. He agreed because I was adamant I didn’t want the hangover in the morning. And I’ve never had any aid to sleep in the form of a sleeping tablet since that one occasion.

20 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 oneself - past experiencing of taking. Not shown here but some could still see the need for use in certain circumstances.

21 Conclusion (1/5) Identity central to medication use – emerges from uncertainties faced when ill Identified a variety of pill user identities – Focused on 5 - Deserving Patient - The Responsible User - The Addict - The Sinful User - The Noble Non User Each identity constructed through intersection of various discourses - Ambivalence, Reflexivity, Addiction & Loss of Control.

22 Ambivalence (2/5) Across all focus groups – even those most anti- meds Anti med group could still see the need in certain circumstances. Deserving patients aware of unpleasant side effects/ doubts about efficacy. Needed but didn’t want. Reflects late modern culture – previous certainties undermined / moral absolutism challenged.

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

24 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 meds General 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

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

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