Medicating sleep?

Medicating sleep? Patient and professional perspectives on prescription hypnotics in UK primary care

Background • Approx. 10 million prescriptions issued for sleeping pills in the UK each year – incl. four ‘short-acting’ benzodiazepines (Loprazolam, Lormetazepam, temazepam and nitrazepam) and three ‘Z drugs’ (Zaleplon, Zolpidem and Zopiclone) • The prescription of hypnotics is a politicised issue in the UK - measures in place to monitor and reduce the prescription of hypnotics in primary care • (Rhetorical) push towards depharmaceuticalisation of insomnia –Non-pharmacological measures are recommended as a first line treatment • All of the sleeping pills currently available in the UK are only licensed for short term use only - No pharmaceuticals are licensed for long term treatment of insomnia due to lack of evidence for long term efficacy, risk of dependency and other side effects.

Aims • To compare and contrast GP and patient views on “medicating sleep” in UK primary care Data are drawn from semi-structured interviews with 7 GPs and 3 focus groups with 12 chronic users of hypnotics

i. Medical uncertainty and diagnostic ambivalence • Ambiguity of insomnia as symptom or disorder– insomnia is distinguished by uncertainty regarding its aetiology, diagnostics and treatment • Insomnia partially medicalised as a disorder it is own right, predominantly recognised as a symptom of another underlying medical disorder (usually a mental health condition) by GPs • Patients hold multiple views about the aetiology of their insomnia • Diagnosis impacts upon which pharmaceutical regime is adopted

GP data 1 We get very few who say “I just can’t sleep and I’m absolutely hunky dorey”. It’s usually because they’re under stress or have lost a relative or depression, I would say, is probably the commonest area. Very few where it’s purely a sleep issue. I would say mental health issues are the main source of insomnia[…] My philosophy is I’d rather treat the cause than the symptom. So, if you can treat the cause that’s far better than just dishing out sleeping tablets, so that’s the way I work at it […] sedative antidepressants. Then, for neuralgia, you know, you try and get rid of the cause of the pain to get to sleep rather than getting a sleeper but sometimes amitriptyline is us is used for neuralgia but it has sedative properties so that’s another area I’ll use (GP1).

GP data 2 [Insomnia is] usually associated with something else. So if we can treat the root cause then we usually find the sleep gets better of its own accord because it’s associated with that particular illness. Say, for instance, depression, we treat the depression; if it’s anxiety we treat the anxiety; if it’s a grief reaction we treat that […] I have a tendency not to prescribe benzodiazepines, and not to use the Z drugs, the zopiclones because from what we’ve been told they’re no more effective than benzodiazepines and as addictive. So, we have a tendency to stay away from all of them. If we do need to use anything it’s usually done sort of on the second or third review of the patient […] then I say try the other things, the non-prescription things first and then if that doesn’t do the trick then, yes, let’s try the IAPT if that doesn’t do the trick then let’s try the amitriptyline, try the atarax and then that’s the route (GP6).

Patient data: I became ill, one of the symptoms is actually insomnia so Dr [name1] let me continue with [the sleeping pills]. (Focus group 1, female 3). I started to get serious insomnia […] And I saw my GP and I spoke for about 15 minutes and he said “you are suffering from depression”. I was like “no, I’m not”. There was no depression, I never suffered from that. He said, “Here are some leaflets about it, go home and read it and I want you to take this medication, this will help with your sleep.” It was an antidepressant. (Focus Group 2, Male 1) I don’t think I actually thought I had a sleep problem. I went to the doctor’s with my migraines and said could I have a sleeping tablet prescribed so I can have a decent night’s sleep? I think analysing it, yes, I would have seen it as a sleep problem in other ways. If it hadn’t been for my migraines, just for sleep, then I don’t think I ever would have asked for them because I’ve always adjusted myself [...] I’m not very forthcoming with why I don’t sleep […] but [my GP] has never asked me why I don’t sleep and why I need [sleeping pills] (Focus group 2, female 2).

GP data 3: You do hear about GPs who don’t prescribe any hypnotics but they have lots of patients on antihistamines with sleepiness as a side effect. And you kind of think “well, is that actually any different to being on long term hypnotics?” As long as people are on a steady dose it probably isn’t. So people are giving alternatives. It’s not like they’ve just stopped. Because you hear about these practices which haven’t got any hypnotics on, but yes the script switch... (GP3)

ii. Pharmaceutical Ambivalence Sleeping pills embody two sets of conflicting social meanings – simultaneously arousing both positive and negative feelings. • Positive - therapeutic narratives of healing, regaining bodily control, relieving suffering • Negative - fear of addiction and loss of control, risk, iatrogenesis and inefficacy

GP data: I’m sure they do help. People do fall asleep very quickly with Zopiclone and report a kind of a nice deep sleep […] I think I’ve always been wary of starting it because the trouble is once people are on them that’s your problem […] But I think unfortunately once people have been prescribed them that’s probably what you’re not going to change because it is very difficult changing once people are on that as a long term medication […]I think you get a bit more flexible once you’re at the coalface. I try not to, again you don’t want people not sleeping and they’re on medication which has side effects. So it’s trying to make sure that if you are prescribing something long term, it’s working and they’re not increasing their usage along those lines (GP3)

Patient data: I find that [Temazepam] doesn’t affect me at all, apart from giving me a good sleep […] it helps me get to sleep […] I’m quite comfortable with it [but] I very much watch it myself and sort of, I would never get another [prescription] more frequently, so in less than three months. So I’m quite strict on myself on that - I just use them as an aid when I think I’m going to have problems […] And I find it very comforting that I’ve got them there for when I need them.[…] it’s an issue in the fact that I don’t want to become addicted, but I honestly don’t think I am addicted […] I mean, they don’t always work, and yeah, I can’t give you a reason why not […]I sort of thought that you know, things that you get over the counter might be better than prescription drugs, Temazepam. I assumed that the fact that Temazepam is not available without a prescription, means it is liable to have more danger. But as I said, it doesn’t seem to affect me at all, so. I’d be very unhappy if I had to take one every night, for instance. I think that you might get into an addiction (Focus group 3, male 1)

iii. Personal ambivalence Personal ambivalence is characterised by conflicting wishes make it difficult to decide how to act. • GPs ambivalence about whether to prescribe hypnotics or not; especially to chronic users • Chronic use of hypnotics also a source of personal ambivalence for some patients, but not all

GP data: I was reluctant to prescribe any sleeping tablets because of concerns about addiction and the risk of the side effects and dependence […] it was mainly older people who were already on benzodiazepines long term and come in see me for a repeat medication […] I had a lot of concerns about prescribing in that age group, those drugs, with the risk of falling and hypertension and polypharmacy or interaction and that sort of thing […] You’ve known them for a long time and they’d come and see me and say “Can I have some more?” or “It’s not working.”That was quite difficult as well […] I’d discuss with them about whether they would want to try a very slow withdrawal […] And usually they may need a bit of time so a prescription would be given in the interim […] I would have to say quite a lot said that they were going to keep going and perhaps a handful said, “OK, let’s try reducing it and then I’ll see you.” From that experience though, I didn’t have anybody come off them […] I think it’s difficult, because many of them would say, “At the time that I was prescribed this, no-one told me about these effects. I wasn’t aware of this. Perhaps if I was then, I would not have started it.” And I fully understood that. (GP2)

Patient data: I push myself to a point where I do need the tablet […] it’s the only way […] to get some form of sleep at night. And that might give me three to four hours with the sleeping tablet, and that’s it. Then I’m awake every hour. […] When I take one I feel dreadful in the morning. I’ve got a horrible taste in my mouth and I feel very drowsy […] I don't take my sleeping tablets on a regular basis, it’s just a one off now and then and that’s how I try and cope with them. It’s for a better night’s sleep, put it that way […] I don’t want to get hooked on them, […] I don’t want to rely on the tablets thinking it’s going to take it away or give me a better night’s sleep. I don’t want to rely on that. You know, I get fed up of taking them so you shouldn’t be having to rely on tablets, you should find other ways of doing it […]I think the pill doesn’t give an answer, it only numbs the effect, you know, what is underlying […] And I know I’m not on a regular basis of them but you do become, in a way, reliant on them, especially, you know, I think “I’m going to have a decent night’s sleep, yes I will take one”. They are there in my drawer, if I want a decent night’s sleep I would take one and it shouldn’t be that way, though. (Focus group 2, female 2).

Temporal dynamics of medicine use • Ambivalence managed in practice through the demarcation of hypnotics based on the temporal dynamics of their use • Hypnotics positioned as a temporary remedy rather than daily therapy • Short term use seen in more positive terms, long term use associated with the negative aspects of hypnotic drug use • Chronic use: Intermittent chronic use at a stable dose seen as more acceptable than daily use or escalating doses • Chronic users: Patients must present themselves as being responsible users in control of the drug rather than being controlled by it, patterns described characterised by intermittent use in times of need rather than daily therapy

GP data 1 It is restricted, but there are certain exceptions. For example, if someone is going through bereavement, for example, or a stressful, acute stressful situations, marriage breakdown, relationship breakdown, trouble with police, for example. You know, not coping, etc. So only those are the times when we take the liberty to prescribe medication. But that also is only short term, maximum of, say, five to seven days, a weeks’ supply of it […] Usually we don’t see them [again]. Once they have gone through their acute stress reaction phase, they don’t tend to ask for sleeping tablets, because they have got over that stressful period and we hope that they are coping all right. (GP4)

GP data 2 I’m not a big believer in prescribing because they’re short term medication and if you use them long term then people are going to need more and more and actually they end up not sleeping, still the same. But there can be a role for short term medication to break the cycle of it […] And if I do prescribe it longer term, because we do have patients on it longer term, is that they’re not going to increase, that this is the dose that they’re going to be at. They’re not going to get increasing doses to deal with it […] my longer term insomniacs are on long term sleeping tablets but they’re quite good at having a night when they don’t sleep when they don’t take the tablet and then a night when they do sleep so they can appreciate the difference […] some of these patients will be 88 or 89 and they’ve been on them for ten years and you kind of think it probably would be quite cruel to instigate a reduction and stopping programme (GP3).

Patient data Some nights I have had a Kalm and I’ve actually gone to sleep without a sleeping tablet and I sort of think “well, perhaps that’s better than having a sleeping tablet”. Because, I still get this, I know you’ve overcome it and I have trouble going along the path where I can just accept it ... like some of us have got, this sort of guilt feeling […]I’m lucky in that I don't have it every night. If I can’t get to sleep at all and its getting towards 1.30am and I’m tossing and turning then I’ll take a tablet. If I have gone to sleep without a tablet but if I’m waking at about three o’clock, then I might take half a tablet […]I can cut mine in two if necessary because the last thing I do I say “I don’t want to take a tablet” like you’ve just said, wean you off […] or some nights it’s a real bad night, and I know I should only have one tablet but I think it might happen about once every two or three months, or something like that, I might end up having 1.5 or two tablets, but I’ve thought “well, I’ve got to get some sleep some time.” (Focus group 1, male 3)

Summary and reflections on the data • Guidelines at the macro level could be seen as creating a space for depharmaceuticalisation of insomnia in primary care • At the medicalization-pharmaceuticalisation nexus – diagnostic ambivalence around insomnia implicated in the ways it comes to be pharmaceuticalised in primary care • Dynamics of pharmaceuticalisation – pharmaceutical and personal ambivalence implicated in the pharmaceutical regimes adopted; hypnotics increasingly positioned as a temporary remedy or intermittent source of relief • Temporal dynamics of hypnotics use – a way to manage different forms of ambivalence, used set boundaries around the (in)appropriate use of hypnotics in practice

Medicating sleep?