Mental Illness

Caregiving: Medication (Part 2)

For a while now, I’ve been thinking about the first article I wrote on medication. Certainly, I still stand by all that I said in that article, despite later writing about the 20 Years Too Soon campaign by Rethink. There’s no getting away from the negative side of medication, that’s for sure. And that negative doesn’t just include (possible) medical consequences, it includes dealing with the public perception of medication. This came to a head when I came across an article in the Guardian about sleeping pills.

Discussion of medication and its use and abuse is absolutely critical, but so is the awareness of all who use medication. It’s quite reasonable to talk about how a medication is being prescribed, but it isn’t reasonable to do so without acknowledging that within those numbers will be those with entirely legitimate reasons to be using the medication in question.

Sleeping pills seem to be a common target in this kind of discussion, with anti-depressants coming a close second, if not vying for joint third with anti-anxiety medication.

The Guardian article begins by proclaiming:

Sleeping pills: Britain’s hidden addiction

One in 10 of us now regularly take a drug to help us sleep. But is it time we stopped popping zopiclone, temazepam and other tablets? And what are the alternatives?

This is where, for me, the issues begin. I have no doubt there are people who are addicted to sleeping pills. That does not mean, however, that the 1 in 10 people who take sleeping pills are addicted, or “popping” those pills. Perhaps it’s just me, but I feel I don’t have to look far to see where stigma around medication use is being encouraged. Within the space of four sentences, the article appears to suggest that people who take sleeping pills are addicts. No exceptions.

As I’ve already said, it is critical that there is discussion about the misuse of medication and how people may be helped to become less reliant (if not independent) of medication. This doesn’t mean it’s helpful to suggest everyone who uses a particular drug is addicted, nor is it helpful to use language like this:

Our desire to medicate ourselves in this way is part of our wider preoccupation with sleep.

Desire? Desire? I can’t think of anyone I know who enjoys taking medication, who skips to the pharmacy excited by the prospect of ingesting toxic substances.

The mention of “toxic” leads me to another point that I feel is essential in the discussion of medication:

The only difference between medicine and poison is the dose.

I’ve tried to find who this is attributed to, and the best I can find is Paracelsus, who said:

Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy.

Where does this sentiment come into the discussion? It’s the knowledge that medication is not (generally speaking) composed of sunshine and daises, and most likely has the potential to be lethal. And that many people who take medication know this. By talking about “popping” pills and suggesting that non-medication alternatives are The Only Way To Go, it undermines the choices people make with their doctors to take medication. Certainly, not everyone who takes medication is informed (or wants to be informed), but there are those who are, and undermining them often means undermining those with considerable health needs who know full well that pretty much every medication out there has the potential to either kill, or cause great harm.

And that’s where a potential Catch-22 situation comes into being. To medicate or to poison? Except for many, it isn’t a Catch-22, it’s the lesser of two evils. Sure, the risks that come with medication can be nothing short of horrendous. As a small illustration of this, there’s a condition called Neuroleptic Malignant Syndrome. It’s horrible. This is the list of risk factors from

Risk factors for developing neuroleptic malignant syndrome (NMS):

  • Use of neuroleptic drugs and genetic/metabolic susceptibility.
  • Withdrawal of anti-Parkinsonian medication.
  • Use of high doses and of depot preparations.
  • Patient agitation or catatonia.
  • High ambient temperature and dehydration appear to increase risk of the syndrome.
  • A previous episode of NMS significantly increases the risk of future similar reaction.

Less commonly, use of other agents with central D2 receptor antagonist activity may cause the syndrome:

  • Prochlorperazine
  • Promethazine
  • Atypical antipsychotics such as clozapine, risperidone
  • Anticholinergic drugs
  • Metoclopramide
  • Amoxapine (tricyclic now discontinued)
  • Lithium

Mr. Juniper uses neuroleptic drugs. Otherwise known as anti-psychotics. He uses them at relatively high doses. His anti-psychotics are two atypical anti-psychotics. He also uses another of the medications listed – as a sleeping pill, no less! But he knows this risk. He’s very aware of this risk. He’s very aware that I broke down and cried the first time I read about this risk. However – and this is a big however – he’s very aware the state he would be in without these medications.

To really force the point home, here’s a quote from a study on death risks and sleeping pills:

Even among patients who were prescribed 1 to 18 sleeping pills per year, the risk of death was 3.6 times higher than among similar participants who did not take the medications. The study looked at patients aged 18 years and older, and found the increased risk in all age groups.

Rates of new cancers were 35 percent higher among patients who were prescribed at least 132 hypnotic doses a year as compared with those who did not take the drugs.

My husband, my darling wonderful husband takes sleeping pills every night. This equates to 730 sleeping pills a year (732 on leap years), given his current dose.

But back to the Guardian article, there is a quote from a professor of  gerontology (yes, I had to look that one up on Wikipedia):

But last week, a leading sleep specialist – Kevin Morgan, professor of gerontology at the University of Loughborough – argued that the NHS should be looking beyond sleeping pills and training its staff to provide psychological therapies such as cognitive behavioural therapy (CBT) to help those with insomnia. Morgan argues that CBT offers a better long-term solution, and that sleeping pills hold further dangers: addiction or dependency, medication-related accidents, and spiraling costs for the health service.

I’m very torn about this point but glad that it is however countered by this:

“They do have a place in treatment,” says Dr Andrew Hall, consultant in sleep disorder medicine and a member of the British Sleep Society, “especially for an acute problem, such as a grief reaction, when it may be a humane act to prescribe them.”

Professor David Nutt, director of the neuropsychopharmacology unit at Imperial College, goes further: “The hope is you knock people back into the routine of sleep,” he says. “Some people, whether for genetic reasons or stress, have persistent trouble sleeping, and some of those people need sleeping pills in the long term.”

I’m not a great fan of Prof. David Nutt, but that’s another topic. Here, he and Dr. Andrew Hall make wonderfully simple yet important points: there is a legitimate need for the use of sleeping pills. As always, it’s the acknowledgement that this isn’t a black and white issue. CBT may be what liberates people from the shackles of drug use, and sleeping pills may be the appropriate treatment route for others. I am, it has to be said, an incredible fan of CBT and its dear friend, DBT. They are two forms of therapy that work wonders for people, but that doesn’t mean they are the be all and end all of dealing with issues that have a psychological component. Often medication is critical in allowing people to participate in therapy.

Medication is never going to be simple, and that’s why it is so important that decisions be made between patient and doctor. That decisions be fully informed ones. That the misuse of medication by patients and doctors not be conflated with the appropriate use by patients and doctors, otherwise stigma is allowed to run rampant and people are left to suffer.

I guess, as is often the case, I’m left hoping that people may give discussions like this a little thought. I hope that people will acknowledge that balance is important, too. The risks of medication are horrific, the risks to my darling husband of not being on medication are worse.

N.B. I would recommend reading the Guardian article in full. Context is everything and when grumpy, this Persephoneer is unlikely to be an objective Persephoneer.

By Juniper

Rarely to be found without herbal tea nearby. Team Unicorn. Often in pyjamas. Also: TEAM KATNISS!

4 replies on “Caregiving: Medication (Part 2)”

This is such a tough subject. I don’t know if people refuse to get better informed (By Gods, you can’t share your medicines with someone!) or just expect the doctor/hospital to take them by the hand on everything about this subject and be ready there for blame if something still goes wrong.

i love reading your articles on these topics. a thought i had while reading this one:

“Even among patients who were prescribed 1 to 18 sleeping pills per year, the risk of death was 3.6 times higher than among similar participants who did not take the medications.”

now i’m no doctor, but aren’t there studies out there that people with more chronic insomnia are at higher risks for medical problems i.e. high blood pressure, cancer, etc? i would say maybe the correlation does not necessarily equal causation in this scenario, but of course i don’t discount it either. a lot of these medications have side effects and underlying effects that still aren’t clearly known.

and i totally agree with evaluating the costs and benefits of meds versus no meds. for many people, taking some sort of medication and understanding possible side effects is far more preferable to being without meds and dealing with the consequences of an illness that is out of control.

I’m really glad you’re enjoying the articles, thank you!

It can be a difficult one, when looking at studies like the ones I quoted. As much as anything, I think it’s important to be aware of the research. And whilst the research may not be able to give certainties, I think it can give an indication to the possible consequences. In other words, expect the worst, hope for the best.

The medication vs no medication part is definitely important too, and as you say, so many people forget that the possible risks of medication are nothing compared to not taking medication.

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