An interview with Dr Catherine Coveney, University of Sussex
How do you define the pharmaceuticalization of sleep? What percentage of people take sleep medications on a regular basis? How has this figure changed over time?
The pharmaceuticalization of sleep, put simply, refers to the ways in which sleep becomes a site for manipulation or augmentation through pharmaceutical use. There are different ways in which sleep can be pharmaceuticalized – for example we can use pharmaceuticals to induce sleep, to consolidate broken sleep, or to prevent or delay sleep.
Pharmaceuticalization can occur across different levels, such as in the way people think about and understand sleep as being something we can alter by using pharmaceuticals, through the prescription of pharmaceutical treatments for sleep problems by a doctor or the purchase of over the counter medicines to encourage or delay sleep within our domestic environments and daily routines.
Studying pharmaceuticalization takes into account a whole range of dimensions, stakeholders and activities operating on different levels and their dynamics including how they act and interact with one another – e.g. the roles of different groups such as sleep scientists, journalists and the wider media in the ways in which understandings around sleep, sleep problems and their solutions are communicated to the public; the role of the pharmaceutical industry in the production and marketing of hypnotic medications; regulators and the way in which the use of pharmaceuticals to augment sleep is enabled and constrained; the medical community in the ways in which sleep problems are diagnosed, recognised and treated; and the use and non-use of pharmaceuticals to alter and modify sleep in daily life.
Pharmaceuticalization, then, doesn’t necessarily have to involve diagnoses of sleep disorders or the prescription of pharmaceuticals as medicines, although this is obviously a major route to pharmaceuticalization of sleep. It can be used as a framework to understand the use of pharmaceuticals to manipulate sleep (induce, delay, consolidate) in all areas of social life and by whatever ways the pharmaceuticals have been procured by users (medical encounter, over the counter, black market, sharing with friends etc.).
Pharmaceuticalization is a process that can also go in reverse, meaning that the de-pharmaceuticalization of sleep is also a possibility. This is something that might potentially occur with insomnia in the UK, as behavioural therapies are recommended by NICE as first line treatments, the prescription of hypnotic medications are not recommended long term and GP practices are encouraged to reduce hypnotic prescribing.
Between 9 -10 million prescriptions for pharmaceuticals classed as ‘hypnotic medications’ (under section 18.104.22.168 of the British National Formulary) are dispensed in the community in England every year. This figure has been slowly decreasing since 2010 (10.4 million in 2010 to 9.2m in 2015).
However, these figures alone don’t give us a complete picture. For starters, they don’t take into account other prescribed medicines that may induce sleep/ sleepiness as a side effect (e.g. sedative antidepressants, some antihistamines or other medicines prescribed as pain killers). These types of medications might be prescribed when sleep problems are regarded as secondary to another medical issue – such as depression or chronic pain. In these cases, sleeplessness is still being pharmaceuticalized but as symptom rather than medical disorder in its own right.
The data do not cover items dispensed in hospital or on private prescriptions. Also, they don’t take into account pharmaceuticals purchased over the counter, on the black market or over the Internet.
Recent surveys such as the The ESRC understanding society survey (2011) suggest that around 10% of the UK population regularly use pharmaceuticals to help them sleep. The ESRC data included both prescription and over-the counter medicines. This can be considered a ‘significant minority’ of the UK population.
Can you please outline your research on the expectations and experiences of sleep? What were the main narratives you found? Were you surprised by your findings?
Our research on “The pharmaceuticalization of sleep in Britain since 2000: A Social Scientific Investigation of Stakeholder Interests, Policies and Practices” took a sociological approach to investigate developments and debates regarding the role of sleep medication in Britain today. The research project was funded by the Economic and Social Research Council (ESRC) and ran from 2011 - 2014. It was led by Prof Jonathan Gabe, along with Prof Simon Williams and Prof. John Abraham and organised by The University of Warwick.
We examined issues regarding the medical, social and personal management of sleep problems with particular reference to the roles, meanings and uses of pharmaceuticals in everyday/night life.
We held 23 focus groups (99 participants) with different populations who might be expected to have particular views and experiences of sleep management. This included those currently taking hypnotics prescribed in a primary care setting, people who had been diagnosed with a sleep disorder (narcolepsy, sleep apnoea, insomnia), and general population groups including students, parents of young children, ambulance service staff (including technicians and paramedics), academics, lawyers and retired people living in sheltered housing. We purposively selected these groups in order to explore diversity in experiences of and attitudes towards sleeping pills rather than for representativeness.
Our data were analyzed around 3 main themes:
- Expectations around and experiences of sleep (Understandings and expectations around sleep – what sleep is for, ideas about good and bad sleep, importance of sleep, values around sleep; experiences of sleep, sleepiness and sleep problems)
- Managing sleep(iness) (Managing sleep and wakefulness in daily life – pharmacological and non-pharmacological strategies; Relationships with medications and/or other medical technologies – accepting/resisting medicine; Seeking information and advice)
- Attitudes towards the uses of sleep and wakefulness therapies (Moral judgements and discourses used to evaluate therapies; Non-medical/ lifestyle uses – social and ethical issues)
What found in our data was a paradox in relation to sleep where it was both valued and acknowledged as being a vital part of everyday/night life, while at the same time was not prioritized and cut back on in favor of the demands of waking life e.g. Work, study, childcare, housework, leisure and ‘me time’.
Many people in our study talked about themselves as being sleep deprived, not getting enough sleep or enough quality sleep. For the most part this was due to a combination of factors in their busy lives and seen as their own fault – they were not prioritizing sleep as there was always something else to do.
We found people often talked about sleep in functional terms, so they recognize that they might not be getting enough sleep or the best quality sleep but as long as what are getting is good enough for them to be able to function the next day, then this was acceptable to them and normal for them.
People often thought that they should be able to manage their sleep themselves. Sleep problems were often not considered to be ‘real’ problems that warranted medical attention. It was only when sleep, or lack of it, became a significant problem for the individual, and by that I mean a problem in the sense that their self-management strategies were not working, their lack of quality sleep was severely impacting their ability to function during the daytime or becoming dangerous (e.g. falling asleep at the wheel) or their sleep pattern was considered abnormal and outside of their control e.g. waking in the night and not being able to get back to sleep - that sleep issues were given more importance and people considered turning to pharmacology.
We found the issue of medicating sleep was highly moralized in our focus group discussions where taking sleeping pills was linked to a weakness of character and the stigma of addiction. This was reinforced by the nature of sleep, being regarded as something people are responsible for and should be able to manage without resorting to medications. Those who had taken this type of medication strove to present themselves as not only deserving patients but also responsible users of these medicines. Prescription validated their perception of being in need of medication – turning sleep into a medical issue.
People have different relationships with hypnotic medications in daily life, and the ways in which they understand and realize their use and non-use of these medications can present challenges to processes of pharmaceuticalization of sleep on the one hand, where people may reject pharmaceuticals in the management of sleep problems, resist seeking medical advice because they don’t want to take sleeping pills and think this is all their doctor will offer, and for those who have been prescribed sleep medicines to selectively alter therapeutic regimens in the home where pharmaceuticals may be used alongside or replaced by non-pharmacological means of therapy.
On the other hand, they may also present various challenges to GPs’ attempts (in line with current mandates) to reduce or restrict prescription hypnotics in primary care, through continuing to present themselves as deserving and in need of pharmaceuticals, questioning medical authority and knowledge and, on occasion, seeking prescription drugs outside the medical encounter, through practices such as sharing with friends, buying sleeping pills on the Internet and stockpiling medications for use at a later date
Do you think there need to be changes in the way sleep problems are managed? Do you think the pharmaceuticalization of sleep will continue?
I think that firstly, there needs to be wider recognition of the importance of sleep for health, wellbeing, productivity and performance and secondly, the huge impact that sleep problems can have on people in their daily lives.
Whether we consider ourselves to have sleep problems or not, we all have to manage our sleep, which often involves trying to fit sleep into our busy lives around our work patterns, caring for others and functioning in other many and varied social roles. For many, this involves using available technologies (including pharmaceutical ones) to help fit our sleep patterns around our lifestyles.
Social and structural changes in the ways in which our lives are organized would undoubtedly have a large impact in the ways in which we manage and problematize sleep. For example, perhaps there are grounds to create a ‘protected space’ for sleep in our daily lives to ensure that sleep time doesn’t get further eroded by social obligations such as working patterns.
Behavioral changes and therapies (such as Cognitive Behavioral Therapy - CBT) have repeatedly been shown to be of benefit in the management of sleep problems such as insomnia, although resources, funding and availability are lacking in most areas of the UK.
However, we must not forget that the benefits of sleep medications are real and tangible for those who rely on them to manage their sleep problems.
The chemical manipulation of sleep and wakefulness has a long history – recipes for sleep- inducing home remedies can be found in cookbooks dating back to the 16th Century and 18th Century medical textbooks list medicines that can be used for their sedating effects.
Although pharmaceuticalization/depharmaceuticalization of sleep can be considered as being somewhat in flux, I’d be surprised if the pharmaceuticalization of sleep and wakefulness did not continue in one form or another both inside and outside of the medical encounter.
Where can readers find more information?
List of publications:
- Gabe, J., Williams, S.J., Coveney, C.M (2017) Prescription hypnotics in the news: A study of UK audiences. Social Science and Medicine, 174:43-52. http://dx.doi.org/10.1016/j.socscimed.2016.11.029
- Gabe, J., Coveney, C.M., Williams, S.J. (2016) Prescriptions and proscriptions: Moralising sleeping pills, Sociology of Health and Illness 38(4): 627–644. doi: 10.1111/1467-9566.12383
- Gabe, J., Williams, S.J, Martin, P., & Coveney, C. M. (2015). Pharmaceuticals and society: Power, Promises and Prospects. Social Science & Medicine 131: 193 – 198. http://dx.doi.org/10.1016/j.socscimed.2015.02.031
- Coveney, C.M. (2014). Managing sleep and wakefulness in a 24 hour world. Sociology of Health and Illness, 36(1):123-136. doi: 10.1111/1467-9566.12046.
- Coveney, C.M., Williams, S.J., Gabe, J. (2014) The Sleep of the Nation: Problems and Prospects, Discover Society, Issue 11, 5th August 2014.
- Williams, S.J., Coveney, C.M., Gabe, J. (2013). Medicalisation or Customisation? Sleep, Enterprise and Enhancement in the 24/7 Society, Social Science & Medicine, Special Issue on Sleep, Culture and Health 79:40-7. doi.org/10.1016/j.socscimed.2012.07.017
About Dr Catherine Coveney
Catherine is a Research Fellow in Global Health at the Centre for Global Health Policy, University of Sussex.
Her research sits at the intersection between medical sociology and Science and Technology Studies (STS), focusing on the sociological aspects of biomedicine, in particular, the meanings and use of biomedical and health technologies in different realms of social life, especially uses at the therapy-enhancement boundary for purposes of not only repair and normalisation, but also optimisation and enhancement.
Her previous research has looked at the moral meanings of medicines in everyday life, the sociology of human enhancement, the medicalization and pharmaceuticalization of sleep, and the development and use of regenerative/biological therapeutics in sports medicine.