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The Effects of Tranquillization:
Benzodiazepine Use in Canada
Health Canada Publication: 1982
6. SOCIAL MEANING OF BENZODIAZEPINE USE
The extensive consumption of benzodiazepines and their effect as mood-altering substances combine to raise important issues about the impact of these drugs on the individual and society. Numerous questions demand attention by the medical profession, social scientists and ultimately, policy makers. For example, given the sedating properties of these drugs and, with steady use, their potential for causing cognitive and learning impairment, how common is the masking of emotions? And, what effect does this masking have on dulling one's perceptions of reality? Do these pharmacological effects impair ability to deal with social strains and difficult life situations? Do they diminish motivation for change?
The paper has discussed how continuous drug use tends to create dependence and encourage the acceptance of chemicals as coping supports. Do they, over time, actively erode the individual's coping abilities?
A Canadian study which attempted to address some of these issues brought together benzodiazepine users to discuss their perceptions of the drugs' effects on their lives. The population studied was largely female, in their middle years and somewhat more educated than the general population. They were almost uniformly long-term users though not at high dose levels.
Analysing the data thematically, continuing use was most understandable in terms of the problems of social roles expressed. Drug use was described as a means of maintaining themselves in roles which they found difficult or intolerable without the drug.
Women described their drug use as an aid in sustaining caring, nurturing relationships with their spouses and children. Many of the women described situations of extreme role strain. For some of the women, the strain arose from major problems or conflicts around the maternal role, conflicts often generated by a sickly or difficult infant or by a lack of preparation for the isolation entailed in early childrearing years. Some spoke of the drugs as a means of adapting to intolerable home situations, such as alcoholic behaviour in a spouse.
In many cases the strain was engendered by an inability to comply with traditional expectations (theirs as well as their husband's). These women commonly felt they lacked the 'right' to express their dissatisfactions and preferences. Some saw husbands as having other escape routes when marital obligations became burdensome, escapes which the women felt they lacked. While there were clear expressions of anger directed at their spouses, many of the women saw no alternative to continued occupancy of the traditional housewife role.
Male informants typically discussed their tranquillizer use in relation to job stresses and strains. They most commonly focussed on somatic symptoms brought on by work stresses or a change in jobs, and saw continued use of tranquillizers as a means of controlling these symptoms. A number accepted that little change in their job status was possible and therefore saw no means other than drugs to alleviate their symptoms.
The issues addressed by many informants were structural, and some, particularly those who had ceased or cut down their drug consumption, were able to describe structural as opposed to individual remedies to their problems. A number of the women found a return to work an aid in reshaping their lives, others gradually had altered marital relations, joined groups and acquired wider social supports. Some found more individualistic solutions through exercise or counselling.
To date, research has not addressed the impact of benzodiazepines on the family or on the interpersonal world of users. In the exploratory study described above, many people referred indirectly to changes in their family life which they attributed to these drugs. For example, one man described feelings of lethargy which affected the amount of time spent playing with his children. Others talked of diminished sex drive. Still others perceived positive effects, because they had less tendency to be irritable. During one group interview one person, who had stopped using benzodiazepines, commented on the impaired communication of members of the group who were using drugs at the time. The quality of family life and interpersonal relationships potentially affected by benzodiazepine use may be far-reaching given the proportion of our population consuming these drugs.
While use of benzodiazepines in family settings requires further study, some of the social meanings of their use in institutional settings have already been demonstrated. Little evidence exists of exact amounts dispensed through institutions, whether nursing homes, correctional institutions, or long-term care facilities. However, there appears to be little doubt that these drugs, along with other sedating drugs, are widely dispensed as a means of behavioural control. A major finding of a 15-year study of nursing homes across the United States stated that patients are tranquillized as a means of social control, to keep them quiet and therefore easier to look after. They also concluded, ironically, that it was precisely these same individuals who may be most favoured for rehabilitation. The limitations of benzodiazepines used in this way were stated clearly by the Director of the National Institute on Aging: "...often drugs represent the only form of treatment given to older persons. An overall treatment plan that includes attention to diet, physical and social activities, psychotherapy and correction of living problems may be totally ignored." With the increase in the proportion of elderly in Canada and the high rate of institutionalization of this age group, the use of sedating drugs may be used as a rough gauge of the value placed by society on the quality of life provided these members.
A major factor responsible for the acceptance of these drugs has been the pervasive mythology that there are instant solutions to problems of living and that the most effective and rapid solutions are chemical in nature. Society has come to expect quick responses to any problem, whether it be the common cold, anxiety or grief. Through acceptance of this philosophy many people have come to view benzodiazepines as essentially a social and recreational drug, not unlike alcohol.
Because of the range of problems associated with steady use of benzodiazepines, it is apparent that these drugs cannot be viewed as substitutes for natural coping abilities. Thus it is important to examine alternatives to the use of chemicals as means of coping with the stresses of daily life. Efforts to provide support to other human beings, meaningful work and economic independence for all segments of the population, can begin the process of minimizing the need for these drugs. Simultaneously, the providers of benzodiazepines, the pharmaceutical industry, should omit references to problems of living from their advertisements and promotion as an indication for prescribing their products. Finally, the medical profession must become knowledgeable about the physical and psychosocial meanings of benzodiazepine use and then work together with their patients and the community to create acceptable and satisfying ways of coping.
7. SUMMARY AND CONCLUSION
This document has demonstrated that there are a variety of positive functions of benzodiazepine use, particularly in short-term use for control of acute anxiety, neuromuscular disorders and as an anti-convulsant. Efficacy as an antianxiety agent has not been demonstrated for longer than a few weeks and, because of the risk of dependency as well as with individual variation in dose response, continuous use should not exceed two weeks. Long-term use brings with it the increased access to the drug, which has been shown to be highly correlated with overdose and polydrug use. Also, the development of dependence and the impairment of cognitive and motor skills have been strongly suggested; this seems to be a function of the dose ingested as well as length of use. In addition, the higher consumption of benzodiazepines by particular high risk groups (e.g. the elderly, chronically ill and women) may lead to special problems for these segments of the population.
Underlying contemporary medical practice, the biomedical model defines the locus of all problems seen by the physician as residing within the individual. It follows, therefore, that all solutions must also be on an individual, i.e. biological, level. Coinciding historically with the development of this philosophical position was the growth and rapid development of new products by the pharmaceutical industry. The benzodiazepines were developed during a period in which acute illness was better controlled. Thus, increasing numbers of patients were presenting symptoms of chronic illness, normal problems of aging, social and interpersonal problems, and symptoms of anxiety and tensions related to all of the foregoing. The medical profession accepted these symptoms as legitimately within its domain for treatment.
The costs of continued use of benzodiazepines require careful consideration. The economic costs may be incurred by the individual or through third party payment. The concern with payment must extend beyond the price of prescriptions to the total cost to the health care system. Inappropriate prescribing may well keep individuals visiting physicians, the most expensive component of the system, for considerably longer than necessary. This does not, of course, include the physical and psychosocial costs incurred through toxic reactions, adverse reactions and overdose.
Although there are a paucity of studies relating benzodiazepine prescribing to aspects of medical organization, what data does exist would suggest that the chances of prescribing appropriately are greater in a group practice than a solo practice. It can be expected that prescribing would be optimized with peer reviews of drug utilization and improved communication through information on therapeutics provided by non-industrial sources.
In drawing conclusions regarding the issue of benzodiazepine use, there are no scientific absolutes or 'objectivity'. Having assessed the data, the authors have formulated a number of conclusions which, in their view, best reflect the relationship between the currently available data on these drugs and their assessment of the health and social care system in Canada.
Resulting from this examination of benzodiazepine use, we question whether many of the problems of living presented to physicians can be addressed in the health care system at all. Although recognizing the value of benzodiazepines in short-term care, their use poses serious questions regarding interference with individuals' abilities to alter their lives and thus cope with stresses without the aid of chemicals.
Given the large numbers of Canadians currently using benzodiazepines, the possibilities of impaired decision-making, decreased learning skills, released aggression and impaired ability to empathize have a significance extending beyond the lives of these individuals to the community at large.
These consequences of use are common to a variety of mood-altering substances such as alcohol, marijuana, and other illicit drugs as well as benzodiazepines. With the exception of alcohol, a larger proportion of the adult population probably uses benzodiazepines on any given day than uses any illicit drug. For this reason, attention to social and legal facets of use is required.
A major concern are those populations at highest risk of receiving these drugs. The populations discussed share common problems and disadvantages in Canada today. These include poor economic conditions, inadequate housing, low social status, frequently inadequate support structures such as day care and community services to maintain the elderly and the chronically ill outside of institutions.
If, as suggested, benzodiazepines are used to dull social pain, then alternative solutions must be found which meet the needs of both individuals and society. The authors recognize that alternatives are being attempted in select communities. However, by articulating the problems associated with benzodiazepine use, it is hoped that this document will contribute to the further development of new concepts of prevention and new models of care.
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