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Current Attitudes About the Benzodiazepines: Trial by Media
Abstract
Trial by media can never take the place of careful scientific evaluation of a psychotropic drug. The two methods are antithetical. Scientific inquiry depends on careful examination of data. The media cannot present information in detail. It titilates, dramatizes and pulls facts out of context. It is unfortunate, but it is so.
... For example, self-help groups (such as 'Tranx') which were run by 'ex and partially withdrawn addicts', emerged specifi cally to deal with iatrogenic addiction (http://www.benzo.org.uk/). In this respect, the UK response mirrored the problem identifi cation and reaction that had occurred previously in the USA (Cohen, 1983). Media attention regarding the iatrogenic effect of benzodiazepines occurred in the late 1970s and early 1980s in the USA (Cohen, 1983). ...
... In this respect, the UK response mirrored the problem identifi cation and reaction that had occurred previously in the USA (Cohen, 1983). Media attention regarding the iatrogenic effect of benzodiazepines occurred in the late 1970s and early 1980s in the USA (Cohen, 1983). In the UK, Bury and Gabe (1990) pointed up the role of the media in legitimizing the social problem status of the benzodiazepines. ...
General practitioner (GP) prescribing has been identified as an arena that has broad social and political implications, which stretch beyond individual outcomes for patients. This article revisits aspects of the controversy about prescribing benzodiazepines (or 'minor tranquillizers') through an exploration of contemporary views of GPs. In the 1980s the prescribing of these drugs was considered to be both a clinical and social problem, which brought medical decision making under public scrutiny. The legacy of this controversy for recent GPs remains a relatively under-explored topic. This article describes a qualitative study of GPs practising in the north-west of England about their views of prescribing benzodiazepines. The accounts of the respondents highlight a number of points about: blame allocation, past and present; clinical challenges about risk management; and deserving and undeserving patients. These GP views are then discussed in the wider context of psychotropic drug use. It is concluded that, while there has been a recent consensus that the benzodiazepines have been problematic, when they are placed in a longer historical context, a different picture is apparent because other psychotropic drugs have raised similar problems.
... According to a Gallup poll, Swedes consider hypnotics and antidepressants to be as dangerous as alcohol, and more dangerous than automobiles and nuclear power (Malmfors er af., 1988). Media amplification and exaggerated health authority interventions have created obstacles to proper anxiolytic therapy for many (Lasagna, 1980; Cohen, 1983; Kraupl Taylor, 1986; Nagy, 1987). One example is the triplicate prescription programme in New York, which resulted in substituting benzodiazepines to a large extent with toxic compounds like meprobamate and butabarbital, which in turn required more intensive care resources in overdoses (Weintraub et al., 1991 ). ...
This paper reviews the conceptualization of addiction on prescribed sedative-hypnotics medications; its evolution, occurrence, characteristics and validity. Such addictive behaviour is often concurrent with severe anxiety and/or personality disorders and follows a dismal course. The rate of suicide is very high, particularly in health care personnel with access to lethal medications. The risk of developing this kind of addiction is miniscule, considering the mass exposure to these medications in the general population. Yet, moralizing arguments amplified by the media, as well as overzealous government interventions create unnecessary obstacles to proper and effective pharmacotherapy for morbid anxiety and insomnia. © 1996 John Wiley & Sons, Ltd.
... As far as the coverage of tranquillizers is concerned this has often been sensationalizing in tone and has frequently given the impression that everyone taking them is dependent on the drug and will automatically have 'terrible' withdrawal symptoms if they try and stop. As several commentators have remarked, this represents 'trial by media' (Lasagna, 1980;Cohen, 1983). ...
This paper outlines a sociological approach to benzodiazepine tranquillizer prescribing. The analysis focuses on both the micro level of the doctor-patient relationship and the macro level of those political, economic and cultural factors which structure the prescribing process. This makes it possible to account for both the overall decline in benzodiazepine prescriptions in the 1980's and the fact that they are still being prescribed on a long-term basis to a significant number of people.
... Mass media heightens public concern and interest about certain types of drug use, through its ability to provide opportunities for the expression of expert and lay viewpoints and by structuring meanings into recognizable images and conceptions. 13,14 Knowledge about depression and its treatment is created through a process in which fragmentary, restricted knowledge is continually transformed into certain and consistent fact. This allows for the creation of technical and moral realities that are given form and meaning through collective social knowledge and beliefs, which can be invoked to encourage certain behaviors. ...
Results of a 20-year study of mass media representations of antidepressant medications and their use are presented. The recent Prozac phenomenon stands out as a primary example of media-generated drug information for patients. Various forms of mass media are important in providing perceptions of the effects, benefits, and safety of these new antidepressant drugs. Clinical research, however, suggests that the latest generation of antidepressant medications is no more effective in treating depressive symptoms than the first generation, tricyclic antidepressants. Yet, these new antidepressants have become the model drug not only for treating depression, but also for cosmetic psychopharmacology.
One of the most difficult problems in discussing drug abuse is definitional. Where benzodiazepines are concerned the definitional problems are particularly complex, since most of their use occurs within a legitimate medical/therapeutic context, and decisions must be made as to where appropriate therapy ends and abuse or misuse begins. Moreover, although a dispassionate appraisal of the abuse problems associated with benzodiazepines is now in process in the scientific literature, information available to the general population of actual and potential consumers of benzodiazepines is not always conveyed with comparable objectivity (cf. Cohen, 1983).
Anxiolytic drugs have been taken by men and women throughout history. There is evidence that opium was used by lakeside dwellers as far back as prehistoric times (Stimmel, 1983) and its medicinal use was later encouraged by Hippocrates in Greece and Pliny in Rome (Olivieri et al., 1986).
The issue of promoting medications for personal or social problems involves a difficult balance between medical definitions of what constitutes a disease and consumers' perceptions of what they want or need in the way of optimal health and well-being. There are certain symptom states and conditions that are poorly defined in terms of the biomedical model of disease. Other conditions, such as child abuse, ordinary stress and tension (“pressures of life”), small breasts, thinning hair, mental fatigue, and certain personal and social problems of life are often considered diseases by some (e.g., afflicted consumers, health product manufacturers and promoters), but not by others (e.g., health professionals, health insurance companies). The key concern is who determines what conditions are diseases to be addressed by medical care systems and public health efforts, and what conditions are problems and concerns better addressed by the family unit, social welfare agencies, religious groups, or society in general.
The Food and Drug Administration's (FDA's) spontaneous adverse drug reaction (ADR) reporting system functions to collect worldwide voluntarily/spontaneously reported medical events that occur in association with the use of a pharmaceutical product from physicians, pharmacists, patients, etc. While publicity surrounding a drug has frequently been considered to directly affect the number of medical events or adverse reactions reported, the effect has usually not been documented. The Upjohn Company prospectively studied the impact of the media on the reporting of Halcion® Tablets (triazolam) medical events during the first quarter of 1989. A survey of the number of medical event reports received before and after the product was discussed on a national television program revealed that reports increased dramatically (nearly doubled) as a direct and indirect effect of the program
Abstract The premature removal of drug products from the marketplace is a very complex, interactive phenomenon, with a number of societal, economic, and regulatory factors playing significant parts in the process. Previous cases indicate that the process involves the interplay of these factors around a drug taking situation. the focal point of most problems is the presentation of effects, usually negative, attributed to a drug, or the nature of a drug's image. It is suggested that this process of premature drug removal be analyzed in greater detail, with the hope of better understanding and preventing the occurrence of this phenomenon. There have been a number of recent cases of drug products which have been removed from the marketplace before their time. While this phenomenon of premature or unanticipated removal is not new, the number of specific situations in which this has occurred does appear to have increased lately. This is a time when societal forces and collective consumer consciousness, in any form, can influence, change, or impede the drug development process and the “normal” life of a specific drug product. It seems, however, that this important issue of early removal of drug products has not been given a great deal of attention.
Allgulander C. Occurence of the anxiety syndrome and possible consequences of absent or inadequate treatment. Anxiety syndromes have many disguises in the primary care setting. They are conducive to suicide, cardiovascular deaths, secondary alcoholism, and impaired psychosocial functioning. The anxious patient who ventures to seek a physician in spite of the mistrust spread by the mass media against medical treatment deserves an empathic and professional reception. More research is needed into the long-term effects of pharmacotherapy in chronic cases.
The purpose of this review is to broaden the base for informed policy and to identify research issues to improve the utility of anti-anxiety agents. Data quality is discussed and the prevalence of morbid anxiety and the exposure to treatment with, and abuse of, anti-anxiety agents in different populations is presented. Findings concerning under-treatment, quality of life and misdiagnosing are also discussed. Based on the findings of this review, controlled studies of anti-anxiety treatments in anxious patients with cardiovascular disease, diabetes mellitus or other chronic somatic conditions should be prioritised. These are likely to show substantial and vital benefits by not only controlling symptoms and improving coping capacity, but also by improving social functioning and somatic disease management. Investing in improved detection and management of patients with anxious and/or depressive disorders in many forms of care will pay rapid direct and indirect dividends. Copyright © 1999 John Wiley & Sons, Ltd.
This paper attempts to highlight the value of the ‘social problem’ perspective for the sociology of health and illness by applying it to the issue of tranquilliser use and dependence. The approach involves focusing on the emergence of benzodiazepine tranquilliser dependence as a social problem and the extent to which it has been legitimated by the media and by the state. In the conclusion we draw out the implications of our case study for the development of a ‘natural history’ of social problems.
The pharmaceutical arena is evolving constantly: new drugs enter the market while older ones are discontinued, clinical practice changes, health care budgets rise and fall, and public health needs are redefined. To assist in thinking about the usage environment of drugs in a comprehensive manner that includes regulation, clinical outcomes, and incentives for innovation, we propose a conceptual post-innovation learning cycle for pharmaceuticals. A primary objective of this thesis is to develop a set of analytical tools to study the post-innovation learning cycle of pharmaceuticals. With these tools we aim to provide an evidence base for the formulation of policies that want to achieve a sustainable balance between providing good quality health care, stimulating the optimal allocation of scarce resources, and fostering an environment where innovation is adjusted to real public health needs. Finally, we want to identify directions for future research. In this thesis we shown that epidemiological methods provide opportunities for studying the links between various aspects of the post-innovation learning cycle of medicinal products. At the same time, we have identified critical issues that need to be addressed for these tools to fulfil their promise.
We studied the impact of suspending oral contraceptive (OC) reimbursement in the Netherlands for women >21 years starting 1 January 2004. Discontinuation and switching patterns and the time course of the policy intervention's effects were determined.
The intervention cohort contained OC users on 1 January 2004; the control cohort users on 1 January 2003. Follow-up duration was 1 year. Discontinuation and switching patterns were assessed using relative risks (RR). Weekly refill fractions were calculated to determine the time course of the policy effects.
Our intervention cohort contained 434,917 OC users; the control cohort 489,904 users. When we excluded patients not affected by the policy intervention (i.e., all patients younger than 20 years), discontinuation rates were 15.3% (intervention cohort) and 12.3% (control cohort) (RR=1.24; 95% CI=1.23-1.26) and increased with age. Switching to cheaper OCs was greatest in the intervention cohort, particularly in the 40- to 44-year age group. Differences in cumulative refill fractions showed large variation over time.
The OC reimbursement intervention led to an increase in the discontinuation rate of 24%. The effect increased with older age groups. Considering the time course of effects of policy interventions is of critical importance.
This paper addresses the issue of the crisis of therapeutic efficacy in Britain through a case study of benzodiazepine tranquilliser dependence. The paper traces the rise of tranquillisers and the crisis of legitimacy in prescribing behaviour in the 1980s. It documents growing concern with dependence and the claims made about it by experts and consumer groups. The paper goes on to analyse the importance of the television in these claims-making activity and its influence in shaping perceptions. Finally, we consider the implications of these events for the future of benzodiazepine tranquillisers as a form of treatment.
From three general practices, served by 11 principals, 205 long-term benzodiazepine users were identified and matched for age and sex with controls. Benzodiazepine users had significantly higher rates of previous physical illness, consultation and non-psychotropic drug consumption than controls. The characteristics of those receiving prescriptions for benzodiazepine hypnotics alone, anxiolytics alone and anxiolytics plus hypnotics were also investigated. Significant differences emerged between these three groups. Patients receiving hypnotics only were older, had a history of more physical illness and had received more non-psychotropic medication than patients receiving anxiolytics only. The anxiolytic plus hypnotic group had previously received more hypnotics and were currently receiving more medication than the group receiving anxiolytics alone. The results are discussed in relation to current concerns about benzodiazepine dependence and withdrawal.
Sedative-hypnotic drug use and abuse increased in Europe after World War II and peaked about 1972. Clinical and follow-up descriptions of abusers support the concept of a psychiatric addiction syndrome, different from a low-dose withdrawal syndrome. Although these drugs may be prescribed unnecessarily, large portions of the general population with pathological psychic distress and insomnia do not receive psychotropic treatment, in spite of findings pointing to genetic and biochemical factors in the genesis of these. Research on underlying mechanisms and the rationale for maintenance therapy is needed.
An inquiry into the role metaphor plays in personal and societal conceptions of drugs and drug taking reveals that drug metaphors and symbols are quite pervasive in individual thinking, social discourse, and the cultural media. They appear to influence beliefs and attitudes regarding drugs, the nature and meaning of drug experiences, and the reasons behind drug-taking behaviors. Some drug metaphors are common to different cultures and historical periods, while others are specific and exclusive to particular individuals and groups or drug-taking situations. These metaphors can carry positive as well as negative connotations. Further study is needed to delineate the metaphorical structuring of our thinking about drugs, and the process whereby these metaphors are generated and spread throughout society.
The present article discusses the media's relationship to public attitudes regarding antianxiety drug use, but recognizes that popular media, in this instance, reflect and mirror a long-held American viewpoint about drug use and serve chiefly as intensifiers and corroborators of long-settled views. Two approaches to thinking about benzodiazepines have been outlined in this assay. The cultural view of the drug as a scourge is not correct. However, an attempt to replace this erroneous view with another context is not entirely believable either. In truth, some synthesis should be made of the two views, s well as some further acknowledgment that the social issues governing the use of psychoactive chemicals often have nothing to do with dope fiends or medical school graduates.
From a sample of 257 elderly patients, 93 subjects who had received benzodiazepine (mainly diazepam) prescriptions for one or more years were interviewed about their subjective perception of the drug's effects and their attitudes regarding its use. The subjects were predominantly women: mean age was 72 years. All subjects had begun use of benzodiazepine more than two years earlier, although some had since stopped using the drug; more than a third had used it for more than six years. About half of the subjects said they took no more of the drug than had been initially prescribed, and three quarters reported they took the medications only when a need was felt. The principal indication for use of benzodiazepines was described as tension. Those who were still taking the drug at the time of interview were more likely to live alone and to say that they had the same problems as when they began its use. None of the subjects who had discontinued use of the drugs had been aware of withdrawal symptoms, and there was no evidence that any subject had become addicted, although several expressed a fear of this. It appears that in this age group, prolonged use of benzodiazepine at low doses, with the patients regulating the quantity, is safe and may be helpful. Most subjects, even if not helped, always kept some of the drug at home in case they might need it.
Assessment of clinical trial safety data for industry, regulatory agencies, medical practitioners and patients requires definition and measurement, monitoring, and overall analysis. Prospective 'safety' definitions and reliable measurement tools reduce inefficient data collection and improve the validity of resulting analyses. Statistical tools can help investigators monitor safety data from controlled clinical trials and help improve post-marketing surveillance. Also, when evaluating overall safety, one needs to assess all available information by combining information from many trials and other sources. Planning for this combined assessment, incorporating flexibility to assess unanticipated yet important nuances in individual trials, may be more important than the actual statistical analysis method used. A keen awareness of the future needs of consumers of this information is quite important. Some current proposals to combine safety information will be discussed.
To ascertain whether benzodiazepines (BZDs) cause behavioural side effects other than those already known or trigger latent mental illness processes, the medical records of 32 patients who had submitted claims for BZD-induced side effects to the Swedish Pharmaceutical Insurance (SPI) claims office during 1985-92 were re-assessed by two psychiatrists on the basis of the DSM-IV system to determine whether a psychiatric syndrome existed before, during, or after the prescription of BZDs. Of the 32 case reports entered into the study, 22 concerned women; mean age at the time of SPI claim submission was 47 years, and the mean duration of BZD treatment was 11.7 years. The BZD dosages were in most cases within recommended therapeutic limits. Twenty-five claimants had also been using other psychotropic drugs. In 28 of the 32 cases a psychiatric syndrome in accordance with DSM-IV was present before the start of BZD treatment-in most cases an anxiety syndrome or anxious personality trait. In the other four cases no diagnosis could be given owing to paucity of information. In the 12 cases of claimants who fulfilled BZD dependence criteria at some point during treatment, withdrawal syndromes might have affected the clinical picture to some extent. Four claimants received additional post-BZD-treatment Axis I diagnoses, but in all four cases the new diagnoses were clearly related to the pre-existing symptom pattern. Thus, apart from the dependence on the drug there was no evidence of psychiatric morbidity caused by the BZDs. The symptoms reported by the claimants as evidence of BZD-induced psychiatric morbidity seem in most cases to have been a feature of pre-existing psychopathology which became more manifest after discontinuation of BZD treatment.
This exploratory, cross-sectional study examined the effect of self-reported cultural background on beliefs about medicines (modern pharmaceuticals) and perceptions of personal sensitivity to the adverse effects of taking medication. Using a validated questionnaire, beliefs about pharmaceutical medication were compared between 500 UK undergraduate students who identified themselves as having an Asian or European cultural background. There was a significant association between cultural background and beliefs about the benefits and dangers of medicines. Students who self-reported to have an Asian cultural background expressed more negative views about medication than those who reported a European cultural background. Students with an Asian cultural background were significantly more likely to perceive medicines as being intrinsically harmful, addictive substances that should be avoided. They were significantly less likely to endorse the benefits of modern medication. There was no significant relationship between cultural background and perceptions of personal sensitivity to medication effects or belief about how doctors use medication. In the total sample, past and present experience of taking medication was associated with a more positive orientation to medicines in general. Students who considered themselves to have a European cultural background had significantly more experience with prescribed medication than those who selected an Asian cultural background. The relationship between cultural background and beliefs about medicines in general was maintained after controlling for potential confounding variables, including chosen degree course, experience of taking prescribed medication, age, and gender. The identification of differences in beliefs about medication, between two specific cultural groups, suggests the need for a greater understanding of the effects of cultural background on medicine-usage with potential implications for the conduct of prescribing-related consultations and for the provision of patient information on medication.
This paper examines the social construction of the new wakefulness-promoting drug Modafinil (brand name Provigil) in the British press. Key themes in this newspaper coverage include the potential 'uses' and 'abuses' of this drug in relation to: (i) medical conditions; (ii) lifestyle choices; (iii) military operations; and (iv) sporting competition. The British press, we show, play a dual role in reporting on these trends and developments: on the one hand constructing this as something of a 'wonder drug' in relation to the treatment of a number of medical complaints or conditions, on the other hand articulating and amplifying a range of cultural concerns and anxieties about the non-medical 'uses' and 'abuses' of this drug, both now and in the future. These issues, it is argued, are best interpreted in terms of media concerns over the pharmaceuticalisation rather than the medicalisation of everyday/night life. The paper concludes with some further thoughts and reflections on these issues, including the potential reworking of notions of 'pharmaceutical Calvinism' and the 'elective affinity' between this 'smart' new drug and the spirit of (bio)capitalism.
This study focuses on the different national coverage and reimbursement strategies and their consequences for access to clopidogrel, a drug with a central European Union (EU) registration. Our objectives are 1) to assess whether changes in reimbursement policies in EU member states influenced clopidogrel prescribing; and 2) to determine whether clopidogrel-specific policy characteristics, general characteristics of the health system, or indicators for the amount of cardiovascular care delivered were associated with the level of clopidogrel prescribing.
Data were collected in Austria, Belgium, Denmark, Germany, Hungary, Portugal, Slovenia, The Netherlands, and the United Kingdom (England). Utilization rates were expressed as defined daily doses (DDDs)/1000 persons/day. To determine whether changes in reimbursement policies influenced clopidogrel utilization, a segmented linear regression approach was used.
Clopidogrel prescribing varied widely in the studied countries, from 2.76 (The Netherlands) to 6.83 (Belgium) DDDs/1000 persons/day (March 2005). Six countries had therapeutic indication restrictions to clopidogrel use. Health system characteristics did not explain variation in clopidogrel prescribing.
A disconnect will be indicated in this study between the concept of a harmonized EU pharmaceuticals market and the reality in an individual member state. Although clopidogrel was centrally registered in the EU, policy measures at the national level result in different roles in clinical practice for this drug.
Diazepam and drug associated deaths. j ournal of the American Medical A ssociation
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