Psychotropic drugs: Long-term use, dependency and the gender factor

Sm. Sci. Med. Vol. 39, No. 12, pp. 1667-1673, 1994 Copyright0 1994 ElscvierScienceLtd Printedin Great Britain.All rightsreserved 0277~9536(!M)EOO55-W 0277-9536194S7.00 + 0.00

Pergamon

PSYCHOTROPIC DRUGS: LONG-TERM USE, DEPENDENCY AND THE GENDER FACTOR ELIZABETH ETTORRE,’ TIMO KLAUKKA~ and ELIANNE RISKA’* ‘Department of Sociology, Abe Akademi University, Gezeliusg. 2 A, 20500 Abe, Finland and *Social Insurance Institution, Finland

Abstract-The study examines the factors contributing to the initiation, continuation and termination of use among female and male long-term users of minor and major tranquillizers. The findings show the importance of the lay-referral system as a channel of introduction to psychotropic drug use, especially for men. The issue of dependency is explored both in terms of the users’ own interpretation of its nature and their reports on the professional responses to their long-term use. The findings indicate that gender and drug use are intricately linked in both the non-professional and professional treatment of anxiety and

Key words-psychotropics,

dependency, gender

INTRODUCTION Concern over the widespread use of psychotropic drugs, i.e. drugs affecting psychic function or behavior, resulted in efforts among researchers to map the extent of use and to provide a social profile of the users in the 1970s. This genre of research was summed up in the now classical review collated by Cooperstock and Parnell [I]. In the 198Os, sociological studies on psychotropic drug users or usage added a new understanding of the social and cultural meaning of this type of health behavior [2-81. More recently issues of long-term use of, and dependency psychotropic drugs, especially benzoupon, diazepines, have been raised as a major public health concern [9, lo] and as a social problem [ll, 121. The latter issues have been widely debated and publicized in Britain whereas they have been mainly restricted to the concern of researchers in the field in other countries. In their review of population surveys on psychotropic drug use conducted in the 1970s and 198Os, Williams and Bellatuono [13] estimated that about 2-3% of the population are long-term users of minor tranquillizers in Western countries. No clear consensus seems to exist about how to operationalize longterm use. In his review on this topic, Gabe [14] defined long-term use as regular use for a year or more. Gabe showed that existing research indicates that 27-45% of the psychotropic drug users report to be dependent upon their drugs. Dependency upon benzodiazepines has physiological and psychological aspects. The physiological aspects include a broad range of clinical symptoms,

*To whom all correspondence

should be addressed.

such as withdrawal symptoms, as well as an increased tolerance level to the drug [IS]. The psychological aspects involve the extent to which the individual feels she or he can behave or exist in everyday life without the drug, an aspect which is socially and culturally situated. Helman’s [16] study constitutes one of the pioneering works on the psychological dimensions of dependency on psychotropics. Helman showed that the drug had a function as a tonic, fuel or food depending on the extent of control that the user felt he or she had over his or her use. But Helman and many others writing on this topic have primarily been interested in dependency as a social, cultural or public health problem in itself. There is still little information about the structural context which channels the coping behavior of the individual towards drug use, especially to a sustained use. More importantly, while research findings from many countries consistently identify women as primary users of psychotropics in comparison to men, this research has not explicitly addressed the question whether or not women use these drugs differently than men. There is still scant information whether the factors which contribute to the initiation of use, to the long-term use and to the termination of use differ for men and women. As has been shown [ 171, the literature in the field tends to be either gender-neutral or gender-biased. This means that women’s high rates have either been ignored or interpreted as a coping pattern connected merely to one gender-women. The gender-specific explanation has been based on sex-role theory which has reduced psychotropic drug use as part of the female sex role interpreted in an almost naturalistic way [18]. These kinds of explanations tend to homogenize women. They not only neglect to consider differences amongst women but also neglect to explore similarities and differences

1667

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ELIZABETH ETTORREef al.

between women and men. The latter issue is important if one wants to illuminate the patterns of psychotropic drug use in Finland, where research has shown that the gender differences in use are exceptionally small [ 19,201. This study examines long-term psychotropic drug use and gender-related factors contributing to the initiation, continuation and termination of use in Finland. METHODS

Subjects The target population was adult persons who were using, or had used, tranquillizers and who were residing in a southern metropolitan area of Finland. The aim was to recruit 50 men and 50 women for a questionnaire survey and to select 10 persons for interviews among the respondents. The study population was recruited in two waysthrough local health care centers and newspapers in January-April of 1992. Health -care centers. Primary-care physicians provided the questionnaire to patients who were users of tranquillizers and who had entered the health-care system through a municipal health center, voluntary health center or an alcohol treatment center. 48 Subjects (30 men and 18 women) were recruited in this way. Newspapers. The recruitment of respondents through newspapers involved two phases. During the first phase, journalists wrote a summary of the aim of the planned study in the local newspapers and provided a telephone number so that people could volunteer. In the second phase, an advertisement was placed in a local newspaper to recruit persons who were users or who had used tranquillizers to the study. This recruitment method yielded 52 persons, 13 men and 39 women. Table 1 shows that women were more inclined to volunteer through the advertisement in the newspapers whereas a majority of the men (30 out of 43) were recruited through health-care centers, in particular alcohol treatment centers. The skewed distribution of the respondents by recruitment site and gender was unexpected and at the same time was an indicator of the gendered character of long-term tranquillizer use.

Table 2. Distribution (%) of social characteristics: age, employment status, civil status and place of residence Total

Females

Males

Average age (yr)

56. I

46.2

51.8

Employment status Retired Employed Unemployed Housewife Other

63 21 II 2 3

28 32 35 0 5

48 26 21

10 40 23

21 32 37

I5 31 29

I8 9

5 5

I2 I

51 28 21

49 40 II

50 33 I7

100 57

100 43

100 100

Social characteristic

Ciuil sta*us Unmarried Married Separated or divorced Widowed Cohabiting Residence Suburb Inner city Other Total (X) n

1 4

The final study population consisted of 43 men and 57 women (three males and seven females were selected for future interviews). The average age for the total sample was 51.8 yr of age: lower for males (46.2) than females (56.1) (Table 2). Almost half of the respondents were retired which was related to the high rate among female (63%) compared to male (28%) respondents. While a third of male respondents and a fifth of female respondents were employed, a much higher proportion of males (35%) than females (11%) were unemployed. The category housewife was not particularly common. As other research has shown, housewives in comparison to employed women in Finland do not have a higher rate of psychotropic drug use although this is the case in the other Nordic countries [20]. With regards to current or former occupation, 84% of the respondents were or had been involved in lower white- or blue-collar occupations. Overall, 44% of the respondents were living with a partner either married or not. Males reported more often than females that they were separated or divorced, while females more often than males were widowed. Half of all respondents lived in the suburbs, while a third lived in the inner city area. Measures

Table I. Distribution

of the study population gender

by recruitment

site and

Males

Females

Total

Health care centers Municipal health centers Voluntary health center Alcohol treatment centers

(30) I 29

(18) 4 2 12

(48) 5 2 41

Newspapers Phase I: story Phase 2: advertisement

(13) 9 4

(39) 31 8

(52) 40 12

43

57

100

Recruitment

Total

site

The questionnaire included 35 questions, of which 11 provided social background information about the respondent. Eleven measures assessed the respondent’s drug habits. Psychotropic drug use was measured by the question: “Do you presently use tranquillizers or sleeping pills?’ Current users were defined as those who responded that they had (a) used such regularly or rather regularly during the past month and (b) used such a couple of times during the past month. Ex-users were those who were not

Psychotropic drugs presently using tranquillizers or sleeping pills but had used such in the past regularly at least during a month. The characteristics of the respondent’s drug use were measured by type of drugs used, number of drugs used, frequency of use, and length of use. Initially the study aimed at focusing only on users of minor tranquillizers. As the analysis of data progressed, it became evident that the respondents had listed major tranquillizers in addition to the 36 minor tranquillizers listed in the appendix of the questionnaire. Concerning type of drugs used, the final list of coded drugs included 36 minor tranquillizers (benzodiazepines, i.e. hypnotics and sedatives) and 28 major tranquillizers (mainly neuroleptics and antidepressants). In terms of drugs used, respondents were divided into three categories: (1) pure minor tranquillizer user, i.e. used only minor tranquillizers; (2) mixed user, i.e. used both minor and major tranquillizers; (3) pure major tranquillizer user, i.e. used only major tranquillizers. (A full list of the drugs can be obtained from the authors.) The mechanisms of introduction to drug use were measured by self-assessed etiology of drug use, type of prescribing physician, and role of lay referral network (i.e. acquaintances, friends, relatives). The mechanisms of continuation and/or termination were assessed by questions concerning experienced difficulties in terminating drug use, desire to stop use, raising the issue of terminating drug use with prescribing physician as well as other persons, and the physician’s and lay person’s reactions to the desire to stop drug use. Ten questionnaire respondents (seven females and three males) were interviewed. The semistructured interviews lasted on the average 30min. The interviews were transcribed and this material amounts to 37 single-spaced type-written pages. Only the issue on dependency from this material will be reported in this article.

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treatment facility. Hence, one type of chemical dependency had most likely resulted in the dependency on another substance-major tranquillizers. Since our data were cross-sectional they did not provide information about the sequence of dependency on substances but mainly about current dependencies. A majority reported that they had used more than two drugs, either consecutively, or one after the other. Female users reported this more often than their male counterparts. The most frequently used drugs were: Oxepam (oxazepam) by 16% of respondents; Halcion (triazolam) by 7%; Diapam (diazepam) by 6%; Mogadon (nitrazepam) by 4%; Insomin (nitrazepam) by 4% and Temesta (lorazepam) by 4%. A majority of the respondents reported that they used their drugs daily, with more females reporting this than males (Table 3). As much as 20% had used over 15 yr some kind of psychotropic drug. The average length of time for use of these drugs was 9 yr, higher for female users (11.4 yr) than for male users (6.1 yr). AGENTS

OF INTRODUCTION TO AND CONTINUATION OF DRUG USE

Help-seeking behavior begins in most cases with a casual exploring of diagnosis and remedies with significant others. This lay-referral system consists of

Table 3. Distribution (%) of psychotropics used, number of drugs used, frequency FWl&S

by type of user, drug and length of use* M&S

Total

81 I9

93 1

85 I5

44

42

43

47 9

44 14

46 II

Number qf drugs used One drug Two drugs Three drugs Four drugs Five or more

I9 23 I8 19 21

28 30 I6 IO I6

23 26 I7 IS I9

Frrquency of use Daily Sometimes during a week Less than once a week Did not remember

67 27 4 2

57 I7 I7 9

63 23 9 5

Lengrh of drug USC
3 I6 9 30 I6 IO I6

19 26 9 25 7 5 9

IO 20 9 28 I2 8 I3

100

100

of user Currentuser

Type

Ex-user Type of drug used Pure minor tranquillizer user Mixed user Pure major tranquillizer user

USE OF PSYCHOTROPICS

A majority of the drug users were current users (85%) while the remainder were ex-users (15%). There were, however, marked gender differences between the current and ex-users: 19% of female and 7% of male respondents were ex-users (Table 3). In terms of drugs used, females were to the same extent as males pure minor tranquillizer (i.e. hypnotics and sedatives) users and mixed users but males were slightly more often than females users of only major tranquillizers (i.e. neuroleptics and antidepressants). The latter finding might be related to the male respondents’ alcohol habits revealed in the findings on health behavior. 29% of the male respondents reported that they drink beer or other alcohol daily and 24% said they do it two to three times a week as compared to 3% respectively 12% of the females. Furthermore, two-thirds of the male respondents volunteered for the study through an alcohol

Total (%) n

57

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ELIZABETH ETTORRE et al.

Table 4. Distribution

(%) of mechanisms ation and termination

of introduction. of use

continuTotal % n

Females

Males

61 16 23

51 23 26

57 I9 24

57 I9 24

20 80

35 65

26 74

26 74

100 51

100 43

100

100

45 40 I5

45 35 20

45 38 11

38 32 15

100 45

100 40

100

85

20 30 30 IO 5 5

44 28 6 II 6 5

32 30 I8 IO 5 5

I2 II 1 4 2 2

100 20

100 I8

100

38

Current wem (n = 85) arm ex-users (n = 15) Yes

NO Do not know Rcceiced

drugs ,from

significant

others

Yes

NO Tolal (%) n Curr wr u.wn (n = 85) Disc dosed stopping

with

docfor

Yes

NO No answer Total (%) n Docror’s stop

response

drug

10 expressed

Positively agreed Said the drug was harmless Said there was no alternative Made no comment Both agreed and disagreed No answer Total (%) n

desire

to

use (n = 38)

non-professionals, such as family members, friends or acquaintances, who assist individuals in interpreting their symptoms and in recommending a course of action [21-231. A majority of the respondents had been introduced to a ‘drug using culture’ either through their relatives, friends or acquaintances. A majority of the male and female respondents said that these significant others, who were part of their primary social networks, had used psychotropics regularly for a long time (Table 4). This lay-referral system constituted the main channel of introduction to psychotropic drug use for a fourth of the respondents. There was a marked gender difference in the non-professional introduction to psychotropic drug use. A third of the male and a fifth of the female respondents reported that they had initially received their drugs from friends, acquaintances or relatives. As Miles’ [24] study showed, other women play a strategic role in this process of lay advice to other women with regard to feelings of ‘not coping’ or ‘sleeplessness’. Furthermore, Graham [25] and Stacey [26] have pointed out women’s crucial role as the primary health workers in the informal sector of health care. This role implies, however, that women share not only their ‘labor of love’ but also their remedies with others. In this way women are likely to unwittingly introduce other women and men into dependency-producing drug use. As previous research has revealed [27], men more than women are more hesitant to seek professional, psychiatric help. Women are most likely to have a major role in the lay

system of diagnosing men’s psychiatric symptoms as well as finding medical remedies. Most drug use is, however, initiated by using professional help: the physician prescribes the drug and determines the dosage and duration of use. About half of the current users had, however, been worried about the duration of their drug use and discussed their desire to stop with their doctors. This desire had received mixed responses from their doctors (Table 4). A third of the current users reported that their doctor had supported their wish to stop using drugs. There was, however, a marked gender difference in this group: male respondents had twice as often as the female respondents received support from their doctor in their desire to stop. By contrast, a third of the female current users had been told by their doctors that there was no alternative to their drug use while only 6% of the male current users had been told this. Furthermore, a third of both male and female current users reported that their doctor had told them that the drug was harmless, i.e. confirmed a continuation of their drug use. The above results on the users’ initiation to, and concern over, sustained drug use suggest that there exist distinct, gendered structures influencing patterns of drug use. The lay-referral system plays an important role in introducing people to psychotropics. Here, women in their capacity as health workers in an informal system of health care serve as initiators of use. Still, men more often than women tend to be the passive recipients in this initiation process. In the formal system of health care, however, physicians appear more often than not to confirm women’s, rather than men’s, sustained use. While doctors viewed women’s use of psychotropics as an inevitable course of action, they did not view men’s use similarly. The above results confirm that gender and drug use are intricately linked both in the non-professional and professional treatment of psychiatric symptoms. THE

ISSUE

OF DEPENDENCY

A majority (71%) of current users wanted to stop using their psychotropic drugs. Half of the current users reported that it would be difficult to stop the use even if they wanted to. Female current users (67%) reported this more frequently than male current users (42%). Half of the current users reported that the reason why it would be difficult for them to stop using was related to dependency problems. A majority (59%) of male current users reported that reason, while females tended to split their reasons between sleeping problems (48%) and dependency problems (44%). Both the interviews and the survey data indicated that men’s drug use was related to their work, which they felt was stressful. One male user, a former insurance director, revealed his earliest memory of

Psychotropic

the need for his drug, of male

a tale

replicated

by a number

in our study:

respondents

It was because I had such stressful work and because of it I could not get to sleep. When things began to bother me in the evening, I began to think about them. It was in my opinion obviously the reason. It was evident. That’s why I explicitly asked for those drugs. But

he acknowledges:

The dependency came very slowly. First there were IO-15 yr when I took them only when 1 really needed them. Perhaps, it is normal with age that insomnia begins to bother you. And one gets used to them [drugs]. Then, there was a physician-prescribed drug in the closet and I developed a habit during the past years. I took them every night, The dependency was in my opinion mainly psychological. 1 did not get to sleep, I had to simply go to get something first. For men their

use was overt

and they legitimized

their

need. By contrast, the women generally felt guilty about their long-term use and perceived that the male attitude towards legal drugs as a form of ‘pharmacological Calvinism’ [28] was the normative pattern. ‘Pharmacological calvinism’ has been defined as an attitude towards drug use which perceives it as either morally wrong or something which one has to pay for with dependence [28]. For women the ethic of drug use was conceptualized in Klerman’s [28] terms as “if a drug makes you feel good it must be bad”. Hence, surprisingly many of the female respondents tried to hide their drug use and even to ‘secretly’ begin the termination of use. One woman commented about her long-term use: long-term

use

as a medical

The doctor says that you just eat them. My husband has said that I am a drug junkie. He has a gift for sleeping, he sleeps whenever. Such a person who sleeps well does not understand. My menopause is of course one reason which influences my sleep.

Another

woman

confesses:

I cannot talk to my husband since he does not understand and he does not approve of it but just mumbles and I secretly take Imedeens [a fish protein preparation believed to make the skin look younger] and other things, since he does not believe in anything. There is really nobody who understands, and I don’t want to bother good friends with these problems. I just don’t want to bother my friends with them.

woman, similar to many women in the study, was unable to get to sleep because she was worried about her now adult children’s ‘house affairs and work situation’. For women, their current insomnia related primarily to problems with husbands or children, although originally their drug use had begun with a physical illness. But many women echoed the voice of one female user who described her dependency in the following way:

This

Yes I was [dependent]. I had to take it [the drug] in the evening. It was the same thing in those days . if something bothered me then I immediately took that Tensopam (di-

1671

drugs

azepam) from the closet. It was like I had to go and get it. I don’t know if it was necessary. It relieved me anyway. Even if somebody would have put calcium tablets there, I think they would have relieved me. Many women had tried to be without the tablets but failed. The lack of support for such an endeavor, illustrated in Table 4, may result in a failure to terminate one’s use. This is vividly described by one woman: I said [to my doctor] that since 1 am a slave to these [drugs] I want to get rid of them but he just said that they are not dangerous and that I could very well use them. They [doctors] are not at all worried about it, even if I am. If a physician would say that you simply do not take them any longer, then it would be easy to stop. But the doctors don’t

really bother. Additionally, the following

the supply pattern is well described female user’s response:

in

I have asked doctors about what I now take [drugs] and when.. They have confirmed that they [drugs] are such small amounts anyway that they don’t have any effects, although I think that they are large [amounts]. They say that they have no harmful effects, they do not harm, that I have to get some sleep. Now I get [the drug] from my municipal physician-he is a wonderful doctor-and then from NN who is my knee surgeon, I ask them in turns when [the drugs] are finished.

In conclusion, the interviews showed that both male and female users were bothered about their long-term use but women more than men had experienced feelings of guilt. In their families women found little support for their continued use and often kept it ‘secret’, while doctors generally saw women’s use as harmless and justified. Men had a more instrumental attitude towards drug use: it maintained their working capacity. Women did not relate their drug use to maintaining a caring role, perceived mainly as affective rather than instrumental. DISCUSSION

The overall objective of the study was to identify whether or not there are gender differences in longterm use of psychotropic drugs. In terms of the use of psychotropics, Finland is an exception because in comparison with other countries, the gender difference in the prevalence of use of psychotropic drugs is exceptionally small [19,20]. Previous Finnish studies have, however, not examined duration of use and the issue of dependency. Our results do not provide an unequivocal list of reasons why women may use these drugs differently from men. Our findings have, however, pointed to the processes whereby women and men are introduced to the drugs, continue to use them and manage to stop using them. A comparison with previous results on psychotropic drug use in Finland shows that the social characteristics of the users are comparable [19,20]. Nevertheless, the male respondents were primarily persons who themselves also had alcohol problems

1672

ELIZABETH ETTORRE et (11.

and volunteered to participate in the study through an alcohol treatment facility. Hence, a large proportion of the men had experienced chemical dependency prior to their current use of psychotropics while the women did not provide this information. Our results showed that the average length of psychotropic drug use was 9 yr. Our study was crosssectional and hence relied on the respondents’ own assessment of the process of initiation and continuation of drug use. Current users felt it would be difficult to stop using their drugs; they wanted to stop using them and saw dependency problems as being both the cause of creating difficulties in stopping and the reason why they wanted to stop. Women alluded to their own illness or family relationships as beginning their dependency on drugs, while men reported work pressure and economic troubles as key initiating factors. In short, they knew they were dependent; wanted to stop, knew why and how this would be difficult and had discussed stopping this with their doctors. Women’s responses tended to be more exact and focused on a feeling capacity (e.g. fear, gaining self-confidence) and emotional well-being. Men’s responses were more ambivalent and revolved around maintaining a daily rhythm and a working capacity, confirming previous findings [3,4]. This result might reflect the current gender order: men’s focus on their ‘working capacity’ and women’s focus on their ‘feeling capacity’ is linked with their experience of being gendered subjects in a drug using society. Given that men were three times as likely as women to be unemployed, these drugs might help men not only to focus on the gender-related norm of men’s commitment to work (when employed) but also to deal with the anxieties of not being able to express publicly their working capacity when unemployed. After all, the function and capacity of the body, operationalized as the working role, is a crucial definition of health and masculinity for men [29]. Women appear as the multiple drug and long-term users of psychotropics, while men’s usage, although long-term, appeared to be slightly sporadic: men had used more often these drugs previously, suggesting that there were ‘starts’ and ‘stops’ in their use. That a third of men respondents compared to a fifth of women respondents had received drugs from significant others suggests that these significant others may provide for men an alternative drug supply to the one provided by a doctor’s prescription. Hence men are more likely to have been introduced into the psychotropic drug culture by significant others, most likely women, who openly share their drugs and initiate them into pill taking. One sees here a type of sex role reversal, if this finding is compared with previous ones in the related field of illegal drug use. There, a consistent finding is that women heroin users are initiated into heroin use by men [30]. In contrast, our study suggests that women rather than men may

be the pushers in the ‘tranx using culture’. ‘Tranx pushing’ is mainly carried out in a private domain of the household where a woman’s provision of drugs to her partner might be experienced as an extension of her caring role. Overall our results indicate that there are genderrelated differences in the initiation and sustaining of use of psychotropic drugs among long-term users. On the level of future research practice, useful pointers around possible gender differences in the use of psychotropic drugs with regards to regular and daily usage, drugs favoured, length of use and means of supply have been established. Additionally, the issues of dependency and dual dependency and their relationship to psychotropic drug use have been flagged UP.

Our research approach has attempted to problematize both men and women’s use of these drugs in both the private and a public domain of social relations. If a new understanding of this issue is to be developed, it must explicitly include both women and men. Ackno\+Gdgements-We would like to acknowledge the research assistance of Johanna ijsterberg who did the interviews and transcribed them. The research was made possible by the funding provided by the Medical Research Council of the Academy of Finland and by the Foundation of Abe Academy University.

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