Ten years ago, Chang Hsiu-chen (張秀珍), a housewife from Taipei, was diagnosed with insomnia after a 10-minute consultation with a physician. She was prescribed Stilnox (a brand name of Zolpidem), one of the most commonly prescribed sleeping pills in Taiwan, and told to go home and take one pill a day. Chang, 70, still takes Stilnox, but she’s concerned about becoming overly-dependent on the drug. To allay her fears, she chops her pills into thirds and takes a third of a pill every night before going to bed.
In 2014, 339 million sleeping pills, including Zolpidem, Estazolam and Zopiclone were prescribed to adults in Taiwan, marking an increase of 12 million from the previous year. (Taipei Times, “Sleeping pill prescriptions surge,” February 25, 2016). The number is astoundingly high for a nation of 23 million people.
Chang’s 10-minute consultation is fairly standard. It is also indicative of the systemic problems that give rise to the over-prescription of sleeping pills.
Illustration: Mountain People
Walk into any government hospital and it’s common to see people crowding the hallways holding number dockets and waiting for hours for a five-to-10 minute consultation.
Clinical pharmacist and deputy director of the Koo Foundation Sun Yat-sen Cancer Center (和信治癌中心醫院) Chiang Shao-chin (姜紹青) says that sometimes, the Chinese idiom “unforeseen disaster” (三長兩短) is used by patients to describe the experience. The idiom, which refers to the three long planks and two short planks on a coffin, is used here to describe long wait times and short consultation times.
Not only is it cheap to see a doctor under the National Health Insurance system, but patients do not need to obtain a referral from a general practitioner and can see any specialist they wish. The result is that doctors are usually overbooked.
This is coupled with a mentality that many patients have that they’re not being cured unless they’re handed a bag of pills, which only serves as less impetus for already overworked doctors neglect to examine the root cause of the patient’s ailment and instead prescribe medicine to treat the symptoms.
LIGHTS OUT
Liu Ching-lung (劉景隆), a chest physician and sleep specialist at Mackay Memorial Hospital’s Tamsui branch (馬偕紀念醫院淡水院區) sees 40 patients on average before his lunch break. The rest of his time is spent visiting in-patients at the hospital, studying for his PhD and teaching.
Liu, who studied at the University of Sydney under Colin Sullivan, an Australian doctor who invented the continuous positive airway pressure machine to help patients with sleep apnea, says that doctors in Taiwan need to cultivate better relationships with their patients.
“We have to sit down and talk to them and get to know more about their lifestyle habits,” he says.
Liu regularly sees patients who practice bad “sleep hygiene” or habits that are not conducive to sleeping well. Such examples include using smartphones while in bed, or, in the case of teenagers and young adults, playing video games until early in the morning. The light emitted from electronic gadgets interferes with the secretion of the hormone melatonin, which controls our sleep and wake cycles, making it harder to fall asleep.
Consuming too much alcohol before going to bed is another example of bad sleep hygiene as it generally induces light sleep rather than the deep sleep that our bodies require.
Being stressed out over school or work, or working late hours can also contribute to having difficulty falling asleep or staying asleep. Such practices cause disturbances to our body’s circadian rhythm and do not necessarily mean that the patient has insomnia.
Liu believes that in these cases, normal sleep patterns can be restored if the patient makes changes to their daily routine such as exercising regularly, eating right and not using electronic gadgets before going to bed.
PRESCRIBING IS NOT CARING
Chiang agrees that the problem of over-prescription in Taiwan is systemic and that doctors, in general, should learn to care more about their patients and address their concerns.
“A lot of the time physicians won’t even look at the patient,” he says. “They just look at their computer screens during the consultation.”
Having completed his residency at the University of Wisconsin Hospital and Clinics, Chiang adds that doctors in the US have more time to get to know their patients personally and instruct them on how to use their medication correctly.
This is simply not possible in Taiwan where the cost of health insurance is low and doctor’s wages are often contingent on the number of patients that he or she sees per day.
For overworked doctors, Chiang says, “the easiest way to end the consultation is to prescribe a lot of pills.”
At the Koo Foundation, the number of patients that physicians see within a four-hour period is limited to 25 to 30, a regulation that Chiang thinks more hospitals should implement. He also believes that older, experienced doctors have a responsibility to teach younger ones about the importance of forging closer relationships with their patients.
Although the mentality that patients are not being properly cared for if they do not receive medicine is slowly changing, especially among the younger generation, Chiang says there needs to be more public education on the matter.
“Receiving medication is not a sign that the doctor cares about you,” he says.
LONG-TERM EFFECTS OF PILL POPPING
Since her insomnia diagnosis 10 years ago, Chang has seen multiple doctors to see if an alternative treatment was possible. But each time, she was simply prescribed more Stilnox. Moreover, she still doesn’t understand why she has insomnia.
“My life is very simple and stress-free,” Chang says. “I stay at home, clean the house, go to karaoke with friends and sometimes do volunteer work.”
Many of her friends, all housewives in their 60s and 70s, also have sleeping problems and take more pills than she does. This causes Chang to worry about the long-term side effects of the drug, which is why she sticks to her self-prescribed dose of one-third of a pill per night.
Her concerns are not unfounded. According to Chiang, going back to the doctor and simply being prescribed a higher dose of pills can potentially be dangerous.
“After a few weeks, when the problem is not alleviated, the patient will return to the doctor who will just prescribe more pills,” Chiang says. “It’s just not a viable solution.”
Long-term use can build a patient’s tolerance to sleeping pills, meaning that the same dose will not have the same effect on them after a long period of time. Also, sleeping pills like Nonbenzodiazepines (or the so-called “Z drug”) are known to cause sleep walking and sleep eating in some patients.
Fortunately for Chang, the same dose has worked on her for the last 10 years. After taking it, she’s asleep in 30 minutes and sleeps for approximately five hours a day, which is standard for someone her age.
MIXED BAG OF PROBLEMS
Not all people with sleeping problems are as lucky as Chang. In an aging society like Taiwan, it is common for older people to have a couple of different medical issues and be on different types of medication at the same time. Sleeping problems can be a side effect of combining various medications.
Work-related stress is also a major factor that contributes to sleeping problems among office workers. Working long hours and late nights means that people do not have enough time to exercise or relax.
“It’s quite sad, really,” says Liu. “People have to work and they can’t go to sleep, so they feel like they have no choice but to take a sleeping pill.”
What’s disturbing is the increase in sleeping problems in children and teenagers, all of whom are too young to be prescribed sleeping pills. Liu says that for some, especially young kids, it may be the symptom of another problem like big tonsils obstructing the airway. If that’s the case, they might have to see an ENT doctor to have the tonsils removed.
For others, the problem might be psychological and, therefore, more difficult to treat. Liu sometimes sees teenagers at his sleep clinic whose parents have brought them there. School-related stress such as problems with academic performance and poor relationships with classmates are all contributing factors to sleeping problems. In these instances, the root cause — psychological issues — needs to be addressed.
“There needs to be more access to therapy and counseling services,” Liu says.
However, huge structural changes need to be made in order for there to be more conducive channels of communication between doctors and patients, and this is not something that will take place overnight.
For now, Chang harbors little expectation for change.
“Doctors are too busy in Taiwan,” Chang says. “That’s just the way it is.”
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