Sometimes I can’t sleep. I have nightmares. I’m woken by the sound of a slurred shout before I realise I’m making it, then toss around in increasingly frustrated rearrangements of sheets and limbs until 5am. Bad sleepers know the countdown. If I go to sleep now I’ll get three hours, now two, now one, now showtime.
If I’m unlucky the nightmare moves in. I walk into my bedroom the next night and smell it. Then I don’t sleep either. By the third night the countdown reverses, and instead of counting what happens if you go to sleep now you count what happens if you don’t. Sleep now, you foolish girl, or tomorrow you’ll be so mentally frayed you’ll probably cry when you see a pair of take-away chopsticks because you realised one day they’ll be torn apart.
When this happens I take one dose of a benzodiazepine. I wash the sheets. Sometimes I’ll turn the bed around 90 degrees or sleep on the couch so I’m not in exactly the same space that nightmare was. But if I’m real these little nocturnal sage-burnings are nothing without also being hit on the head with the cartoon mallet of half a Valium. It means I sleep whether or not I was afraid to, and once I’ve slept I’m no longer afraid. It unplugs my brain and plugs it back in again.
Last week the nightmare moved in. I slept on Monday night and on Thursday I went to a doctor to say I hadn’t slept since. I asked if I could have a refill of the prescription that has been on file for two years. She said: “I don’t feel comfortable doing that.” She suggested I buy a bottle of nighttime cough syrup. The appointment was less than 50 seconds long, which I know from the timestamp on the podcast I didn’t have time to pause, before I was gathering up my things on the way out the door. I stood on the steps outside the doctor’s office knowing I’d already tried sleeping on both the available couches.
I understand why she didn’t feel comfortable: benzodiazepines are ferociously addictive. Remember Renton’s mother in Trainspotting, with her TV and her bottle of Valium, “who is, in her own domestic and socially acceptable way, a drug addict”? There are millions of people like her stuck in the wretched spiral of tolerance and dose-increase, and unsupervised withdrawal can be hideous. I know a man who came back to himself after three days of withdrawal from a Xanax addiction to find that he’d ripped out all his arm hairs. Of course any reasonable doctor is slow to give out the medication that paves the way to this kind of hell. But the resting place of healthcare cannot be that in the name of avoiding one kind of hell we consign patients to another.
Not sleeping simply isn’t an option. The membrane that separates us all from madness is frighteningly thin, and made up of about three nights’ sleep. I am not exaggerating when I say I was hearing things: I went for a walk in the woods and heard people calling my name. In outrage afterwards I repeated my doctor’s line to my friends: “You don’t feel comfortable? I didn’t realise this appointment was about how you feel.” I could hear that I sounded like an addict. It was one sentence away from “lady, just give me the pills”. But in truth I did want the pills. Of course I wanted the medication that would deliver me from this.
People who rely on opioids sometimes report the same thing: that the reasonable fear of patients coming into doctors’ offices wanting pills obscures the fact that there could be very good reasons for wanting pills. These medications save people from the pain of cancer, or chronic arthritis, and without them being awake can be torture and being asleep impossible. If one reason for wanting to prevent addiction was because of the path it lays to suffering and suicide, it is worth noticing that chronic pain can lead to many of the same places. One patient writes on the experience of needing opioids to function: “I am also dependent on 2 anti-hypertensives. Would anyone ever imagine taking [them] away because I am dependent on them?”
The perverse thing is that your persuasive power gets deflated the more you try to point out how unliveable life can be without these medications, because the desperation of suffering looks very much like the desperation of addiction. Who looks less like they can be trusted with a medication than the person urgently insisting that they need it? Saying “I can’t function without pills” is as bad a way of getting them as saying “I’m not lying” is of being believed, even when both statements are perfectly true.
So it occurs to you that masking your suffering might be a better way of getting it treated. You could learn to better perform the role of responsible prescription-haver, concealing your desperation; you could do without, but sure, doc, if you think so, and this is how the completely reasonable fear in your doctor’s mind that you were only pantomiming could be the thing that gives you reason to learn how.
The way out of this mutual doctor-patient mistrust isn’t obvious. What is obvious is this: it cannot be that we make “preventing addiction” the goal of healthcare, so much so that in its name we are prepared to forfeit the goal of helping people who are suffering. Indeed the reason we cared about preventing addiction in the first place was that we care about people and we want their lives to go well. Doctors and patients are on the same side in this when it comes to addiction; neither of us want to deal with withdrawal and dependence in six months’ time. But just as important as this is that we are on the same side against the suffering these medications were designed to treat.
• Eleanor Gordon-Smith is a writer and ethicist currently at Princeton University
