DThe use of benzodiazepine-based
tranquillizers and hypnotics-sedatives has
led to a major public debate in Sweden,
where all interested parties have become
involved. In Finland the authorities and
physicians have to a large extent set the
pace of the debate. In this paper the
author analyses the role of the mass
media, physicians, the authorities, the
pharmaceutical industry, and patient
organizations in the construction ofthe
use of these drugs as a social problem.
ANTTI SCHONBERG
Tranquillizers and Hypnotics-Sedatives
as a Social Problem in Finland and Sweden
I
n the 1980s, concern was raised over the
widespread use of benzodiazepine-based
tranquillizers and hypnotics-sedatives. The
central focus of the medical debate was on
physiologica1 dependency,;md long-term use.
Benzodiazepines were seen as a major public
health problem (Peturson & Lader 1981) and
as a social problem (Gabe & Bury 1991).
Gabe and Bury (1988) argued that the public
media played an imponant role in legitimizing benzodiazepine dependence as a social
problem in Britain. The media offered an arena for expens and consumer groups to present
their concerns over the issue of dependence.
This paper focuses on how concerns over
the use of drugs based on benzodiazepines
were presented in Finland and Sweden from
the early 1980s to 1994. In Sweden there
emerged a major public debate around benzodiazepines whereas such a debate did not
emerge in Finland. In Sweden the long-term
use ofbenzodiazepines became a public health
problem and a social problem whereas in Finland concern was only addressed to the abuse
of these drugs. Meanwhile, the use of benzodiazepines in Finland was growing whereas in
Sweden it was decreasing in the late 1980s. In
1989, Finland passed Sweden in the total con-
This research was made possible by funding provided by the Finnish Foundation for Alcohol Research. This
article was previously published in Swedish in Nordisk alkohol- & narkotikatidskrift vol. 14 (1996) 1.
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VDL. 14. 1997 (ENGLISH SUPPLEMENT)
1
17
sumption of benzodiazepines measured as
DDD/1000 inh.lday. The scale of the consumption of minor tranquillizers would not
seem to predict the status of the problem. In
the beginning of the 1990s, there was no clear
picture of the frequency of long-term use of
minor tranquillizers and dependency either in
Finland or in Sweden.
This article will examine the debate waged
in the two countries. First, I shall describe the
trends in consumption and discuss the professional debate about benzodiazepines. Second,
I shall reconstruct the professional and media
debates in Finland and Sweden. Third, I shall
compare the two cases and consider their implications for actor relations in the making of
medicine and health policy.
Method
The approach used in the analysis is in the
tradition of contextual constructivism (Best
1987, 115-8). The questions asked are: What
influences a question so that it will become a
social problem, and what kind of process gives
rise to a social problem? Behind the constructive tradition is the idea that social problems
do not have purely objective criteria. " ... social problems are rather projections of collective ideas than reflections of objective conditions" (Hakkarainen et al. 1993).
In general the rise of a social problem transfers the responsibility in a question from the
individual to the society. The benzodiazepine
debates were conducted in different arenas:
medicine, politics, administration, and the
media. The persuasion process in these arenas
works in different ways. In the public debate,
actors have to show themselves as convincing,
legitimate, andi or necessaty in order to
achieve their goals and keep their position
(Hakkarainen & Hoikkala 1992, 1). Benzodiazepines are commonly prescribed drugs
and debates concerning them reveal something more general about medicine, health,
18 I
and drug politics.
Two types of material were collected. First,
the debate about benzodiazepines in the leading medical journals, Låkartidningen in Sweden, and Duodecim and Suomen Lååkårilehti
in Finland, was used as the major material. All
research, news, and debate articles concerning
benzodiazipines were collected between 1.1.
1981 and 1.7.1994 (39 issues in Sweden and
39 in Finland). Second, the debate in the public media in Sweden was wide and intensive
between 1988 and 1992. I followed the debate
in the major national newspapers and in some
regional ones from 16.10.1988 to 22.4.1992.
The research, news, and debate articles published in Dagens Nyheter and Svenska Dagbladetwere collected (68 issues), using the archives of the patient group RFHL-Kilen in
Stockholm and the archives of the Swedish
National Radio. There was not a big debate in
the Finnish public media about benzodiazepines. The Finnish medical authority, the
National Board of Health and Welfare, withdrew triazolam products (i.e., Halcion) temporarily from the market on the 2nd of October, 1991. The action brought up minor public debate in October-December, 1991. I followed the debate in the major national newspapers Helsingin Sanomat and Ilta-Sanomat
and in some magazines. Atter the triazolamHalcion case (1992-1994) a few articles concerning benzodiazepines were published. I included these articles found in a Finnish bibliography (Kati) in my data (25 issues). All the
official papers mentioned in the debate were
included in the data (5 in Finland and 16 in
Sweden).
The international debate over
benzodiazepines, and sales trends
in Finland and Sweden
The international concern over the use ofbenzodiazepines grew in two stages. In the 1970s
some physicians and social scientists were con-
NORDISK ALKOHOL· & NARKOTIKATIDSKRIFT, VDL. 14, 1997 (ENGLlSH SUPPLEMENT)
cerned over the widespread use (Gabe et al.
1986) and abuse ofbenzodiazepines (Gabe et
al. 1988). Controlling Psychotropic Drugs The Nordic Experience (Bruun 1983) was the
main product of the first wave of critical research on psychotropic use in the Nordic
Countries in the 1970s.
In the 1980s physiological dependence on
therapeuric doses became the foeus of the diseussion (Gabe et al. 1986). The epidemiological studies estimated that 27-45 % af longterm users were dependent on their drug
(Gabe 1991). Gabe (1991) defined long-term
use as regular use for a year or more; however,
there was no clear concensus about the concept. Williams and Bellantuono (1991) estimated that 2-3 % of population are long-term
users in most western countries. In Sweden a
strong tendencywas found towards long-term
use (Isacson et al. 1992). In their review Lilja
and Larsson (1994) found that risk factors for
becoming dependent on benzodiazepines are
daily dose, period of usage, drug preparation
used, personality of the drug user, patient's use
of alcohol, and cultural beliefs. Social scientists paid attention to social, cultural, and psychological factors influencing the use of benzodiazepines (Cooperstock et al. 1982; Helman 1981; Golombock 1989, 1991).
The use of benzodiazepines grew fast in the
l%Os and in the beginning of the 1970s in
Finland and Sweden. From the mid-1970s to
the mid-1980s the use in Finland was stable,
but it began to grow in the late 1980s and
surpassed that of Sweden in 1989 (Hemminki
1983; Riska 1993). The growth was especially
marked in the sales of hypnotics-sedatives
(Riska 1993). The trend stopped in 1991
when the National Board ofHealth and Welfare withdrew rhe most commonly used hypnotic-sedative Halcion and other triazolam
products from the market. In the late 1980s,
the sales of benzodiazepines began to decline
in Sweden.
Figure I. Sales of tranquillizers (DDDII ,000 inhl
day) in the Nordie countries, 1975-1991 (Riska
1993)
60,-----------------------------,
50
10
Figure 2. Sales of hypnotics-sedatives (DDD/I ,000
inh/day) in the Nordie countries, 1975-1991
(Riska 1993)
80.-----------------------------~
20
0+-,-,-,-,-r-'-",,-1-'-'-'-'-+-1
1975
--+----v--
1980
1985
1990
Denmark
--B--- Iceland
Finland
~
Sweden
Norway
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOl. 14. 1997 (ENGLISH SUPPLEMENT)
[19
The Swedish debate on benzodiazepines
The Swedish medical profession was divided
into two groups over their standpoint on benzodiazepines in the 1980s. Some professionals
argued that dependence on therapeutic doses
is a serious health and public health problem
[1-6]. Others concluded that dependence
does not occur on therapeutic doses. The
problems in the use of benzodiazepines are
instead the physicians who are afraid of prescribing them and a small group of patients
who abuse drugs [7-12].
The patient organization RFHL (Riksforbundet for hjalp åt lakemedelsmissbrukare)
was one of the central forces in the public and
professional debate. RFHLs general aim was
to help intoxicant abusers. In the beginning of
the 1990s, RFHL-Kilen was set up in Stockholm. It concentrated on the benzodiazepine
question. RFHLs policy towards benzodiazepines was very critical.1t defended nonpharmacological therapies in treatment of anxiety
and insomnia [13]. RFHL took part in the
preparation of official reports [14-16].
The medical profession and National Board
ofHealth and Welfare (SoS) held in 1988 two
consensus conferences concerning drug therapies in the treatment of insomnia and anxiety
[17,18]. In the conference papers and in the
official report for the new drug legislation,
dependence on benzodiazepines was seen as a
major health and public health problem [14,
17, 18]. SoS extended the range of the problem in 1990 when it published a general
guideline for the use of psychotropic drugs
causing dependence [15]. The central concept
was low-dose dependence, i.e., dependence
that could develop at a normal dos e and in a
short period of time (which was not defined)
[15]. SoS arranged informational and educational meetings around the country. At the
same time, benzodiazepines were being widely
discussed in the public media. The public and
professional debate became heated and some
20
I
in the medical profession began to become
concerned. The physicians appealed to the
government arguing that there was an "intimidation campaign in the media" against benzodiazepines. Theyalso claimed, without proper
scientific examination, treatment policies
were being forrned in the public media and by
authorities [19].
The letter caused a hearing which took place
in December 1991. Actors in the drug debate
were collected around one tab le. The debate in
drug politics is rarely as open and concentrated as it was at this point. After the hearing,
the debate diverged into different topics. In
the summary of the hearing papers Professor
Marie Åsberg [20] wanted to restore the debate back to the arena of medicine. She restricted the concept of dependence so that it
would always require an increase in dosage to
be diagnosed.
In September 1990 a group of benzodiazepine users started a legal process against
drug producers on the basis of a lack of product liability [21]. However it soon became
obvious that it was hard to find evidence for
this kind of a case.
In the period of 1990-1993 benzodiazepine
dependence became institutionalized in the
agendas of the Swedish health care administration as a major health and public health
problem, and was separated from abuse,
which was seen as a minor problem. The benzodiazepine question came up in the preparation of various laws [16,22,23]. The Parliament took part in the debate in the sessions
during 1990-1991 and 1991-1992 [24-26].
The Parliament demanded governmental action. In November 1990 the Social Committee of the Parliament argued that it was tired of
waiting for governmental action on the question of dependence. The Committee saw dependence as a major problem. The Ministry of
Social Affairs replied that the criticism was
exaggerated [27]. In the 1991-1992 session
the government gave a proposal for new drug
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT, VOL. 14, 1997 (ENGLlSH SUPPLEMENT)
legislation to the Parliament but dependence
was not dealt with [28]. In their proposals the
members of the Parliament demanded clarification of the scope and the character ofbenzodiazepine dependence, and called for control
and regulation actions, resources for treatment and education, and raising the status of
the dependence problem [24, 26].
Benzodiazepine users in the public media
The benzodiazepine debate in 1988-1992 in
the public media was widespread in Sweden: If
one paid any attention to the media, one
could not avoid the question. The media presented ordinary, working people who told
about their dependence. The user was portrayed as a victim of the health care system.
The doctor had prescribed herlhim a drug
which (s)he had used according to instructions but had become dependent. The media
picture of the drug dependent person differed
clearly from that of the drug abuser (see Hakkarainen 1992). Users i.e., often appeared
with their own names.
"The doctor made me an abuser", told 38
year-old Lena Bengtsson [29], and 54 yearsold Lee Gorringe claimed that, "Not a single
doctor wanted to hear that I would stop taking
my medicine, no matter how Iasked. 'You
need pills, I myself take them sometimes' , I
was calmed by the doctor" [30].
The concerned users were organized by a
patient organization, RFHL, and by a physician, psychiatrist, and researcher, Stefan Borg.
Borg was not only a passive expert but his role
was a kind of a mixture between an investigating journalist and an expert. This in turn put
his physician's role under scrutiny. Stefan Borg
was presented as a Robin Hood of modern
society. [31-35]
In a two page article a picture is showing
Borg standing in his long white doctor's coat
with a pill in one hand and a pillbox in the
other. The tide of the article is: "Every seventh
patient becomes an abuser. A senior physician:
This is an insidious catastrophe" [33].
According to Borg's and RFHLS definitions
there are 200,000 Swedes who are dependent
on benzodiazepines. They also argued that
benzodiazepines cause far more side effects
than the health care system is able to recognize
and that users try not to increase the dose. Side
effects will develop on a normal dose. [31, 36,
37,38]. Borg and RFHL did not struggle in
the media only over the definitions of dependence and the status of the problem but also
over their research and operational resources
[38, 39]; this was the case also with the other
actors.
Criticism ofthe health care system
In the center of the criticism of the health care
system were the GPs. In the public debate it
was claimed that GPs prescribed most of the
benzodiazepines but they lacked psychiatric
education [40, 41, 42, 43]. They also did not
generally offer alternative therapies and they
treated not only patients' mental but also social problems with the drug [44, 45, 46]. The
GPs were criticized for prescribing drugs for
toa long periods and causing dependence. The
authorities were criticized for being careless
because they did not pay enough attention to
the dependence question. The pharmaceutical
industry was accused of a lack of ethical responsibility for their products [47,48]. [32,
33,36,49].
The central concept in the media debate was
physical dependence, diagnosed as withdrawal symptoms. The media voiced this interpretation of dependence. The interpretation widened the scope and the character of dependence symptoms. What was most important,
the intepretation shifted the moral responsibility in the question from the patient to the
physician [50-54].
When SoS pursued a broader definition of
the problem in 1990 [50, 55, 56], the media
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL. 14. 1997 (ENGLlSH SUPPLEMENT]
I 21
debate became even more active and actors
like RFHL and Borg, who wanted to raise the
status of the problem, seem to have reached a
more legitimate position. At the same time,
SoS's act brought two schools of among the
physicians into the public debate [57-63].
The media debate also caused an evaluation
of the available treatments for dependent users
and a demand for resources [64-72]. Pioneer
work with dependent users had been done in
a TUB-project which was lead by Stefan Borg
at the St. Gorans hospital. They had concentrated on difficult cases. Now there were demands for new services. The message of these
new demands was that the character of dependence differs so much from that of problems the available services address that there is
a need for developing new kinds of services. It
was especially emphasized that dependence
should not or could not be treated in already
existing psychiatric or drug treatment centers.
Dependent users are not "crazy" and they are
not abusers. They have at least some kind of
control over their life and work. Dependence
does not depend on the users thems elves but
on physicians who prescribe the drug and it
has to do with the health care system which
allows the use of these drugs.
Countercriticism in the public media
Before SoS joined the debate, the media argued for the higher status of benzodiazepine
dependence in the agendas of the health care
system. When it became obvious that these
ideas were to be institutionalized into the
health care system, the physicians and institutions who did not see dependence as a major
problem became involved in the public debate. At this stage of the debate the issue was
current also in the legal system because of the
process dependent users began in September
of 1990. The issue became also a resource
question when more resources were asked for
to treat those dependent on benzodiazepines.
22
I
A group of 50 physicians, led by Christer
AlIgulander, saw dependence as a minor problem and argued that the scope of the side effects had been exaggerated and the media
campaign had caused damage to the patients.
The physicians also denied that dependence
was a public health problem. According to
them the problem in the use of benzodiazepines is a small group of physicians who prescribe drugs too often and a small group of
patients who abuse them. The physicians demanded that the Ministry ofSocialAffairs and
the government organize an impartial hearing
about benzodiazepines [57,61-63].
For the first time both parties had stepped
into the public debate and theywere talking to
each other. In September 1991 the media featured people who had been benefitting from
their use ofbenzodiazepines [61, 62] and ideas
which would support a narrower definition of
the dependence question [62-64]. They argued that there are only a few thousand dependent people in Sweden. A much bigger
problem is, for example, the mixed abuse of
benzodiazepines and alcohol [61].
SoS proposed tightened control over the
abuse ofbenzodiazepines in preparation for a
law concerning the controlof the health care
system [22]. The means of control would be to
ease privacy protection so that the exchange of
information between the authorities would be
easier [53, 56]. Also the national purchaser of
drugs, Apoteksbolaget, supported changes in
the privacy protection [52]. RFHL suspected
that the authorities were again trying to shift
attention from dependence to abuse and from
physicians to patients. According to RFHL
the core of the problem was physicians who
order drugs too often and too much [50, 54].
After the hearing in December 1991 the authorities supported in the public media the
idea that the problem with benzodiazepines
was the GPs. The authorities did not talk
clearly about the definition of abuse and dependence [73, 74]. Later the authorities gave
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL. 14. 1997 (ENGLlSH SUPPLEMENT)
up the demand for strong controlof physicians and patients [16].
The Finnish debate
The Finnish medical profession debated
about benzodiazepines during the 1980s in
the leading national medical journals Liiiikiirilehti and Duodecim. The major focus in the
discussion was clinical pharmacological argumentation in which the patient was discussed
in biological terms [75-82]. In the late 1980s
and the beginning of 1990s, the presented picture of side effects and patients became more
complex.
Dependence on benzodiazepines came into
the discussion slowly during the 1980s. In the
beginning of the decade dependence was understood as developing a tolerance and as
abuse [83, 84]. The potential of benzodiazepines to cause dependence was considered
contradictory [77, 78, 83-85]. The potential
to develop a tolerancewas seen as possible [78,
85].
In the rnid-1980s, ideas about dependence
and abuse were changing [86, 87]. Dependence was regarded as possible at therapeutic
doses in long-term use [77, 79, 80, 86] and for
the first time withdrawal symptoms were presented as adequate criteria to diagnose dependence [86]. The magnitude of the dependence problem was seen as smaIl [86] and it was
connected to the drug used [88] and to the
patient's personality type [86]. There was also
some discussion about the drug rebound effect [86, 87] and the problem of distinguishing it from ordinary anxiety or insomnia
symptoms [87]. There were different opinions
over the possibility of developing tolerance
[86,87,89].
In the late 1980s and the beginning of the
1990s the problems with benzodiazepine use
were connected more clearly to dependence
which was defined as withdrawal or rebound
symptoms in conjunction with long-term use
[79-81,90-92].
The discussion among Finnish medical professionals was composed of single articles or
debate articles, but it could hardly be called a
full-fledged debate. The few health political
initiatives presented did not raise any response
[79, 80]. There was no drug policy debate.
The criticism of the medical profession pointed to treatment practices [80, 90]. There was
no criticism of the medical authorities. The
treatment of dependent users came into the
discussion in the mid-1980s [86] and it continued to the beginning of the 1990s [90-92].
Dependence was seen as legitimate in the
treatment of diffkult insomnia and anxiety
[91].
The state and benzodiazepines
The use of benzodiazepines became a public
problem in Finland on the 2nd of October of
1991 when the National Board ofHealth and
Welfare (5TH)! withdrew triazolam products
(used as hypnotics) from the market. The
Finnish National Medical Council was following the lead of the British National Medical Council (see Gabe & Bury 1996). The reason for thewithdrawal was said to be psychiatric side effects which occur more often in use
of triazolam than with other benzodiazepines.
The temporary withdrawal of triazolam
products from the market in October 1991
was a surprise to many physicians [93-95].
The withdrawal concerned Halcion, which
had rapidly become the most commonly used
drug for insomnia. 5TH reasoned that Halcion caused psychiatric adverse effects like
temporary amnesia and depression [96]. The
National Social Insurance Institution and a
sector of the medical profession criticized the
action. They argued the action had been taken
too rapidly and it was exaggerated and caused
more harm than good for the patients. There
was also criticism over the way the National
Medical Council had relied rather on its Brit-
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL. 14. 1997 (ENGLlSH SUPPLEMENT)
[23
ish associate than its own experience [93, 96].
5TH decided to form a working gro up which
would study all drugs available for insomnia
on the Finnish market and make propositions
for their future use [97]. 5TH returned rriazolam products in smaller doses and packages
to the Finnish market in January 1993. 5TH
also made some changes in the texts in the
guide to medicines [98].
In the report of the 5TH working group the
central concepts are physical and psychological dependence in long-term use ofbenzodiazepines. Dependence is presented as a major
problem and abuse as a minor one [99]. Definitions of dependence and abuse closely resemble the way Swedish authorities defined
them in the consensus papers in 1988 [17, 18]
and in the 1987 report for new drug legislation [14], but there are some differences from
the 50S 1990 general guideline [15]. The
Finnish report stresses dose increase in dependence whereas the Swedish guideline
stresses dependence in short-term use.
Halcion in the public media
Halcion was the most commonly used sleeping pill in Finland in the early 1990s. Approximately 50 000 - 60 000 patients used it. That
is about 1 % of the Finnish population [93].
In the beginning Halcion was internationally considered a very promising new short-acting benzodiazepine which would cause only
fewadverse effects. Sales ofHalcion increased
rapidly and it became the most-sold drug for
insomnia. In 1979 Halcion was withdrawn
from the market in Holland because of occurrence of unexpected psychical adverse effects
like amnesia, depression, hallucinations, and
aggressive behavior. The drug was later returned to the market in smaller doses. In the
beginning of the 1990s, France, Italy, Germany, and the USA had withdrawn large doses
from their market because of the adverse effects [100].
24 I
In the Finnish debate the withdrawal action
of the National Medical Council was criticized as too strong and hasty [93-95, 101103]. Anxiety, depression, amnesia, confusion
[%, 102], and problems in long-term use [95,
103] were raised in the debate as adverse effects. Older people and psychiatric patients
were recognized as problem groups [95, 103].
It became clear that Halcion had been debated
also in Britain and the USA [95, 100, 103,
104].
Some writers appreciated the withdrawal
decision of 5TH. They were concerned with
the adverse effects in general [105], with dependence and older people's large scale use of
benzodiazepines [106, 107], the need to
srrengthen drug regulation [105], and suspicions in general over drug therapies [107].
The use of psychotropic drugs was discussed
also more generally [108-111]. There was discussion about the mixed abuse of alcohol and
psychotropicdrugs [109, 111], treatingsocial
problems with a drug [109], long-term use of
psychotropics [109, 110] and dependence in
long-term use [109].
Afrer the Halcion debate, the medicai profession brought up more clearly the possibility
of dependence in long-term use of benzodiazepines [112-114], but they still stressed abuse
[112-115]. Dependence instead of abuse was
presented for the first time in the media as a
major problem in 1992. Responsibility for the
problem was laid now on the health care system and physicians, not on the patient [116118].
The arguments of the medical profession
and authorities transferred from professional
media to the public media. Journalists did not
actively try to define the problem. Physicians
and authorities acted as definers of the problem in the professional and the public arena.
Journalists expressed the ideas of authorities
and physicians. Patients' voices did not appear
in the discussion whatsoever, not even in a
single debate article. Physicians discussed
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VDl. 14. 1997 (ENGlISH SUPPLEMENT)
about the best interest of the patient within
the perspective of patient security. Pharmaceutical authorities were divided when physician Timo Klaukka, the leading drug authority of the National Social Insurance Institution, joined the criticism over the STH's act to
withdraw benzodiazepines from the market
[95, 110, 119].
Patient organizations and benzodiazepines
In the beginning of the 1990s, official and unofficial organizations dealing with intoxicant
abusers were interested in the problems of
benzodiazepine use. These organizations had
a critical view of benzodiazepines [108, 111,
112,114,120-122,123-128]. However, their
ideas of dependence conflicted in an interestmgway.
The organizations argued that dependence
could occur at a normal dose, but at the same
time they defined abuse to be the major problem in Finland [108,112,114,115,123,127,
see 129-131]. As we saw earlier, the patient
organization RFHL in Sweden acted on the
question in quite a different way. They defined
dependence to be the major problem. At that
time in 1991 in both Finland and Sweden
there was no clear information about the
scope of dependence at therapeutic doses or
with long-term use. However, international
studies suggested that this was a big problem
in western societies (Williams et al. 1991).
The question why Finnish patient groups defined the dependence problem so narrowly
when they had all the possibilities to consider
it as a major problem remains open.
Comparing Finland and Sweden
Representatives of the drug industry were
missing in the public media and professional
debates in Sweden and Finland although the
debates influenced medical practices, and
drug and health politics, and in this way the
vital interests of the drug companies. It remains unclear how the industry may have responded to the debate (see Hemminki 1975;
Hemminki et al. 1977; Riska et al. 1991).
In the Finnish debate patient organizations
and the public media which would try actively
to define the problem were also missing. In
Sweden the patient organization, RFHL, was
able to enter the negotiations about the drug
policy and practices. RFHL was also successful in getting the attention of the public media. The Swedish debate reminds one of the
British discussion (Gabe et al. 1988; Gabe et
al. 1991; Gabe et al. 1996) in the way patient
organizations and the public media had an
important role in directing and maintaining
the debate, and organizing and mobilizing
patients. The public media had an important
role in forming the status of the problem. In
Finland the problems in the use of benzodiazepines - long-term use and dependence came on the drug politics agenda partly by
accident (Halcion case), and partly due to the
authorities and the way they defined the question.
In the British debate a central conflict was
between psychiatrists and GPs (Gabe et al.
1991). In Sweden there was a similar kind of
arrangement, but it was not as important as in
Britain. The issue of defining dependence and
abuse divided Swedish physicians. The Finnish debate was not as organized as it was in
Sweden and Britain. The Finnish discussion
was composed of single articles or debate articles which did not form an interactive debate. Authorities did not debate publicly with
physicians or other actors. There was no drug
policy argumentation in the physicians' writings. The Finnish medical profession was generally united in the benzodiazepine debate
although a few critical opinions towards the
profession were presented. The argumentation of the Finnish physicians about the problems in benzodiazepine use proceeded without conflicts. New information was connect-
NORD[SK ALKDHDL- & NARKDT[KAT[DSKR[FT. VDl. [4. [997 (ENGlISH SUPPLEMENT)
I 25
ed to old knowledge and necessary corrections
were made. Finnish drug politics was in the
beginning of the 1990s clearly directed by authorities whereas in Sweden different actors
like patient groups had possibilities to influence drug politics.
Constructive logic of a social problem
Why was benzodiazepine dependence regarded as a social problem in Sweden but not in
Finland? Gabe and Bury (1988) have proposed that there have to be present conditions
that transform a private concern to a social
problem. First, certain objective conditions
need to be met. Second, the question needs to
be made legitimate among the general public,
which then has to be mobilized around the
issue. FinaIly, the problem has to become public and political, and the state has to respond
to the question. Objective conditions were
met in Finland and Sweden in the sense of
consumption of benzodiazepines.
Responsibility for the origin of the problem
in Sweden belonged to physicians and in Finland to the patient. In Finland benwdiazepines never became a moral question in the
same way as in Sweden. The moral climate the
Swedish public media forrned made it possibie
to legitimize the critical view over benwdiazepines among the public. What values were
touched in the Swedish public debate so that
large scale use of benzodiazepines became
problematic? The core of the moral offense is
described in two pictures, firsdy in the picrure
of the physician, psychiatrist and researcher
Stefan Borg with a pillbox in his hand, and
secondly the picture of Lena Bengtsson, an
ordinary looking Swedish woman, apparendy
interviewed in her own home (see above p.
21).
A prestigious physician publicly brings the
health care system under moral scrutiny; an
ordinary Swedish woman has, beyond her
own responsibility, become a victim of the
26
I
health care system atter she has used drugs
according to instructions which a physician
has prescribed her, and become dependent.
Physicians as professionals and drug treatments have been called into question by a
medical expert and a lay person. Traditional
medical authority is forced to defend itself.
Gabe and Bury (1991) have suggested that
this indicates a crisis in health care. Their interpretation and prognosis is a shift in social
relations in health care. Social costs have become a central value.
The state, the authorities, the physicians,
the health care system, and the pharmaceutical industry have been the central actors in
forming medical, drug, and health policy and
practices. Patients have been the object of
these practices. British and Swedish debates
over benzodiazepines argued for a new kind of
patient. This new patient is self-conscious and
will express his/her feelings and opinions by
him/herself or with the help of a patient group
in medica1, drug, or health political debate.
Braithwaite (1993) argues that the pharmaceutica1 industry has improved its course of
action in the last ten years, which is linked
with improvement in state actions but especially in actions outside of the state, like the
activities of international organizations, consumer and professional groups, and intra- and
intercorporate self-regulation. However, there
is no problem in finding criticism to counter
Braithwaite's arguments; for example, how
intra- or intemrm self-regulation has failed
(Hemminki 1989; Lexchin 1990; Coney
1992; Herxheimer et al. 1993; Kawachi 1992;
Kawachi et al. 1992; Pearce 1992).
The role of the public media is important in
presenting and evaluating problems in the use
of drugs. However, it is questionable whether
the media is able to manage its task. Experience has not been very promising about the
medias ability to critically evaluate drugs
(Lexchin 1990; Coney 1992). Journalists get
most of their information about drugs from
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL 14. 1997 (ENGLlSH SUPPLEMENT)
medical journals, universities, and hospitals,
but also the pharmaceutical industry is an important informant (van Trigt et al. 1994). In
drug polities, patient/ consumer groups may
play part as an important informant and can
aet as mediators which collect and disseminate
critical information about drugs (van Trigt et
al. 1994). Many reasons ean be found for a
lack of criticism: The information comes in
bits, it has to be collected from many sources,
it is difficult to intepret, and it is pardy seeret.
The patient as a self-conscious actor is still
mainly excluded from drug or health political
arenas and the prognosis for a change in practices is not always very strong (Lexchin 1990;
Davis 1992). However it may be more and
more difficult for the traditional actors, physicians, authorities, and the drug industry, to
marginalize the patient.
NOTE
1. At the time of study in Finland National Board
ofHealth and Welfare regulated drug selection and
price on the market. National Social Insurance
Institution decides about reimbursement policy.
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RESEARCH MATERIAL
[Abbreviations:
Ab (Aftonbladet), AT (Alingsås Tidning), Arb
(Arbetet), DN (Dagens Nyheter), Expr (Expressen), GP (Goteborgs-Posten), HJ (Hemmets
Journal), HS (Helsingin Sanomat), IS (llta-Sanomat), Ka (Kommunalarbetaren), SH (Sairaanhoitaja), Sp (Smålandsposten), SyD (SvenskaDagbladet), T2 (Terveys 2000), UN (Upp & Ner)]
1. Melander, A. et al. (1984): Anxiolytika-hypnotika i oppen vård - omfattningen av bruk och
missbruk. Lakartidningen 81 (41): 3690-3692
2. Melander, A. et al. (1984): Motverkande av
rnissbruk av anxiolytika-hypnotika. Annu har
lakarorganisationerna inte ersatts. Lakartidningen
81 (41): 3692-3693
3. Albinson, ]. et al. (1985): Ångesten ar iatrogen vid "lakemedelsrnissbruk". Lakartidningen 82
(8): 578-579
4. Borg, S. et al. (1986): Bensodiazepinberoende
och andra långtidsbiverkningar - en oversikt.
Lakartidningen 83 (5): 321-326
5. Vikander, B. et al. (1987): Avgiftning av bensodiazepinberoende patienter. Lakartidningen 84
(41): 3276-3278
6. Westerholm, B. (1989): Vad gor regeringen åt
rnissbruk och beroende av lakemedel? Lakartidningen 86 (23): 2191-2192
7. Nagy, A. (1984): Ångest bagatelliseras, bensodiazepinmissbruket overdrivs. Lakartidningen 81
(48):4497
8. Nagy, A. (1985): "Beroende" ar inte "missbruk"! Lakartidningen 82 (8): 597-598
9. Nagy, A. (1987): Bensodiazepiner hanteras
mer subjektivt an andra lakemedel. Lakartidningen 84 (40): 3167-3168
10. Allgulander, C (1987): Bruk och rnissbruk
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL. 14. 1997 (ENGLISH SUPPLEMENT)
av bensodiazepiner - en psykiatrisk och epidemiologisk oversikt. Lakartidningen 84 (41): 32743276
Il. AlIgulander C. (1991): Nya ron om karakteristik av och terapi vid generaliserat ångestsyndrom. Lakartidningen 88 (39): 3177-3180
12. Wålinder, J. (1989): Bensodiazepiner på
gott och ont. Lakartidningen 86 (23): 2193-2194
13. Albinson, J. (1991): Angående nytta och
risker med anvandningen av bensodiazepiner. In:
Hearing om bensodiazepiner - Nytta och risker.
Stockholm. (Ed. Socialstyrelsen et al.)
14. SOU 1987:20.: Lakemedel och Halsa.
Betankande av 1983 års lakemedelsutredning.
Statens offentliga utredningar. Socialdepartementet. Stockholm
IS. Socialstyrelsen (1990): Beroendeframkallande psykofarmaka. Att behandla och forebygga
beroende och missbruk. Allmanna råd från socialstyrelsen 1990:7. Stockholm
16. SOU 1993:S.: Bensodiazepiner- beroendeframkallande psykofarmaka. Delbetankande av
psykiatriutredningen.
Socialdepartementet.
Stockholm
17. National Board of Health and Welfare &
Drug Information Committee, Sweden (1988):
Pharmacological Treatment of Anxiety. 1988:1,
Uppsala
18. National Board of Health and Welfare &
Drug Information Committee, Sweden (1988):
Treatment ofSleep Disorders. 1988:4. Uppsala
19. AlIgulander, C. et al.: A letter to state government 20.3.1991
20. Asberg, M. (1991): Hearing om bensodiazepiner - en kommenterad sammanfattning. In:
Hearing om bensodiazepiner - Nytta och risker.
Stockholm: Socialstyrelsen & Lakemedelsverket
21. SyD 9.9.90 (news): Tablettslavar kraver
upprattelse. Skadeståndskrav på miljoner vantas i
anmalningar mot lakemedelsforetag och lakare.
22. SOU 1991:63.: Til!synen over halso- och
sjukvården. Slutbetankande av Tillsynsutredningen. Socialdepartementet. Stockholm
23. Ds 1992:104. Natverkfor1akemedelsepidemiologi - NEPI. Rapport från utredningen
(1990:72) om ett centrum for lakemedelsepidemiologi och utveckling av lakemedelsterapier. Socialdepartementet. Stockholm
24. SoU4 1990/91.: Socialutskottets betankande. Halso- och sjukvårdsfrågor
2S. SoUS 1991/92.: Socialutskottets betankande. Halso- och sjukvårdsfrågor
26. SoU21 1991/92.: Socialutskottets betank-
ande. Halso- och sjukvårdsfrågor
27.DN 18.11.90 (news): "Medicinberoende
har svikits"
28. Reg. prop. 1991/92:107. Regeringens proposition om nya lakemedel m.m. Band B 13
29. Expr 18.3.90 (article): "Lakarna gjorde mig
til! missbrukare"
30. Expr 8.2.90 (article): Eva, 28 kunde inte
leva utan tabletter - På vårdhemmet traffade hon
sin lakare - som patient
31. SyD 16.10.88 (article): Nar hjalpen skapar
missbruk
32. SyD 23.10.88 (article): Tabletterna tar over
33. Ab 2S.1.90 (article): Var sjatte patient blir
missbrukare. Overlakaren: Detta ar en smygande
katastrof
34. Ab 1.2.90 (article): Ring i kvallom de farliga
tabletterna
3S. Ka 8.10.90 (article): Gittan kamp ar for att
bli frisk från sin medicin
36. Art 18.10.88 (article): Det glomda beroendet. Lakemedelsmissbruk ett "hål" i valfarden
37. SyD 23.10.88 (article): Ett tecken på lakarnas vanmakt?
38. DN 16.3.92 (news): Okad hjalp til! svårt
beroende
39. DN 12.3.92 (news): Ingen vård for missbruk av tabletter
40. SyD 4.10.90 (news): Tablettberoende forenar sig. Lakemedelsforetag stams på mångmiljonbelopp i skadeståndsprocess
41. SyD 3.3.91 (news): "Forebygg medicinmissbruk"
42. DN 10.3.91 (news): Lakare slår larm. Halsingborgare forbrukar mest lugnande medel i landet
43. SyD 28.11.91 (news): Lugnande ges i onodan. Många recept skrivs utan riktig diagnos
44. Ab 10.3.91 (news): Lakare slår larm om pillermissbruk
4S. DN 31.10.91 (news): Somnlos ska få vila
utan piller
46. DN 14.12.91 (debatearticle): Nog blir man
beroende
47. Ab 26.1.90 (article): "Jag korde rakt in i
bergvaggen" - Christer orkade inte med livet utan
tabletterna
48. Ab S.8.91 (article): "De tycks sakna all kansla for manskligt lidande"
49. Sp 19.9.90 (article): Missbrukare efter en
vecka. Lugnande medel skrivs ut for fort.
SO. SyD 1.3.91 (debate article): Krankande
hava sekretess. Annu svårade for missbrukare av
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT, VOl. 14, 1997 (ENGllSH SUPPLEMENT)
I 29
lakemedel, anser Alec Carlherg
51. Syd 12.3.91 (dehatearticle): Sluta dalta med
patienter. Lagandring kan hjalpa misshrukare av
lakemedel, anser P.H. Bohlin
52. SyD 16.3.91 (dehate article): Sekretesslagen
ar i hog grad inhuman
53. SyD 26.3.91 (dehate article): Overhlick
over tablettmisshruk kravs
54. SyD 8.4.91 (dehate article): Tahlettheroende ar ej misshrukare!
55. SyD 12.1.91 (news): "For latt få lugnande
medel"
56. Ah 10.2.91 (news): Lugnande medel oroar
socialstyrelsen
57. SyD 26.4.91 (news): Lakare varnar om
psykmedel. "Skramselkampanj om medicin"
58. SyD 6.5.91 (dehate article): Bensodiazepiner hjalper. "Angelaget att lakare foljer socialstyrelsens råd vid forskrivning"
59. SyD 15.5.91 (dehate article): Boten varre an
soten. "Det finns ingen saker anvandning av hensodiazepiner"
60. SyD 11.6.91 (dehate article): Ångest dampas. Blandmisshruket om
61. UN 10/91 (article): Stormvarningpåmogadonkusten
62. GP 24.11.91 (article): Medicinens två ansikten
63. DN 28.11.91 (news): Liten risk for misshruk. Forsme anser att riskerna med lugnande
medel overdrivs
64. DN 7.2.90 (dehate article): Hjalp ur tahlettheroende
65. GP 11.3.90 (dehate article): Mer Hjalp åt
lakemedelsmisshrukare
66. HJ 18.6.90 (article): Lasare i ko for att tala
om tahlettmisshruk
67. SyD 24.9.90 (news): Jourhem for drogheroende
68. SyD 27.3.91 (news): Misshrukare slipper
klinik
69. AT 22.4.91 (news): Temadag om lakemedel
- och misshruksfrågor
70. AT 26.4.91 (news): Man rar inte skynda på
manniskor som forsoker sluta med tahletter
71. SyD 9.12.91 (news): Hjalp från heroende.
Klinik for lakemedelsmisshrukare planeras.
72. DN 20.2.92 (news): Kilen ska ge hjalp och
stod. Forsta institutet for lakamedelsmisshrukare
73. SyD 6.12.91 (news): Skarptkontroll av lugnande medel. Forslag om dataregistrering av all receptutskrivning for att stoppa oseriosa lakare
74. DN 6.12.91 (news): Hårdare tag kravs mot
30 I
"valiurnlakare"
75. Mattila, M. (1981): Onko eri hentsodiatsepiinien valilla kaytannon eroja? Suomen Laakårilehti 36 (28): 2234-2235
76. Olkinuora, M. (1981): Onko hentsodiatsepiineilla merkittavia eroja? Kliininen merkitys.
Suomen Laakarilehti 36 (28): 2236
77. Syvalahti, E. (1981): Bentsodiatsepiinien
haittavaikutukset. Suomen Laakarilehti 36 (32):
2608
78. Viukari, M. (1982): Kaytetaanko Suomessa
psyykenlaakkeita liian vwan? Duodecim 98: 495497
79. Viukari M. (1986): Bentsodiatsepiineihin
liittyvat vieroitusoireet. Duodecim 102: 1618
80. Viukari, M. (1986): Bentsodiatsepiinien
vaarallisuus. Suoinen Laakarilehti 41 (26): 23992403
81. Hyyppa, M.T. & Kronholm, E. (1988):
Unihairioista kuntoutuminen. Suomen Laakårilehti 43 (16): 1598-1603
82. Hemminki, E. (1981): Kaytetaanko
psyykenlaakkeita liikaa? Duodecim 97: 16441646
83. Elosuo, R. (1981): Onko hentsodiatsepiineilla merkittavia eroja? Vaste ja haitat yksilollisia.
Suomen Laakårilehti 36 (28): 2235-2236
84. Elosuo, R. (1981): Edellisen johdosta.
Suomen Laakarilehti 36 (32): 2608
85. Niskanen, P. & Ruuska, J. (1984): Bentsodiatsepiinien kaytto. Duodecim 100 (14): 829-831
86. Aranko, K. & Seppala, T. (1985): Bentsodiatsepiinien farmakokineettiset ja -dynaamiset
erot. Suomen Laakarilehti 40 (28): 2653-2662
87. Mattila, M. (1986): Huumeidenfarmakologiaa. Suomen Laakårilehti 41 (16): 1489-1497
88. Aranko, K. & Syvalahti, E. & Alhava, E.
(1989): Lyhytvaikutteisten hentsodiatsepiinien
kaytto on lisaantynyt. Suomen Laakårilehti 44 (4):
434-435
89. Syvalahti, E. (1986): Unettomuuden hoito.
Duodecim 102: 1700-1708
90. Koskinen, T. (1990): Psykofarmakologit
huolissaan hentsodiatsepiinien kaytosta. Suomen
Laakårilehti 45 (4): 284-286
91. Huttunen, M.O. (1991): Uneton potilas
yleislaakårin vastaanotolla. Duodecim 107: 14891498
92. Kajaste, S. & Palomaki, H. (1991):
Unilaakkeiden hyodyt ja haitat. Duodecim 107:
1501-1508
93. Pekkarinen, T. (1991): Laakevalvonta kompastelee. Suomen Laakarilehti 46 (30): 2809
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL. 14. 1997 (ENGLlSH SUPPLEMENT)
94. Anonymous (1991): Outoja yli- ja alaslyonteja? Suomen Laakarilehti 46: 3215
95. Klaukka, T. (1991): Tapaus Haleion.
Suomen Laakarilehti 32: 3280-3281
96. Anonymous (1991): Triatsolaamia sisalnvat
laakkeet myyntikidtoon. Suomen Ui.1ikarilehti 46
(29): 2719
97. Sosiaali- ja terveyshallitus: Unilaaketyotyhman asettaminen. Hdsinki 4.11.1991
98. Sosiaali- ja terveyshallitus: Triatsolaamivalmisteet uudelleen myyntiin tarkoin rajauksin.
Tiedote Nro 5/93. Hdsinki 13.1.1993
99. Sosiaali- ja terveyshallitus: Unilaaketyoryhman raportti. Hdsinki 30.11.1992
100. Fabrizio, T. (1991): Haleion painajainen.
Suomen Laakarilehti 46 (36): 3504-3506
101. HS 6.10.91 (debate article): Oli hatikoity1i
kieltaa unilaakkeiden myynti
102. HS 20.10.91 (news): Suosituimman
unilaakkeen myyntikidtoa arvostellaan
103. T2 5/91 (article): Psyykenlaake-pdottava
pilleri?
104. HS 9.7.92 (news): Unilaake Halcionilla ei
ole muita enemman sivuvaikutuksia
105. Ollila, E. et al. (1991): Laakareiden usko
laakevalvontaan horjuu - mutta miksi? Suomen
Laakarilehti 46 (32): 3307-3308
106. HS 13.10.91 (debate article): Vihdoinkin
eroon Halcion-laakkeesta
107. HS 17.11.91 (debate article): Puhuminen
auttaa unetonta
108. HS 25.8.91 (article): Psyykenlaakkeita
otetaan yha enemman alkoholin rinnalla
109. HS 6.11.91 (article): Unilaakkeidenkaytto
ei ole tarpeeksi huolellista
110. T2 6/91 (article): Unilaake uhattuna
111. HS 7.3.92 (news): Psyykenlaakkeet ovat
tutkimuksen mukaan huumeita isompi ongdma
112. Seppa, K. et al. (1992): Psyykenlaakkeiden
liittyminen naisten alkoholinkayttoon. Suomen
Uiåkatilehti 47 (30): 2807-2809
113. Saarijarvi, S. et al. (1994): Ahdistushairioiden laakehoito. Suomen Uiåkatilehti 49 (1-2): 912
114. Holopainen, A. (1994): Laakkeiden ja
alkoholin aiheuttaman unettomuuden hoito.
Suomen Laakarilehti 49 (13): 1382
115. Ovaska, L et al. (1994): Paihteiden
sekakayttajat
terveydenhuollon
haasteena.
Suomen Laakarilehti 48 (22-23): 2120-2123
116. HS 22.12.92 (article): Huumeongdma
laakarin maarayksesta
117. SH 2/93 (article): Uiåkeriippuvuus
118. Tiimi 2/93 (article): Nieminen, Hannde:
Psyyken laakkeet eivat ole ainoastaan paihdeongdma
119. IS 9.10.91 (news): Kansandakdaitos: Halcion-unilaakett1i saa kayttaa
120. Tiimi 4/92 (article): Tavallisin monipaihteisyys: viina ja laakkeet
121. Tiimi 2/94 (article): Viinisalo, Sirpa: Kettutien A-poliklinikka: asteittain eroon laakkeisn
122. Tiimi 3-4/94 (article): Laakeriippuvuus salattu karsimys
123. Koistinen, P. (1990): Laakkeetko harmittomia? Alkoholipolitiikka 55 (4): 198-199
124. Koistinen, P. (1991): Miten on kollegat?
Suomen Uiåkatilehti 46 (11): 1091-1092
125. Lehto,]. & Nuorvala, Y. (1991): Paihdetapauslaskenta 8.10.1991. Unpublished. Sosiaali- ja
terveyshallitus. Hdsinki
126. Lehto, J. & Nuorvala, Y. (1992): Laakkeiden paihdekaytto lisaantynyt. Dialogi (2): 24-25
127. Lehto, J. & Nuorvala, Y. (1992): Paihdehuolto lamasyksyna 1991. Sosiaaliturva (8): 10-12
128. Tuomola, P. & Ovaska, L (1991): Paihteiden sekakaytto - haaste myos terveydenhuollolle.
Manuscript for Suomen Laakarilehti.
Summary
Antti Schonberg: Tranquillizers and hypnoticssedatives as a social problem in Finland and
Sweden
This paper documents debates over benzodiazepine-based tranquillizers and hypnoticssedatives in Finland and Sweden during the
period of 1981-1994. It looks at the emergence of benzodiazepine dependence as a social problem in medical journals, newspapers,
magazines, and administrative documents.
The paper analyses the role of the media, experts, authorities, the drug industry, and patient organizations in the claims-making
process. It compares Finnish and Swedish cases and locates the position of patients as selfconscious actors in the debates.
In Sweden there was genuine debate where
physicians, medical authorities, and patient
organizations took part. The public media had
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT, VOL. 14, 1997 (ENGLlSH SUPPLEMENT)
I 31
an important role in den.ning the status of the
problem. The Finnish discussion was composed of single articles or debate articles, but
did not form an interactive debate. Finnish
authorities did not debate publiclywith physicians or other actors. In the Swedish debate
patients took part as self-conscious actors,
while patients were missing from the Finnish
debate.
32 [
FinaIly, the author considers the change in
actor relations in medicine, drug, and health
politics, and concludes that it may be more
and more difficult for the traditional actors to
marginalize the patient.
Key words:
tranquillizers, hypnotics-sedatives, benzodiazepines, social problems, debate, Finland, Sweden
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT. VOL. 14. 1997 (ENGLlSH SUPPLEMENT)