By Graham Balmforth, LLB, DipFMS (Glasgow) M.Sc. Solicitor Advocate.
It has recently been my privilege to deal with a Clinical Negligence action on behalf of a woman of substantial character, who has, in early middle age, suffered an enforced and difficult withdrawal from the drug Zopiclone. The process of that withdrawal for her has been long, complex and filled with emotional distress and physical discomfort. She has however, maintained her commitment to detoxification.
Once relatively, clear of the reach of this addiction, the patient could be described as “a new woman” she has regained control of her familial relationships, her employment and career and her wider outlook has enabled her to re-engage with her local community. She had however, suffered 12 years of addiction and a string of damaging relationships and failed jobs behind her. Her life once in descent, was seemingly spiraling toward an early exit. Her GP made little attempt to deal with the addiction in spite of identifying it. Her medication reviews, instead of resulting in any action to combat her deteriorating position, simply resulted in increased doses to combat the anxiety of her situation.
It has been both a saddening and a rewarding case.
What is Zopiclone?
Zopiclone, which is also available with the trade or brand names, Zimovane, Imovane and in East Asia and in some southern European countries as Dopareel is a non-benzodiazepine sedative typically prescribed for use in the treatment of insomnia and is often given as an accompanying treatment to those with anti-depressive medications or anxiety related talking therapies.
It has a developed a reputation as a notoriously effective recreational drug and around 2003-2009 it reached notoriety as was labelled as one of the so-called “Z drugs” (see here 1) which are a group of prescription sedatives which can provide an intense “legal high” (legal if prescribed of course).
Zopiclone is is however, a particularly addictive and controlling medicine and it has highly dangerous side-effects the threat from which is far from remote. These side effects include;
- Impairment to motor skills,
- listlessness, exhaustion· emotional distancing,
- lack of focus
- slurred speech and impaired cognitive function
- behavioral and personality changes and
- impaired impulse control.
In terms of its addictive properties, this is always difficult to measure but some users can develop a strong addiction to zopiclone within only a few weeks of use. Although the BMJ indicated that a 4 week period of prescription is unlikely to stimulate a addiction cycle (here 2) Very few users who have longer than a continuous 6 month course are likely to evade addiction. Within the UK (I include Scotland for the purposes of this article but the circumstances of restriction are slightly different) zopiclone is a class C controlled drug, supposedly available only through an authorised medical prescription. Inevitably given its potency there is a thriving trade in illicit medication obtainable either through approved patient user prescribed medication being traded locally for cash or through internet marketing for the drug through a series of street names (which I am not going to repeat here).
What are the Effects on the patient?
Zopiclone users inevitably initially obtain a waking euphoric dreamlike high. Depending upon dose and the individuals morphology, this can last for between 1 – 6 hours. Users on the whole though, are likely to fall into a deep sleep for several hours usually within 15 mins after medication is taken and wake without substantial memory of the experience. Typically then, there will follow a series of metabolite related after-effects which can be felt for at least 24 after consumption. This is not any different to most sedatives in this respect and is comparable to a mild hangover with symptoms of dizziness, nausea and occasionally headache.
Many users controversially, have reported unconscious behaviors including; sleepwalking, cooking, gardening and even driving a vehicle. These extremely dangerous activities have been linked to several accidents. Many users also report soft tissue injury and even more serious fractures to upper limbs from walking / stumbling accidents whilst under the influence. Fatal overdose is also capable from zopiclone although I have been unable to isolate statistics on this in the UK it is seemingly a regular contributor to emergency room appearances in the US.
How is this Addiction Revealed
Users are likely to display uncoordinated behavior and may have substantially reduced speed of response to normal conversation, slurred speech or possibly word salad can result from complex conversation. The greatest single symptom is likely to be the inability to focus with increasing frustration which can result in either a abandonment of task or an attempt to avoid task. Zopiclone has a plethora of physical accompaniments including; heart arrhythmia and palpitations; nightmares; short and long term memory loss; constipation; throat related infection (quinsy – abscess) ; lethargy; rheumatic like pain; dizziness and nausea; and depression, It is often highly difficult to untangle the symptoms from those that may flow from the individuals adopted lifestyle whilst addicted.
Zopiclone has a plethora of physical accompaniments including; heart arrhythmia and palpitations; nightmares; short and long term memory loss; constipation; throat related infection (quinsy – abscess) ; lethargy; rheumatic like pain; dizziness and nausea; and depression, It is often highly difficult to untangle the symptoms from those that may flow from the individuals adopted lifestyle whilst addicted.
In the instant case Zopiclone addiction had inhibited the patients ability to function at any level which is consistent with normal life; there was no viable steady employment at all and in spite of good results at higher A grade education there was a descent into “menial” (absolutely no offence is intended here) employment such as basic cleaning duties. Even these duties proved to be a strain with consistent disciplinary offences for timekeeping and unauthorised absences. Ultimately the addiction is easily confused with symptoms of depression and is only revealed by enforced withdrawal. Very sadly in the instant case, the appearance of a unrelated but deteriorating and ultimately fatal disease meant that the medication was swapped out for pharmacological reasons of contra-indication and this sparked the resultant “awakening”. In many cases, similar intervening events lead to the medication being substituted or withdrawn on a trial basis.
Withdrawal from Addiction
Zopiclone addiction is likely to result in significant withdrawal symptoms (here 3), the neuropathology of its addiction is very strong and the addict will resist all attempts to diagnose the addiction for fear of withdrawal of its availability. There is also likely to be failed attempts with illegal purchases being made to supplement any decreasing dosage levels.
Inappropriate attempts to withdraw without medical supervision or staged therapies can result in death. Most supervisions though appear to be successful in mild or short-term addictive issues. However, the interplay between the individual and the medication is highly sophisticated and for some individuals the only suitable methodology for detoxification may well be by utilising institutional admission or residential rehabilitation.
The process of addiction is well known, there are no observable benefits in long term medication without substantial and meaningful review. Other medications are available which regardless of their relative efficacy should be considered and utilised to minimise the danger posed by addiction.
Addiction should be counselled by the GP as part of the prescription process along with the dangers of addiction and the difficulties of withdrawal. This should be explored with the patient in full. That process should be documented, and the patient should have an outline of the time frame for prescription at the outset of prescription. That document can be used effectively as an aide memoire for a patient who is demonstrating symptoms of reliance and addiction.
It is essential that the medication review is a platform not just for assessment of the efficacy of the medication but as a review of the issue of addiction and the GP should not bow to pressure to continue prescription or interfere with dose size or frequency. Any referral to addiction or mental health services should be carefully monitored.
Ultimately, failing to diagnose the condition is likely to be the primary negligent act, however, as indicated above, the withdrawal process for chronic addicts is likely to be substantially demanding and could result in very anti-social behavior and even physical harm. As with any detoxification, medical supervision is essential but is likely to be effective only if it flows from an experienced practitioner. Poorly supervised withdrawal may well result in an action.
The Clinical Negligence claims are always likely to be historic in nature. Notwithstanding the obvious strain that this poses on limitation, they introduce complex issues of employment and capability and are fraught with personal evidential issues that can severely damage the case. The clients are likely to be highly motivated claimants but are regrettably, nearly always very poor historians of their own life. They are demanding of attention and seek continuous reassurance.
These failings are of course a manifestation of the symptoms of the condition that has been pervasive for much of the very period that the claim is founded on. However, there will be little sympathy from this by the Defendant or from the Court who cannot realistically, postpone the principle of reliable fact. Solicitors with Zopiclone clients, therefore, will have to be aware of the need to question and check any allegation or half remembered “fact” against cross referenced witness evidence. This in itself may be problematic as the clients may well have been set on a course of alienation from their friends and family for many years and witnesses can often be scarce. Relationships with such clients are therefore also – fragile.
Defendants tend to act fast on the issue of culpability, the real issue for them is one of quantum and this resounds with the above facts. Like any claim based on an ethereal assumption about a person’s potential, the claims can be easily overstated.
I am of course, always available for Solicitors and Litigators across the UK who need to talk about potential experts and / or tactics and the way forward for investigations. I, however, continue to believe that legal support for these clients should be reserved for very senior Litigators in Healthcare and Clinical Negligence and Solicitors with a long history of complex and high value claims management experience.
Graham G Balmforth, LLB, DipFMS M.Sc.Università degli Studi di Verona