Understanding ‘embedded pharmaceuticalisation’: A case study of sleeping medication use in later life

Abstract

Sleeping medication use in later life is linked to adverse effects including falls, cognitive decline and dependency. Despite guidelines advocating reduced prescribing and sociological findings of ambivalence and unease among older adults, long-term use remains prevalent. This paper explores how and why sleeping medication use persists in later life, drawing on interviews and diaries with 38 UK adults (65+), whose average use spanned 17 years. While participants expressed familiar moral concerns around use, these were outweighed by a profound emotional need for sleep and reliance on what they saw as the sole effective remedy. We conceptualise this enduring use as ‘embedded pharmaceuticalisation’: a process through which sleeping medication becomes woven into emotional life, personal identity and daily behaviours. Participants’ use was sustained with active strategies (e.g. sourcing, stockpiling) and passive ones (e.g. avoiding reviews), reflecting forms of consumer agency rooted in fear, habit and necessity, rather than optimisation. While much sociological work has focused on the initiation or moral framing of pharmaceutical use, less attention has been paid to the trajectories through which medication comes to be viewed not only as normal, but as necessary. Attending to different forms of pharmaceuticalisation, such as embedded, helps illuminate tensions between expressed desires to reduce or avoid medication and continued long-term use.

Introduction

This paper explores the long-term use of prescribed sleeping medications from the perspective of older adults in the UK. Although sociological studies often emphasise older adults’ reluctance to use sleeping medications, citing unnaturalness and risk (Pegado et al., 2018; Venn and Arber, 2012), prescribing data reveal widespread and sustained long-term use (Johnson et al., 2016), raising the question of what sustains use over time. Our central concern is how sleeping medication becomes embedded in later life, and the roles of fear, habit and routine in this process. These dynamics must also be understood in relation to later life itself, where bereavement, solitude, altered rhythms and night-time vulnerability intensify both fear of sleeplessness and the reliance on routines.

To explore this, we draw on the concept of pharmaceuticalisation – the process by which everyday conditions are increasingly managed with pharmaceuticals (Abraham, 2010; Bell and Figert, 2012; Williams et al., 2011). Sociological work has shown that older adults are not passive in this pharmaceuticalisation process; rather, they actively shape and negotiate their medication use, including for sleep (Pegado et al., 2018). Previous research has highlighted older adults’ moral and identity work in managing medication, but has primarily focused on non-adherence; either as a form of resistance, to preserve autonomy over sleep or to avoid the stigmatised identity of a ‘pill user’ (Venn and Arber, 2012).

Less studied are what we term ‘strategic maintenance’: behaviours that sustain or extend use over time. Though concepts like reluctant pharmaceuticalisation capture users’ moral ambivalence about medication use (Coveney et al., 2019), few studies examine how some older adults actively preserve access. Where older adult agency is typically framed in terms of reducing or refusing medication (Venn and Arber, 2012), we instead highlight a form of agency directed at preserving use. Understanding long-term use would contribute to explaining why the rates of use and length of prescriptions are still far beyond what clinical guidelines indicate is appropriate for older adults (National Institute for Health & Care Excellence (NICE), 2021). Such patterns of use also need to be understood in relation to wider systemic factors, including healthcare policy, prescribing norms and cultural shifts. In particular, the recent push towards deprescribing of sleeping medications in later life (NICE, 2021) has created new structural pressures that shape the possibilities of continued use. These conditions may at times sustain reliance, for example through repeat prescribing systems, but at other times constrain it, by reinforcing precarity and limiting access.

Drawing on interviews and sleep diaries from 38 older adults (aged 65+) who had used sleeping medication for at least 3 months, though often considerably longer, this paper examines how such use becomes understood as emotionally necessary, behaviourally routine and strategically protected. We introduce the concept of ‘embedded pharmaceuticalisation’ to capture this process. Rather than viewing long-term use as simply medicalised or passive, we show how sleeping medications can become integrated into identity, survival and daily life. In doing so, the paper extends debates on medicalisation and pharmaceuticalisation by foregrounding the emotional, strategic and temporal dynamics of sustained use.

While embedded pharmaceuticalisation captures the emotional, behavioural and strategic dimensions of long-term sleeping medication use, it is important to recognise that these medications also possess addictive properties and can cause physiological dependence (Lader, 2011; Weaver, 2015). This biological dimension interacts with, and likely reinforces, the social and experiential processes through which medication becomes deeply embedded in users’ lives. Thus, embedded pharmaceuticalisation should be understood as a multidimensional process encompassing both lived experience and biological mechanisms.

Sleeping medications

Medications commonly prescribed for poor sleep include sedative-hypnotics such as benzodiazepines (BZD) and newer Z-drugs, which reduce anxiety and agitation and induce calm (sedative effect) and sleep (hypnotic effect). Whilst each generation of sleeping medication has been touted as safer and more effective, in each iteration evidence has rapidly accrued concerning side-effects and misuse (Schifano et al., 2019). Additionally, a third of UK GPs regularly prescribe Amitriptyline, a sedating antidepressant, off-label for poor sleep, despite guidance discouraging use in older adults due to adverse reactions (NICE, 2025).

Concerns have motivated limits on sleeping medication prescribing in recent years (Chen et al., 2025). In the UK, clinical guidelines recommend limiting use to 2 weeks and encourage discontinuation in older adults due to side-effects (National Health Service (NHS), 2022). Similar guidelines are found across Europe, where CBT-I is emphasised as the first-line treatment for chronic insomnia, though in practice – as in the UK – it remains seldom available (Espie and Henry, 2023). Meanwhile, research suggests medical professionals are growing increasingly reluctant to prescribe (Ceuterick et al., 2023; Moloney, 2017).

Shifting attitudes may be starting to take effect, with studies showing a slight decline in the number of prescriptions in the UK and abroad (Moloney et al., 2019). Nevertheless, prescribing to older adults is still widespread across Europe, with rates as high as 38% for zopiclone use (Mokhar et al., 2018). In England, around 1.4 million adults received a BZD prescription in 2017–18, including substantial long-term use among older populations (NICE, 2021). Despite clinical guidelines advocating short-term use, these figures indicate the enduring reliance on pharmacological solutions to sleep in later life. Yet, as guidelines tighten, older users who began under more permissive regimes face new challenges to access. This paper investigates how they experience and respond to this shifting prescribing climate.

The medicalisation and pharmaceuticalisation of sleep

 High levels of sedative-hypnotic and other sleeping medication use have been understood in the context of medicalisation and pharmaceuticalisation. Medicalisation, defined by Conrad (1992) as ‘the process by which non-medical problems become defined and treated as medical problems’ (p. 209), has since the 1970s been used to critique the expanding role of medicine in everyday life, especially under the influence of pharmaceutical interests and ‘disease mongering’ (Moynihan et al., 2002). The transformation of sleep from a natural, private phenomenon into a site of medical scrutiny led Williams (2002) to describe it as ‘the next chapter in the medicalisation story’ (p. 185), evidenced by a proliferation of diagnostic categories, treatments, and sleep clinics. This shift has resulted in the reframing of poor sleep as a disorder requiring intervention, often in the form of pharmaceuticals.

Pharmaceuticalisation describes the growing use of pharmaceuticals to manage social, behavioural, or bodily conditions (Abraham, 2010). While prior research focuses on ‘top-down’ prescribing influences (Sismondo, 2018), patients are now increasingly recognised as active agents in shaping use. Research has demonstrated how users resist or adapt pharmaceutical regimes, challenging notions of passive compliance (Fox and Ward, 2008; Gabe et al., 2015; Williams et al., 2012). Yet, both processes are uneven and contested. The medicalisation of sleep is complex, contested, and partial, wherein certain features of sleep have been more medicalised than others (Williams et al., 2013). Insomnia, for instance, has largely eluded medicalisation over the years, proving far more problematic than conditions with a ‘tangible’ physiological basis.

Likewise, the nature and extent of the pharmaceuticalisation of sleep varies by context and group, shaped by structural forces, actor interactions and personal meaning-making. In institutional care, the documented over-prescription of sleeping medications can be read as part of the medicalisation of older age itself, where pharmaceuticals are used to manage and discipline residents (Pegado et al., 2018). Care homes often enforce fixed bedtimes shaped by staffing patterns rather than resident preference (Luff et al., 2011), and in such contexts sleeping medications may function as tools to secure compliance with institutional routines as much as to relieve symptoms. Our focus on independently living older adults complements this work by showing how, outside institutional settings, ‘embedded pharmaceuticalisation’ is sustained less by structural enforcement than by emotional reliance and self-management – processes that sit alongside and at times in tension with, accounts of consumer agency and reluctance to use medication.

Consumer agency and reluctant use

Prior work has characterised attitudes towards sleeping medications as ‘reluctant’. In the US, Moloney (2017) found that physicians and recently prescribed patients often framed sleeplessness as a symptom of other problems rather than an illness, and expressed reluctance about medication. Moloney introduced the term ‘reluctant medicalisation’ to highlight the gap between ambivalent attitudes and high levels of consumption. In the UK, Coveney et al. (2019) described GPs as engaging in ‘reluctant pharmaceuticalisation’: they did not necessarily resist framing insomnia as a disorder, but expressed moral unease about prescribing sleeping medications, which they considered professionally problematic.

Reluctance is also evident in consumer perspectives, particularly among older adults. Growing public awareness of the risks of prescribed sleeping medications has generated stigma around their use, especially the potential for dependence and addiction (Gabe et al., 2015; Schifano et al., 2019). This stigma shapes older adults’ ‘moral repertoires’ of use, where they frame themselves as cautious, responsible and reluctant consumers (Lumme-Sandt et al., 2000). For example, Canham and Rubinstein’s (2015) US study of 12 older women found that participants justified their use as a necessary and virtuous means to end: optimal daytime functioning and productivity. Our study extends and unpacks what ‘necessary’ means in this context.

Hislop and Arber’s (2003) focus groups with 82 UK women over 40 revealed ‘widespread disillusionment and fear’ (p. 828) of sleeping medications. Medications were viewed as a deviant ‘last resort’, to be used only after all other options failed. Other studies suggest that older adults tend to naturalise poor sleep, framing it as a non-disease and inevitable fact of later life (Elias and Lowton, 2014) and characterising sleeping medications as ‘unnatural’ interventions (Pegado et al., 2018). Some resisted pharmaceuticalisation by relying on herbal remedies (Venn and Arber, 2012) or restricting dosage (Hislop and Arber, 2003). Adherence patterns vary by setting. Pegado et al.’s (2018) study of 100 Portuguese older adults found higher hypnotic use in institutional care, where prescribing norms can facilitate dependency. By contrast, independently living individuals were more likely to resist pharmaceuticalisation, trivialising or naturalising poor sleep and associating sleeping medications harm.

Yet, sleeping medication use among older adults remains widespread, and the reasons for sustained long-term use remain underexplored. Most sociological work has focused on non-adherence (using less than prescribed), resistance or stigma management. Where over-adherence is discussed, explanations often centre around cognitive decline or confusion, with behaviours such as stockpiling read as pathological (Mokhar et al., 2018). However, a pilot study by Smith and Farrimond (2019) suggested that such behaviours may also reflect intentional and strategic efforts to preserve a medication supply seen as essential to wellbeing.

Our study develops this line of inquiry. While we did not set out to study long-term users, use in our sample averaged 17 years. Rather than emphasising initiation, non-adherence or reluctance, we focus on how participants describe and sustain ongoing use. This shifts attention to a different form of consumer agency: one rooted in emotional dependence, routinised behaviour and deliberate strategies to safeguard access. In this sense, sleeping medications had become not only used but embedded.

Towards ‘embedded pharmaceuticalisation’

Drawing on interview and diary data from long-term users, we explore beyond initiation to examine the long-term relationship older adults develop with sleeping medications. Over time, these drugs are not simply taken but lived with – integrated into how individuals manage, understand and sustain themselves. For many, sleeping medications were not only tools for inducing sleep but vital supports for coping, so embedded in everyday life that imagining sleep – or themselves – without them felt impossible. This embedding may also reflect the addictive properties of these medications (Lader, 2011; Weaver, 2015), although addiction was not measured formally in this study.

 This approach contributes to pharmaceuticalisation theory by introducing the concept of ‘embedded pharmaceuticalisation’: a process in which medication use becomes emotionally indispensable, behaviourally routine, and strategically safeguarded. ‘Embedded pharmaceuticalisation’ unfolds across three interlocking dynamics: (1) Emotional attachment, where medication provides reassurance and becomes essential to emotional survival; (2) Identity integration, where medication use becomes part of how individuals understand themselves over time; and (3) Behavioural routinisation, where use is woven into daily routines and supported through strategic maintenance of supply. Taken together, these dimensions highlight how medication becomes more than a medical intervention: it becomes part of identity, survival and daily practice, sustained through both emotional need and deliberate effort. The concept also underscores the complex interplay between pharmacological dependence, emotional reliance and symbolic meaning-processes.

Whereas medicalisation explains how sleeplessness is constructed as a disorder requiring pharmaceutical treatment, ‘embedded pharmaceuticalisation’ captures what follows: how, over years of continued use, these medications become interwoven with identity, emotion and routine. In contrast to ‘reluctant pharmaceuticalisation’ (Coveney et al., 2019), which foregrounds ambivalence among doctors and patients, our concept highlights sustained reliance rather than resistance. It also extends beyond accounts of pharmacological dependence, which emphasise biological mechanisms such as tolerance, withdrawal and rebound insomnia (Lader, 2011; Weaver, 2015). While such physiological effects undoubtedly reinforce reliance, they operate in complex interplay with the symbolic and emotional dimensions of use that this paper foregrounds.

Methods

This study was conducted in the South-West of England with 38 independently living older adults (aged 65–88). Participants were recruited via flyers and snowball sampling, with attention to involving men (n = 14) and women (n = 24), given the historic focus on women in sleep research (Venn et al., 2013). The most common medication was Zopiclone (n = 23), followed by Amitriptyline (n = 10) and Zolpidem (n = 4). Reported use ranged from 3 months to 60 years, averaging 17 years, with 68% using for 10 years or more – an unexpectedly long history (long-term use was not specified in our advert) that shifted the study’s analytical focus towards sustained and embedded use.

Episodic interviews (Flick, 1997) encouraged participants to move between remembered episodes and broader reflections on sleep and sleeping medication. Interviews were conducted in participants’ homes, lasted 40–100 minutes and were audio-recorded and transcribed verbatim. Twelve participants also completed 2-week solicited diaries, seven of which were returned before interviews, allowing insights to inform subsequent questioning. As in prior work (Hislop et al., 2005), diaries provided unique access to the emotional and embodied experience of medicated sleep and helped triangulate emerging themes.

Data were analysed using framework analysis (Ritchie and Spencer, 1994), a systematic form of thematic analysis that supports in-depth exploration while maintaining a transparent audit trail (Kiernan and Hill, 2018). Ethical approval was granted by the University of Bristol Research Ethics Committee, and all participants gave informed consent. Identifying information has been removed, and pseudonyms are used.

Findings

Our analysis identified three themes: (1) Fear of Sleeplessness; (2) Embedded Pharmaceuticalisation; and (3) Securing a Supply.

 Fear of sleeplessness

Prior research often frames older adults’ use of sleeping medication as a way to manage the absence of sleep and its daytime consequences (Canham and Rubinstein, 2015). In contrast, participants here described their use as driven less by sleeplessness itself than by the experience of sleeplessness or bedtime. The suspended hours spent trying – and failing – to sleep became a psychologically volatile threshold, marked by escalating anxiety, emotional overwhelm and dread. Helen (70) captured this anticipatory dread in his diary:

I felt so anxious & scared last night. I was fine all day, but as soon as I turned the light off it started to creep in again.

These fears were frequently linked to major life events – illness, trauma or bereavement – that resurfaced with renewed intensity at night. Keith (70) had been prescribed sleeping medication following his unexpected and, in his view, unjust redundancy. The distress of feeling undervalued and cast aside led him to ruminate obsessively during long, wakeful nights – ultimately pushing him towards suicidal thoughts:

I was going out on the Friday to have a mishap. I was going to fall over whilst peeling an apple with a long sheath knife. . .that was sad, that was a bit bloody extreme, but I wasn’t sleeping- I was fed up of not sleeping.

Bedtime magnified ordinary worries. Jane (73), who lost her husband of 26 years to a sudden head injury, described the ‘debilitating and dreadful sleeplessness [that] really kicked in’, and the ‘crippling loneliness’ she experienced around bedtime since. Esther (88) echoed this sense of loss and loneliness:

My husband died six years ago this June. You lie in bed and you think, ‘I don’t like this! It’s horrible! It’s lonely! I can’t sleep!’

William (74) explained: ‘It’s the fact you can’t hold someone’s hand, even if you want to, that’s the hardest’’. In sleep, dreams would bring his wife back to life – a common experience – leading him to ‘relive the total loss of them’ upon waking. Bedtime was a uniquely distressing time of day for our participants, magnifying everyday concerns to distorted proportions in the absence of distraction and company. As Syd (83) explained: ‘If you’ve got something on your mind it becomes a hundred times worse at night’. Betty (79), struggling with conflict in her sheltered accommodation, wrote in her sleep diary:

Went back to bed at 2.30am. Having trouble with constantly going over the events of the meeting. . .feeling very depressed with the futility of the whole affair. . . I feel old and utterly defenseless against the bullying crushing indifference. . . no wonder I can’t sleep.

This pattern of emotional escalation did not remain confined to night-time. It bled into participants’ daily lives, shaping their behaviour, routines and social engagement. Helen (70) reflected in her diary:

I’m going to the theatre tonight to see ‘Buddy.’ Because of my insomnia, I don’t tell anyone I’ve got tickets until the day! Luckily one friend could come with me! It’s no way to live!

 In a later entry, she explained:

Insomnia has affected my life really badly as I find it difficult to plan anything as I get anxious about not sleeping and, of course, I then don’t sleep- sometimes all night.

Dread accumulated as bedtime approached, with many describing triggers such as the darkening of the night sky, or turning off their television or, in Eric’s (65) case, the bedside lamp:

I go into instant panic in my mind. I think, ‘Oh shit! It’s that time of night again! I hope to God I can sleep. . .’ It really does freak me out; I hate it. I’ve even started thinking maybe I should just forget about sleeping and stay awake for twenty-four hours a day.

Liz’s (65) sleep-related anxiety had culminated in body-focused repetitive behaviours whilst lying in bed at night, including Trichotillomania (hair pulling):

I’ve caused baldness because I’m just lying there thinking, ‘What do I do with my hands?’ I hate it because I close my eyes and I go, ‘Go off to sleep, will you!’ It’s battling with yourself, isn’t it? When you go through bad sleep you then dread it. I’ve come to a point where I think, ‘Oh no, bedtime!’ It’s a freaky sort of time.

The ability of sleeping medication to manage such turmoil saw their transformation from pharmacological intervention to symbolic safety object – tools that helped participants cross into sleep and shield themselves from the emotional volatility of night. This emotional embeddedness, however, was only one aspect of a deeper process, as will now be explored.

‘Embedded pharmaceuticalisation’

Over time, participants’ use of sleeping medication became woven into their lives through what we term ‘embedded pharmaceuticalisation’. This process unfolds across three interconnected dimensions: (1) emotionally, as medication provided comfort and reassurance; (2) in self/identity, as use became integral to how individuals understood themselves; and (3) behaviourally/materially, as medication was routinised and strategically managed.

For many participants, emotional attachment was especially pronounced. What began as a pharmacological aid evolved into a symbolic safety object, providing reassurance even before ingestion. As Lynne, aged 79, explained: ‘It helps because you know it’s there. . .it makes you feel safe’. For Ted, aged 74, half the benefit lay in anticipation:

I suppose it’s like a drug addict really, isn’t it? It’s not just the taking of it- it’s the knowing that you can take it- and you’ll sit in the chair thinking, ‘I’ll take it in another half an hour’, and you’re so chilled out.

Participants valued the rapid effect of sleeping medications that could ‘knock you out. . .like being put under anesthetic’ (Keith, 65). As Cynthia, aged 76, explained: ‘There’s no thinking, no worrying. You just put your head down and it’s lovely- out like a light’. They also appreciated the reprieve it offered from ruminating thoughts and upsetting dreams. These effects transformed sleeping medications into symbolic safety objects, described by Esther (88) as ‘security blankets’; items imbued with emotional reassurance (Helman, 1981). Emotional reliance ‘embedded pharmaceuticalisation’, as the medications became intertwined with both nightly routines and emotional survival, solidifying their role in participants’ lives and coming to be seen as the singular solution for their struggles. Our interview question regarding alternative remedies for poor sleep was often met with dismissal, derision of disbelief:

If a cup of chamomile tea could fix it, I’d have done that thirty years ago- I’ve tried everything (Mary, 68).

Identity integration developed with time, as years of use reshaped how participants understood themselves. For many, sleeping medication no longer functioned as a discrete medical intervention, but as part of their emotional stability and sense of self. Esther (88), when asked how long she had used them, replied: ‘Forever. I don’t suppose I’ve ever missed a night; they are part of me’. She later added: ‘I depend on them. I’d be sunk without them. . . I think they’re a Godsend’. Over time, the boundary between medicated and unmedicated sleep – and even between medicated and unmedicated selves – had blurred. Florence, aged 79, admitted:

I can’t remember really what it was like before I started taking them. . . I wouldn’t know what my sleep would be like without them.

Similarly, Peter (81), stated: ‘I don’t know what I’d be like without them anymore’. These accounts illustrate how medication use had become temporally embedded and identity-defining, no longer a temporary aid but an essential feature of daily life.

Behavioural routinisation further anchored sleeping medication into everyday life, as they were integrated into nightly rituals alongside brushing teeth, locking doors or changing clothes. Ted (74) illustrated this with precision: he took his medication at 9:30 pm, ran a bath for his wife, watched television and went to bed at 10:30 pm. He described the effect at this time as one of ‘floating’:

It’s like when you drink and you think, ‘I really don’t give a shit now.’ It’s cool, the stage where you think, ‘I feel nice’, plus ten times. I relax.

A delay such as when hospital staff dispensed his dose later than usual – rendered the tablet ‘ineffective’, prompting him to smuggle in his own supply to maintain routine. Medication was often stored in habitual, proximate locations (bedside drawers, dressing gown pockets), reinforcing its place in nightly rhythms. For many, these embodied practices carried as much weight as the pharmacological action itself, making medication use feel inevitable and naturalised within the broader choreography of bedtime. As the next section explores, some engaged in deliberate and strategic acts to ensure continued access to their medication; acts that, in turn, further reinforced its embeddedness in their lives.

Securing a supply

The dread of sleeplessness was matched by equal dread of a disrupted sleep medication supply. For long-term users, the pills were not simply sleep aids, but sources of psychological security. When asked to imagine a life without them, responses were emotionally charged, laced with words such as ‘panic’, ‘stress’, ‘dread’ and ‘worry’. Eric (65), recalling a time he ran out of medication, described feeling:

Stressed! Stressed! You really panic! It’s more panic for me. I go, ‘Oh, shit! How am I going to manage tomorrow?’ . . .I freak out massively!

Such anxieties were rooted in the perception that access to sleeping medications had become increasingly precarious. Participants attributed this precarity to a shifting healthcare landscape: the decline of longstanding doctor-patient relationships, increasingly rushed consultations and a cultural turn against long-term hypnotic prescribing. Doctors had once been viewed as empathic prescribers ‘who truly knew you’ (Dot, 83); they ‘appreciated the seriousness of sleep deprivation’ (Linda, 84) and issued prescriptions with trust and ease.

Now, participants felt dismissed as ‘just another patient number’ (Heather, 86) by GPs they considered to be overly cautious when it came to prescribing. Gloria’s (72) previous doctor, who had ‘known her all her life’, prescribed her sedative barbiturates, even as a teenager. Recently, she’d had to ‘beg the doctor’ for Zopiclone; they would ‘only prescribe for a month at a time- something about the government’. Similar experiences were echoed by Keith (70): ‘My doctor says the sleeping pill police won’t let him prescribe it regularly’.

In practice, however, most participants were still able to obtain their prescriptions through repeat systems with minimal review. Despite continued access, these users spoke of their supply as precarious, drawing on broader cultural narratives and media portrayals of the risks of long-term hypnotic use:

I always watch the programmes like, ‘Trust Me, I’m a Doctor’, and it’s interesting because they’ve picked up about people being on them long-term and it doesn’t cure and in fact it makes things worse (Dot, 83).

Fears of supply instability and losing their sole remedy for sleeplessness led participants to adopt behaviours to safeguard access. These strategies exemplify ‘embedded pharmaceuticalisation’, where medication use extends beyond clinical settings into daily life, both reflecting and reinforcing long-term embeddedness. One common approach was avoidance. Whilst participants criticised the impersonal nature of healthcare in contemporary Britain, they colluded simultaneously with the status quo of hands-off doctor-patient management. Interactions with GPs were largely avoided; participants neither requested or attended medication reviews, avoiding the potential threat to their continued supply. In this sense, the very same conditions identified as making access to sleeping medication precarious, were utilised for the purpose of ensuring a long-term supply:

The only time they ever did a review wasn’t about my [sleeping] tablets. . .I’m quite happy the way it is, because I’ve got my tablets (Syd, 83).

Every now and then it says the repeat prescription is going to be reviewed on such-and-such a date. Well, that date comes and goes, and then it’s another date a year ahead, so I don’t ask and they don’t bother me (Florence, 79).

Ambivalence shone through such comments, in terms of what patients said and what they did with regards to sleeping medication management. During interview, individuals simultaneously criticised doctors for benign neglect and yet avoided them, and the topic of sleeping medication, at all costs:

I wouldn’t say I’m happy as it is, but I’d say I am happy that I can get them and that it’s up to me to manage them. . . so I rarely go to the GP. . . I don’t think I’m on their radar (Hazel, 68).

Beyond avoidance, some overtly challenged or persuaded GPs to maintain prescriptions. Peter, aged 81, described anticipating his GP’s reluctance and pre-emptively addressing it:

Each time we have a review I sort-of jump in quickly: ‘You’re not going to stop the Zopiclone are you?’ and I make him feel ashamed to say yes. It’s sort of a psychological trick. . .I don’t pull seniority unless I really sort-of want something.

Alongside interpersonal strategies, many reported stockpiling medication; ‘stashes’, ‘stockpiles’ and ‘back-up supplies’ filled kitchen cupboards and bedside tables. Cynthia, aged 76, joked about the extent of her accumulation: ‘I could make a fortune with what I’ve got, but I will ask for more. . . it’s like a chemist here, isn’t it?’ Syd (83) explained: ‘They do not check what you’re ordering. I order more than I need. . .I’ve got loads’.

Others circumvented traditional prescribing routes entirely, procuring medication via alternative, sometimes illegal, means. Betty (79) reported to have imported a stronger variety of sleeping medication, Bromazepam, from South Africa, whilst Gloria (72), unsatisfied with the strength of Zopiclone, ordered Nitrazepam, a benzodiazepine, ‘on the black market’. Ted had at times sourced sleeping medication from a ‘dealer’:

I can get them any time. If I can’t get them from the doctor’s I can get them down in [town]. You can get them from a guy called Dave- he can get all sorts (Ted, 74).

Esther (88) described intentionally fostering a trusted relationship with a pharmacist to secure a supply, minimising GP involvement:

I get on well with the chemist. . . she just fills it [the prescription request] in there. I don’t have to go back to my doctor and renew (also cited in Smith and Farrimond, 2019).

Eric (65) had attempted to do the same, with less success:

Our mugshots were in the back of the bloody chemist. They called security on me because I was saying ‘I have not slept in two weeks, now give me my bloody tablets!’ They said, ‘Sorry, it’s regulation, and if you can’t sleep properly you’ll have to see your GP.’

Others would access medication via family or friends. Barry (74) had ‘sorted himself out’, accessing medication via a friend whose GP was ‘more generous’ and ‘willing to supply them, as easy as that!’

Together, these practices illustrate ‘embedded pharmaceuticalisation’ in action: the ways in which long-term reliance on sleeping medications reshaped not only medication use, but also the strategies used to preserve access. These strategies were driven by the medication’s deep integration into participants’ lives – and in turn, they further reinforced its embeddedness, entrenching the view that continued use was both necessary and non-negotiable.

Discussion

This paper has explored older adults’ long-term use of sleeping medication, introducing the concept of ‘embedded pharmaceuticalisation’ to extend sociological understandings of pharmaceutical use. Whereas previous work has emphasised initiation or short-term consumption (Fox and Ward, 2008; Gabe et al., 2015), or portrayed adults as ambivalent or reluctant (Pegado et al., 2018; Venn and Arber, 2012), our findings highlight a different trajectory. ‘Embedded pharmaceuticalisation’ describes a distinct and enduring process in which sleeping medication use is not resisted or relinquished, but sustained over years through emotional reliance, integration and routinised and strategic behaviours.

At its core was a profound fear of sleeplessness. As opposed to naturalising or trivialising sleeplessness as an inevitable part of ageing, as in other research (Elias and Lowton, 2014; Hislop and Arber, 2003; Pegado et al., 2018), participants described sleeplessness as intolerable, saturated with dread. This fear was inseparable from the conditions of later life – bereavement, solitude and altered temporal rhythms – which shaped both the dread of sleeplessness and the stabilising role of routine. In this sense, ‘embedded pharmaceuticalisation’ cannot be disentangled from ageing itself: participants’ anxieties about sleeplessness were intensified by the vulnerabilities of later life, where night-time wakefulness could feel especially stark, lonely, and unsafe. Prior research has highlighted how the ‘emptiness’ of the night can amplify feelings of isolation and vulnerability (Hawkley and Cacioppo, 2010; Reiss, 2016), making medication use an emotionally protective response. The perceived effectiveness of sleeping medication as the solution to sleeplessness was not only tied to their pharmacological but symbolic power, accrued via years of ritualised use. Akin to a child’s soft toy or blanket, sleeping medications offered safety and reassurance, functioning as ‘transitional objects’ (Williams, 2007) that facilitated sleep and therein laying the foundation for embeddedness over time.

Where existing literature portrays older adults as pluralistic in managing health through pharmaceuticals, behaviours and complementary approaches (Gabe et al., 2015; Joyce and Loe, 2010; Venn et al., 2013), our participants consistently rejected plurality. Lifestyle approaches were dismissed as ineffective; sleeping medications were positioned as almost the sole viable solution. While Coveney et al. (2019) interpret mixed strategies as evidence of sleep’s partial medicalisation, our participants rarely framed sleeplessness in medical terms. Instead, they understood it through emotional and existential frames – loss, loneliness, fear – yet managed it exclusively pharmaceutically. In this way, the findings support arguments that pharmaceuticalisation can advance independently of medicalisation (Coveney et al., 2019). In institutional settings, embedded pharmaceuticalisation may be structurally facilitated, with sleeping medications used to manage residents and enforce order. In our community-living sample, by contrast, it was shaped by emotional reliance and self-management.

The persistence of exclusive reliance must also be read through the sample itself. Participants had used sleeping medication for an average of 17 years, a duration that both reflected and deepened perceptions of necessity. Over time, medication was naturalised, affectively charged, and integrated into daily life. Yet this invites reflection: if sleep disruption endured so long, why did participants not experiment with broader repertoires? Given that pharmacological effects often diminish over time (Chen et al., 2025), one might expect experimentation. That they did not suggests ‘embedded pharmaceuticalisation’ is both a cause and consequence of non-pluralism: as reliance deepens, alternatives are not only abandoned but rendered unthinkable.

It is also important to recognise that embeddedness is not only socially and emotionally constructed but also grounded in pharmacology. Sleeping medications carry addictive potential and can produce physiological dependence (Lader, 2011; Weaver, 2015). Withdrawal can be severe – even at low doses – producing symptoms such as seizures, psychosis and rebound insomnia (Santos et al., 2017). These biological processes not only complicate discontinuation but also amplify the very fears of loss and anxieties of sleeplessness described by our participants. In this sense, sleeping medications exemplify how ‘embedded pharmaceuticalisation’ can be ‘fuzzier’ than in cases of pharmaceuticals lacking addictive properties: reliance reflects both biological dependence and symbolic attachment, operating in complex interplay. More broadly, different medications exert varying levels of physiological and symbolic power, with prescribed sleeping medications representing a case where both dimensions converge to particularly strong effect.

Embeddedness also made the prospect of loss especially troubling. Despite repeat prescriptions, participants voiced constant anxiety that supply might be restricted, citing shifting medical attitudes, weakened GP continuity, and growing scrutiny over hypnotic use (Coveney et al., 2019; NICE, 2021; Scambler, 2012). In response, they engaged in strategic maintenance: stockpiling, cultivating relationships with pharmacists, or even illicit sourcing. Echoing Gabe et al. (2015) on bypassing formal prescribing, this study highlights avoidance as a distinctive, under-acknowledged strategy. Participants often evaded reviews or deferred or maintained a low profile in order to preserve access without confrontation. This quiet persistence contrasts with the more active, problem-solving orientations described by Gabe et al. (2015), and reflects an equally deliberate commitment to continuity.

It appeared that doctors often tacitly permitted this. Prescriptions were routinely renewed without discussion, whilst dose reduction was rarely raised. This dynamic reflects what Elias (2000 [1939]) termed a ‘dance’ of interdependent agency’: a choreography in which both doctor and patient avoided open acknowledgement of the stakes. For older adults, this dance carried particular weight, as age-related vulnerabilities – such as heightened fears of losing sleep, reliance on established routines, and the fragility of continuity in long-standing GP relationships – made the prospect of withdrawal especially threatening. Within a policy environment increasingly oriented towards deprescribing (NICE, 2021, 2025), doctors performed responsibility by nominally monitoring use, while patients performed compliance by not disrupting the status quo. This mutual avoidance helps explain the persistence of hypnotic use among older adults despite clinical guidance to the contrary (Arber et al., 2018), and reveals a relational facet of ‘embedded pharmaceuticalisation’ sustained by tacit cooperation in the face of systemic pressures.

More agentic strategies of continuity can also be situated within broader sociological accounts of later-life health identities. Scholars have noted the emergence of more critical, health-literate ‘technogenarians’, who creatively and selectively adapt medical technologies – including pharmaceuticals – to support wellbeing and autonomy (Joyce and Loe, 2010). While not all participants matched this profile, their more active strategies illustrate how long-term pharmaceutical use is shaped not only by fear or structural gaps but also by evolving forms of health agency in later life.

Together, these findings show that ‘embedded pharmaceuticalisation’ is not a static state but a dynamic, relational process – formed over time, reinforced by habit, and sustained through both cooperation and quiet resistance within a system ambivalent about ongoing prescribing. What persists is not merely a pharmacological habit but a deeply sedimented reliance – affective, symbolic and practical – that resists both clinical scrutiny and policy withdrawal.

Policy and practice implications

These findings carry important implications for policy and practice. Current deprescribing initiatives emphasise risk communication and guideline enforcement, yet our data suggest long-term use is sustained less by ignorance of risks than by profound fears of sleeplessness and the symbolic security medication provides. Deprescribing strategies must therefore address the emotional and existential dimensions of sleep, not only the pharmacological. For practitioners, this means acknowledging the lived significance of sleeping medications, offering gradual, individually tailored withdrawal plans, and ensuring that non-pharmacological alternatives (e.g. CBT-I) are accessible and responsive to the realities of later life, such as bereavement and loneliness.

At the same time, deprescribing does not occur in a vacuum: systemic factors such as prescribing regimes, healthcare resource constraints, and cultural narratives about ageing and sleep create conditions that older adults cannot fully control. These structural dynamics may at times sustain continuity (e.g. through repeat prescribing systems), and at other times constrain it (through deprescribing pressures). Policy frameworks that overlook these intertwined experiential and systemic dimensions risk reinforcing precarity, stigma and resistance among older users.

Limitations and future research

This study focused on older adults living independently in their own homes, who may be more autonomous and medically dependent than those in institutional or sheltered settings and thus better positioned to sustain pharmaceutical use. Although long-term use was not an inclusion criterion, all participants were in fact long-term users, suggesting the sample reflects a subpopulation for whom sleeping medication had become particularly central. Those with more intermittent or less attached use may have considered their practices unremarkable and opted not to participate. As such, the findings likely represent cases where embedded pharmaceuticalisation was especially advanced. Accordingly, our claims are not of statistical representativeness but of analytic generalisation – mechanisms and dynamics likely transferable to comparable contexts. The study was conducted in South-West England, and dynamics may differ in other health systems with alternative prescribing regimes.

Only 12 participants completed diaries, though smaller diary samples can still yield valuable insights (Bowling, 2009). Interviews remain open to recall or social desirability bias, despite the use of episodic interviewing designed to mitigate such effects (Flick, 1997). Diaries, while valuable for capturing immediacy (Hislop et al., 2005), may have involved selective reporting or favoured more articulate participants. These factors caution against over-generalisation, yet the convergence of interviews and diaries and consistency of themes across cases, provide confidence in the robustness of the analysis.

Conclusion

This paper has introduced the concept of ‘embedded pharmaceuticalisation’ to capture how sleeping medication use is sustained through emotional, behavioural and relational processes. Moving beyond accounts that emphasise ambivalence or pluralism in older adults’ medication practices (Joyce and Loe, 2010; Venn et al., 2013), we show how use becomes taken for granted – woven into identity, routine and relationships. Reconceptualising pharmaceuticalisation in this way highlights not only how use begins, but how it endures as a symbolically powerful and emotionally stabilising feature of everyday life. In doing so, the paper has addressed the question of how sleeping medication becomes sustained and embedded in later life, showing that fears of sleeplessness and the reliance on routines are central to this process.

Future research should examine how ‘embedded pharmaceuticalisation’ unfolds across different settings, such as care homes where organisational logics may drive embeddedness or across health systems with different prescribing regimes. Comparative studies with those who have discontinued or resisted sleeping medication could clarify what makes embedded use persist in some cases but not others. Finally, given the emotional, behavioural, and relational dimensions identified here, further qualitative work could explore how pharmaceutical reliance intersects with ageing, gender, class and caregiving.