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MRIC


2023/5/27

Fumiue Harada, M.D., Ph.D.

Chief of Internal Medicine, Soma Central Hospital, Fukushima, Japan


“Can I die with sleeping pills?” This was the question I was asked as the chief of Internal Medicine at Soma Central Hospital by a 70-year-old man who runs a business.


"With modern sleeping pills, you cannot die. Please live well and continue your work, for my sake as well," I responded. The man has a history of myocardial infarction.


On May 18, 2023, a famous Kabuki actor was found unconscious at home along with his parents and was rushed to the hospital. At the time of discovery, his parents were said to have been dead for 1-2 days, but the details are not clear at the time of this writing (May 22, 2023).

According to reports, an overdose of psychotropic drugs is suspected as the cause of death. The actor himself was in a semi-conscious state when found but is now reportedly being questioned by the police. There must have been a deep darkness that only the family could understand.


Why were they able to obtain a large amount of psychotropic drugs?


Sleeping pills and psychotropic drugs can only be prescribed for one month as a rule in Japan, so patients should not be able to get them in large quantities. However, this only applies to prescriptions obtained through outpatient clinics.


Famous people like actors often find it difficult to visit clinics and sit in waiting rooms like everyone else. This is not because they are given special treatment, but because their presence can cause panic in the waiting room. It's also hard for them to visit the clinic every month during their busy schedule, so sometimes the medication for them is prescribed for a longer period as if it were a semi-long-term prescription.


In fact, there are "tricks" to prescribe medication for a longer term. For example, a sleeping pill might be prescribed as a regular medication, with a few extra tablets added to be taken as needed for insomnia.


There are also cases where medication is given away. "I shared some of my sleeping pills with a friend who couldn't sleep during a trip. Now I'm running low, so I need a new prescription for sleeping pills," some patients say. Even though I give them a little rebuke, they don't seem to feel guilty about it.


There are also cases where patients stockpile their medication. Doctors often choose not to change the prescription content if the patient is doing well. Even when a patient says, "I'm sleeping well," it's uncommon for a doctor to suggest, "Let's stop the sleeping pills." That's because it's difficult to fully "cure" insomnia.


According to a report by the Ministry of Health, Labour and Welfare of Japan, 30-40% of adults in Japan suffer from some form of insomnia. Chronic insomnia is seen in about 10% of adults, with causes ranging from stress, mental illness, neurological disorders, alcohol, and side effects of medications.


The prevalence of insomnia increases with age, with over half of those aged 60 and above experiencing it. Moreover, there is a transient increase in insomnia following major disasters, such as the Great East Japan Earthquake in 2011 or the COVID-19 pandemic. The reality is that 5% of adults in Japan take sleeping pills for insomnia. In fact, many doctors and politicians regularly use sleeping pills.


I, the author, have more than ten years of experience conducting general outpatient consultations in downtown Tokyo. I am currently practicing internal medicine in Soma City, Fukushima Prefecture. When I first arrived, I was surprised at the number of patients taking sleeping pills.


Although I haven't investigated precisely, my impression is that a higher proportion of patients are taking sleeping pills than in Tokyo. Countryside nights are dark and quiet. Enduring the loneliness of the night can be tough. With the coronavirus pandemic reducing interaction with others, there could be an increase in sleeping pill use due to feelings of loneliness.


Will taking a large amount of medication kill you?


The sleeping pills and psychotropic drugs that are commonly available today are designed to be difficult to die from, even if consumed in large amounts. According to the 1964 White Paper on Crime, a trend of using sleeping pills like “Haiminal” for a sense of euphoria, referred to as "sleeping pill play", was popular at the time.


The sleeping pills at the time were mainly high-dependency, high-fatality "barbiturates." These types of sleeping pills have been linked to suicides, and current doctors hardly ever prescribe them (at least, internists don't). The "Halcion" implicated in the recent death of the Kabuki actor's parents is a "benzodiazepine" drug, which is hardly ever heard of in terms of fatality.


However, there have been reports of a connection with dementia, and it's recommended that they are administered with caution to the elderly. But, if the patient requests it, it may still be prescribed. That's because sleep itself is a form of treatment. Lack of sleep can exacerbate lifestyle diseases like high blood pressure and hyperglycemia.


Conversely, there are many patients who resist taking sleeping pills. For such patients, I sometimes persuade them by saying, "Just try taking it silently for just a week. You don't have to take it after that." I've seen cases where their blood pressure has dropped after taking sleeping pills.


On the other hand, in cases where patients are dependent on sleeping pills or have developed a tolerance, we might switch types or even use a placebo. For homebound patients, the issue of falls while in a state of semi-consciousness arises. In such situations, with the understanding of the family, we actually use a placebo.


This kind of medical practice might be criticized from a medical standpoint. However, there may be cases where it is appropriate in terms of healthcare, even if it is wrong from a medical perspective, to prescribe medication at the discretion of the doctor, understanding each patient's circumstances. That's what clinical practice is all about.


Was it just psychotropic drugs?


On August 28, 2009, American singer Michael Jackson (51 years old at the time) died from a drug overdose. His personal physician reportedly administered propofol every night for six weeks to treat his insomnia.


Propofol is an anesthetic used for the induction and maintenance of general anesthesia in surgery. Because it has a respiratory inhibitory effect, it can cause respiratory arrest and cardiac arrest unless it is used under the proper administration by an anesthesiologist and constant monitoring in a well-equipped environment.


While it is hard to imagine a Japanese doctor administering propofol to a patient, it can't be said that it's impossible for individuals with special connections, such as celebrities. Even if it's not propofol, the fatality rate could increase if combined with a drug that is close to an anesthetic.


Could there have been asphyxiation from inhaling vomit?


According to reports, the parents of the actor were found lying on their backs. This is a posture prone to asphyxiation, so it's generally recommended that patients with sleep apnea not sleep on their backs. If alcohol or other substances were also involved, there's a chance they could have choked on their vomit.


There are still many unknowns about the incident that occurred in the Kabuki actor's family home. There have been reports that the mother had been taking care of the bedridden father for a long time. It's possible that the family, exhausted from caregiving, felt cornered to the point where they saw no choice but death.


The disparity between the glamorous world of the stage and their reality may have been too great to bridge, and they might have been able to maintain balance only by taking large amounts of psychotropic drugs. Causes leading to death are often due to a complex mix of factors.


There are many speculations, but only the family involved knows the truth. As the initial patient question illustrates, reports on celebrities have a significant impact on patient psychology. As a clinician, I want to watch the progress carefully.


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