We did a study of these physicians. Some are very reputable men. The majority of physicians are doing a good job. Others are completely no-goods-selling prescriptions for money, for example. This has been documented. There are more and more and more running obesity clinics where they give out 21 uppers a week under the guise of reducing patients.

Mr. DORNAN. Could I ask you to pause right there for a time elaboration. Are most of the responsible physicians using a different pattern now than they did 10 years ago when psychotropic drugs were sort of the new miracle drugs? Have doctors started to-I wish I had a better term-clean up their act?

Dr. MARONDE. I don't have that information. One thing I noticed when the phenothiazines came out they were used much more for anxiety and now they are confined to treatment of psychosis. That has been the trend. I think that is simply medical education and realization of the proper application of drugs.

What I am afraid of is the majority being penalized-it's a big problem. I am not denying the problem.

Mr. DORNAN. Is it a growing problem?

Dr. MARONDE. I can't tell that. I don't have the information. In our environment we have controlled it. I can cite evidence of that. One of our local supervisors, interested in the drug scene, tried to find a physician in the county system who was abusing the prescription system. He called me up. They had access to all drug-related deaths from the coroner's office. Not one of those was related to the county system nor did they find abuse of prescription drugs which were handled by our computer system.

I'm saying it is a solvable problem. That is what I want to emphasize. I don't want to prosecute or indict. I want to solve the problem. Mr. DORNAN. With a million visits a year-and I know how USC. turned that hospital from the dregs into a superinstitution in less than a decade-and-a-half. But what about the individual doctor out in the field who generally will say to a woman-look, there I go again. But it has been my experience that women are two to three times as much

Dr. MARONDE. I think this is a problem, and I think when you find a problem of abuse or excess or excess prescribing it has to be a judgment by society; I can't make it.

Mr. DORNAN. Doesn't he usually say to the patient, "Where is your pharmacy?"

Dr. MARONDE. And we will find a small percentage of doctors who aren't conscientious about this and overprescribe.

Mr. DORNAN. How does the pharmaceutical industry play a role? If there is an overprescription problem, and they are putting out a number of pills of any one type of drug-there's got to be a responsible point where they say, "Well, it's the doctor's fault for succumbing to our fantastic advertising, but maybe we have a responsibility to back off."

Dr. MARONDE. Being a physician I am biased the other way. I think the physicians are mostly pretty good. There's a lot of advertising, and so forth, but there are a lot of people abusing the system.

But what I believe is there has to be some enforcement, not legislation, but some agreement as to what we need for controls, and develop these controls. Because we are always going to have the system abused. Any time the county of Los Angeles can buy Valium for 32 cents a tablet and it goes for $1.50 on the street

Mr. DORNAN. What was that again?

Dr. MARONDE. 32 cents. There's a problem. And someone is going to use that situation.

Mr. DORNAN. Is there a problem here of too much success? And let me elaborate for just a second. I had a friend in high school that would eat for lunch a full head of lettuce he picked up various nicknames like "Lettuce" and "Rabbit" and so forth. Now, if he was "addicted" to lettuce using that term loosely-he was not in danger of harming himself if he upped his addiction to three heads a day. But with things we ingest into our system, such as liquor and prescription drugs, you get to the point very quickly where it's hurting you. So we get to the point of what is happening out there with Valium and how it is being abused. If you take 100 percent of all the people of the United States, the largest, most industrialized nation ever in history, then no doctor would sit here and tell me I'm a freak if I take nothing except an occasional aspirin.

And what about the difference between men and women with addiction-there is a large amount of anxiety in America, I guess, but at what point is Hoffmann-La Roche going to say, "We have maxed out the true need at 62 percent of the population"?

Dr. MARONDE. I have never seen a factual study that really identified this person. I happen to have a colleague at UCLA, a rival institution across town, who gave me an article that has been accepted for publication titled "Outpatient Treatment and Outcome of Prescription Drug Abuse." And it is the first time I have known of a study where they tried to treat these people, as he said, with a Cadillac approacheverything. The results were miserable. And he claims in his study at UCLA that these are not people that would turn to something else anyway. They are people who get on a drug because it is prescribed. But I don't have complete data. This is a very small sample. We have to identify this population, who they are, and how to handle the problem.

Mr. DORNAN. This problem has frustrated me for over a decade-anda-half. I may be a member of an unusual family, even though this person, me, I have never taken anything all my life. I watched my father at the end of his life having Valium pitched at him; the same with my father-in-law, my mother-in-law, and brothers-in-law. My wife, and all three of my daughters have been offered Valium. It is obviously not an uncommon drug either in California or on an elevator in our Rayburn Building.

In trying to be fair to the Pharmaceutical Association, I want to ask: What is too much success for them? I use stress and exhaustion and anxiety as warning signals to my body that I'd better change my rhythm and system. Now, I think that is a very normal approach, even if I am approving my own approach in saying it.

I'm not so sure that you haven't already passed and gone beyond that point where the percentage of people who really need medica

tion for a good health regimen in their lives, plus I think other people that I see that are no more anxious or tired or stressed than I am are taking pills. I feel sorry for them. During this last decade every time whenever I checked back with friends, their lives would be totally screwed up, never improved by constant drug use. And I think the medical profession, together with the pharmaceutical profession, are the experts and they cannot rely on reasonable patients reading "Reader's Digest" and coming in and saying:

Don't offer me Valium. I have a better suggestion. Tell me to do 50 push-ups and eat better and more nutritious food and stop smoking.

But when the doctor tells them that they walk out of the office happier people. I don't think that is going to happen too often, now however.

Where is the research being done by these people who call themselves research laboratories? I don't see it.

Ms. BOE. I don't know the answer to that.

Mr. BRENNAN. Can we offer some counsel on what we have done, not necessarily on research, to lower the number of people in the categories you are talking about-the efforts we have made.

Mr. EVANS. Would you identify yourself for the record.

Mr. BRENNAN. I am Bruce Brennan, vice president and general counsel for PMA.

I think Ms. Boe has a number of instances of the kinds of things we have undertaken ourselves or have contributed to with others. Why don't you outline those?

Ms. BOE. I will outline those but I'd like to also comment quite a bit on your question of what is the role of the pharmaceutical industry when you have this number of medications. You must understand at the company when you get in orders it is difficult to understand which is an order for a valid amount and which is not. However, what the companies have done right along is check those orders when they are for an unusually large amount, whether this comes from a wholesaler or directly from a physician. They do check it out to see whether it is a valid order and they can justify the need for it. If it is not, the order is not filled, and there is an accountability going on within the company to be sure.

Mr. DORNAN. That is the specific problem. What about the whole overall nation?

Ms. BOE. That is what I will get into, what we have done through the years in various different areas. Because we felt we needed to get at the young persons so they'd grow up with a more responsible attitude toward medicine, back in 1969, in cooperation with the American School Health Association, we helped develop this curriculum guide [indicating] for kindergarten through high school that is used in about 100,000 schools throughout the country and the world, actually.

Mr. DORNAN. For kindergarten?

Ms. BOE. Kindergarten through high school, to teach concepts about all types of substances. And this has been very well accepted by edu

cators.

Mr. DORNAN. Ms. Boe, one point. I don't think you know, and I don't, or does anybody know at this point whether it's 40 percent of

our population or 60 or 80 that 50 years from now should be on some miracle drug or other. The Russians are running experiments with sleep to get more hours out of their workers and they think they can get our sleep down to 2 hours per night by chemical additives to the body system.

In this book I wonder if it says that there are some of us who do not need anything unless bitten by a rattlesnake or need an antibiotic to fight some infection.

Ms. BOE. I'm sure you will find it is a very well-balanced presentation because we had a great many educators on the committee that developed it, and they were very conscientious about being sure it was a well-balanced publication.

Mr. DORNAN. Is this a PMA book?

Ms. BOE. It was produced by the Committee on Drugs of the American School Health Association. I was on that and some of the physicians from our companies, but in addition we had educators and physicians in school health programs. The list of the committee who prepared this is in the front of this, and I will file it with the committee so you will have a copy of it in the record.

Mr. EVANS. Without objection, that will be made part of the record. [The information referred to is in the committee files.]

Ms. BOE. In addition to that we have also funded a lot of treatment center programs through the years. We have also funded and helped provide training courses for faculty persons in how to teach students and faculty on drug education. We have had for 10 years a kit of consumer information about drugs. The main item in here is a pamphlet titled "The Medicine Your Doctor Prescribes-A Guide for Consumers" that starts out in the very beginning telling them what questions they should ask the doctor about so they'd have adequate information about their medicines.

In addition to that, we have also had for over 10 years a national speaker's program so that local community groups would have access to a representative from the industry to discuss questions of interest

to them.

And frankly, in the years between 1968 and 1974, I would say, the major topic that was asked for by these community groups was drug abuse. And we did present a great many presentations to local people around the country and respond to their questions on this topic.

We also worked at it from the other standpoint of providing several workshops for our member companies to assist them in improving and adding on to their security measures so that they could be sure that none of the materials were diverted from their plants.

Mr. DORNAN. What would you use as your speaker's pool?

Ms. BOE. This includes both field personnel and home office personnel. Mr. DORNAN. From what industry?

Ms. BOE. The pharmaceutical industry.

Mr. DORNAN. Would you have doctors that are part of it?

Ms. BOE. Some of them are. One of the major drug abuse speakers was a doctor from Eli Lilly.

Mr. NELLIS. If I may at this time, I'd like to make a point here that I think is important for the committee's record.

Ms. Boe, you are talking about situations in which drug manufacturers receive orders for drugs that exceed the normal and there are

security measures applied to keep those drugs from getting into the wrong hands or getting into the hands of doctors who overprescribe; right?

Ms. BoE. Generally.

Mr. NELLIS. What I want to know is: Why hasn't your industry ever established a ceiling, a reasonable ceiling, with respect to the legitimate medical needs of the American people so that Valium producers wouldn't be out proselytizing doctors to increase production and get to the point where we are overproducing these pills, which accountand I think Dr. Maronde will substantiate what I say-for the misery that licit drugs are causing? Where is the legitimate medical need of the American people?

Ms. BOE. The reason that isn't possible is because there is no hard data on how many people in this country have particular symptoms that would be treatable legitimately by these drugs.

Mr. NELLIS. That could be obtained, Ms. Boe. It can be obtained under national health insurance or without national health insurance. What I am getting at is this: The ethical drug companies and correct me if I'm wrong-adopt the commercial practice that is adopted by car manufacturers, aircraft manufacturers, and others, of doing their best to sell their product.

Mr. DORNAN. And the sky's the limit.

Mr. NELLIS. Exactly, the sky's the limit. That means this is consistent and I have been in this for years, as you know, Ms. Boe, and I have had this argument with you many times there is a consistent year-upon-year increase in production that nobody wants, that nobody needs, and that is only going out to the public because of supersalesmanship and the kind of ads you see out there [indicating].

Ms. BOE. The production figure records do not indicate a consistent increase regularly, and that might be justified if it were there because of the increased population. Given the type of society we have and the pressures and anxieties in it as more people grow older, there are likely to be more valid candidates for medication. And many of those persons are not in the health care system. It has only been when more publicly funded programs have allowed the medically indigent to get this type of treatment that they have then received the medication which may have benefited them 10 years ago had they been able to get it. Mr. DORNAN. May I get back the time, Counsel ?

Mr. NELLIS. Yes.

Mr. DORNAN. Let me ask Dr. Maronde a historical question without using 250 historical references, but say just 3.

Would you say that living somewhere west of the Caucusus, over a 500-year span of history in the Middle Ages when Huns would sweep down upon you and kill farmers and rape their wives and daughters, that this would lead to a stressful situation for those farmers?

Or would you say living before World War I or the action on the Western Front in France in World War I when a whole generation of young males were killed would have led young males to stress?

Or a third one: Do you think living in the years of 1666 and 1667 in London when one year the Black Plague struck and the next year the entire city burned down might have led to stress?

I wonder what your medical opinion is as to this argument that Ms. Boe uses and it is used by respected Ph. D.'s across the country in