every field—that somehow or other modern-day Americans live in the most anxious, stressful age in all of history. I personally don't buy that statement any more as of about 2 years ago.

Dr. MARONDE. Well, it is a personal opinion and philosophy; I don't have hard data. But I think there should be a distinction made between nonprescription, nonmedical use, and medical use, and I am saying nonmedical use is bad. It is used on the street. Maybe it is obtained through prescription. Maybe these people are selling it just for the trip.

Mr. DORNAN. Could we call that self-medication?

Dr. MARONDE. It is not medical use. It is street use of a prescription drug. That is very prevalent. There's a lot of drugs diverted to get it on the street because of the obvious cost markup that occurs.

There is one facet of this distribution system that is being ignored that should be looked into, and that is the drug wholesaler. We should look at the origin of the drug wholesaler and where he came from.

And I think the medical profession gets accused of the overuse of drugs and a lot of it is street drug use, diversion, being obtained from prescriptions or false prescriptions. Then we have the housewife that goes to the physician that you described, and the physician doesn't want to listen to her for 15 minutes and writes the prescription, as you said this morning. I think that's another facet. I think that is there, but I think it's the minority of physicians.

I think the stress we have today is different. I have talked to some of these people trying to understand it. I don't understand it. I identify with your approach. Stress creates the flight or fight response. Some of these people can't fight, and that's what I see as sad. They are in a situation and I don't blame the economy or society for it-where there is no way out. They have five kids and they are unemployable. They will always be unemployable. They are in a trap, and what are you going to do with them? They are on the drug.

Mr. DORNAN. Doctor, if we limited our discussion for the rest of the day to just middle-class or high-income people and their drug problems-I am willing to accept a ghetto or barrio or Appalachian area as stress producing, per se

Dr. MARONDE. I used to practice in Pasadena for 15 years.

Mr. DORNAN. Do you believe their claims of stress?

Dr. MARONDE. I don't know. It's a tough problem. It's a social problem-I'm not a psychiatrist. I don't understand it, but I do know there is an identity problem particularly with a lot of housewives in the middle-class environment where they feel they have nothing—and I don't know why.

Mr. EVANS. Ms. Boe.

Ms. BOE. I wanted to say you misinterpreted what I said. I didn't say we lived in the most stressful environment that has ever existed. I said, "Given the stressful conditions inherent in our environment today, so on and so forth." I would not doubt that back in 1666 or those other traumatic periods you mentioned, had there been the medications available that there are today, sales would have been greater than they are today.

I can give you a beautiful example if you don't mind the personal experience. If I had not handled the anxiety built up in me to be here testifying before you today to the point I was vomiting all over the

place, I would have been a prime candidate for any kind of medication that would have calmed my anxiety so I could function, since I am supposed to function here today. I don't have that problem. My anxiety I can control. What is it in my environmental background that trained me how to handle my anxiety? If you can answer that, you can get into the motivations, all the environmental influences that have affected a person's ability to handle their problems. When we talk about prescribing these agents, we are talking about prescribing them to people whose reactions are abnormal. And those are the people who go to the doctor. If they are handling it normally, they are not going to spend the money to go to the doctor.

Dr. MARONDE. May I say one thing and then I will be quiet. I am overstepping here. I take exception to one thing Ms. Boe said, and that is there is demonstration that any of these drugs that calm you down increase the coping mechanism. That I have trouble buying.

Mr. DORNAN. Let me ask why.

Dr. MARONDE. Some people can't cope. That's another problem.

Mr. DORNAN. This is maybe a superficial evaluation but somebody is going to have to show me otherwise. However, every person I have seen in my experience using psychotropic drugs and I am not talking about those with deep emotional problems, schizophrenia or some problem where deep psychiatric or person-to-person care is called for-but every other person using psychotropic drugs for their nervous symptoms or to calm anxieties, the drugs increased the problems they were supposed to correct. The users were more nervous and were more anxious than when they started.

It is the excuse of the person trying to give up smoking. "I smoke to calm my nerves," they say. And yet, there isn't a smoker in the world that kicks the habit and puts some months between the habit and himself who won't find out his nerves are calmer once he is off the smoking. Then he or she laughs at those periods in their lives when they said, "I smoke to calm my nerves."

And the same applies to alcohol.

Here is one of the things you showed me, Doctor-and I will close on this; and it is the best thing I've gotten out of these hearings today. I have long been aware that if the liquor industry with its positive PR programs to help alcoholics could wave a magic wand over the country and cure instantaneously every alcoholic in the Nation, they wouldn't do it because their entire profit margin would disappear. There would be hundreds of liquor industry layoffs across the country because the alcoholics of America account for 50 percent of the alcohol sales. And liquor profit margins aren't as good as the drug industry's. So, if we could clear up your street problem, vour lying-to-themselves middle-class problem, then Hoffmann-La Roche and all the other drug companies would have to take a new look at the black ink in their profit margins.

And I'm not saying they deliberately overproduce to feed off the heavy users, but your statistics prove to me again that the heavy users account for 14, 15, 16, 20 percent-and I'm convinced in some localities an even higher percentage of the total sales. And anybody that can make 20 percent profit on any business in this country today with our current interest rates has really set up a great operation.

So I thank you very much for your testimony. I am still open to any and all suggestions on how to attack this problem because I am not inclined toward Government regulation as a solution.

Mr. EVANS. Thank you. Does counsel have questions?
Mr. NELLIS. Yes; I'd like to ask a couple of questions.

Ms. Boe, we have a serious problem that seems to have been recurring for at least the 20 years or so I have been involved in it. Please explain to me why it is that the industry cannot come up with some reasonable data on what the legitimate medical needs of the American people might be even including export sales, if they want to so that overproduction, the system Congressman Dornan was talking about, would not be the kind of thing we face year after year. It is the same old story. I have heard this story, and I am sure you have, for 15 years. Why is it we can't stop the overproduction and the sales push to get people to use these drugs that eventually turn out to be pretty dangerous?

Ms. BOE. Well, Mr. Nellis, you have asked a group of questions.

First of all, I do not agree there has been overproduction, because a company is not going to overproduce. It produces what it thinks it can sell. And to the best of its knowledge it satisfies that it has sold its product on the basis of the legitimate prescription.

Why there isn't data as to what the total universe is for the patients who would be candidates for that, my understanding is that that is because there is still a large percentage of our population that is not incorporated in the health care system. In other words, even the Food and Drug Administration doesn't have figures and had a great deal of difficulty in arriving at what it assumed might be the legitimate need for certain types of illnesses because they don't know how many people are out there who have never gone to a doctor with these complaints, who would be diagnosed as having this illness.

We don't know. There are estimates, and in the longer version of our testimony there were the estimates of how many people in the United States should be under treatment for mental disorders of one type or another. That is a guesstimate, however, because how can you estimate that when those people are not exposing themselves to a diagnostician?

Mr. NELLIS. MS. Boe, I understand that position and I have read much material that explains it. But I am still at a total loss to understand why it is that each year the sales of Valium increase. In 1977, 57 million out of your 100 million prescriptions were written for Valium. The year before it was something like 43 million. The year before that it was something like 36 million. Every year the prescription rate increases. And I cannot believe that that is because we are seeing on the market more people who need Valium each year. We don't have a birth rate that heavy to begin with.

Ms. BOE. That may be one of the reasons, but some of the other reasons are that it is a safer drug than some of the other drugs that used to be prescribed for those symptoms so it is becoming the drug of choice with physicians over those that would have been previously prescribed.

In addition, as I explained, a lot of those raw prescription numbers can be explained by the fact that because of the Comprehensive Drug

Control Act of 1970, you have to get a new prescription every 6 months. It can only be refilled five times within that period. If somebody is on a maintenance dosage, they have to get another prescription. Also the fact they are being treated in the community at mental health centers where they have to have retail prescriptions filled-that adds up the tab of the total number of prescriptions. When they had to be hospitalized they didn't show up as retail prescriptions because they were dispensed in the hospital. So just from a technical standpoint you are going to have more and more prescriptions as these people are treated in the community.

Mr. NELLIS. On another subject, Ms. Boe, is the PMA satisfied with the level and the truthfulness of the advertisements that the industry places in the medical journals?

Ms. BOE. As you know, we have our code of fair practices, and we have had that in effect since 1958. We have also looked at those FDA statistics on how many ads they have reviewed and how many they found noncompliant, in their opinion-there is always an argument about that with the company. The percentage figures ought to be certainly less than 2 percent of all of the ads that have had any faultfinding. When any ads are called to our attention, we would have the mechanism for reviewing them, but that has not happened often.

Mr. NELLIS. You have not used that mechanism except where FDA calls your attention to them; is that right? I'm talking about the code of ethics mechanism in PMA.

Ms. BOE. No; that is not true.

Mr. BRENNAN. FDA has never asked us to do that.

Mr. NELLIS. Have you had self-starting investigations into advertising and detailing practices on your own?

Mr. BRENNAN. Not detailing, no.

Mr. NELLIS. Not detailing?

Ms. BOE. We set up the commission to review the training of detail persons.

Mr. NELLIS. But on the question of detailing and advertising, is there a mechanism within PMA that would help to regulate excesses? Mr. BRENNAN. Yes.

Mr. NELLIS. Have those mechanisms been used?

Mr. BRENNAN. Only seldom.

Mr. NELLIS. Why is that?

Mr. BRENNAN. Because it was not requested. The mechanism is a code of promotional practices. As I am sure you understand, Mr. Nellis, an organization like ours has a very difficult time in complying with the antitrust laws in enforcing promotional practices. In fact, when we established this code we took it to the Department of Justice to determine what kind of enforcement we could have associated with it. And they basically turned us down on enforcement, other than calling people's attention to the fact that they did not seem to be in compliance with the code. And it has only been a couple of occasions that member companies of ours have brought to our attention matters which they thought were not in compliance with that code. Mr. NELLIS. So the effect is that your mechanisms are not terribly effective.

Mr. BRENNAN. The mechanisms don't need to be effective, Mr. Nellis, outside of voluntary compliance, largely because subsequent

to the time this code was adopted in 1958, the 1962 drug amendments imposed very rigid controls on all prescription advertising, and that kind of relieved the need for a voluntary program such as we established in 1958 when there weren't the strict Federal controls.

Mr. NELLIS. I was looking at Ms. Boe's testimony in which she said in part on page 5 that:

Illustrations in medical ads, as in all ads, are designed to attract the attention of the reader. They typically depict individuals who the physician will relate his own practice-people like those he's seen in his own office. There are many women and men who show up in physicians' offices who look just like those depicted in pharmaceutical ads.

And so on.

Do you recall an ad showing a beautiful girl in a swimsuit, and I think the appelation attached to it went like this, "Swimsuit by Jantzen; body by Preludin."

Do you recall that one? [Laughter.]

Ms. BOE. I don't recall seeing that particular one.

Mr. NELLIS. Would you regard that ad as being within the confines of your ethical practice?

Mr. EVANS. And I'd like to ask along with that same question, if I may, are there any doctors, Dr. Maronde, that would believe those advertisements that Mr. Nellis is talking about?

Dr. MARONDE. I don't know what other doctors believe. We can't even agree on the time of day. [Laughter.]

Ms. BOE. I would point out to you, sir

Mr. NELLIS. I don't think any physician would see that lady in his office.

Ms. BOE. Still, the vast number of physicians are males, society being what it is. And as I said in here, "Illustrations, as in all ads, are designed to attract the attention of the reader." If you have the vast majority of them being male readers, a girl in a bathing suit is obviously going to attract their attention. That is the purpose of the illustration. Beyond that, the judgment of the ad ought to be based on what the content of the copy says as to whether it does then continue, and point out to the physician why that is a valid point. Mr. BRENNAN. That's a bad ad. [Laughter.]

Mr. NELLIS. Thank you.

Mr. DORNAN. May I point to one other ad with the chairman's acquiescence.

Here is an ad in this corner that says, "The drug that is helping her depression may be causing her constipation. Modane." And I guess this looks like a typical sad lady that we see in a lot of doctors' offices. Is this typical of the ads-if you don't get them at one end you get them at the other? [Laughter.]

I have seen people get severe headaches from what it says on the bottle they should take with some of these psychotropic drugs. And then they are subject to the pitch of the aspirin ads with the handsome, intense face of actor David Janssen telling them Excedrin really does the job.

This group here for instance [indicating], with the Gish sisters and all these little old ladies who are insomniac patients, it rivals the Russian ads of why you should love Lenin.