cated." Scientists taking the over-medicated position point to such factors as: amount of drugs being manufactured vs. the number being prescribed, the intense market competition among pharmaceutical companies, the large amount of money spent on advertising the psychotropic drugs, the increase in long-term use of the psychotropics and the increase in adverse drug reactions (Parish, 1974; Seidenberg, 1971). Other scientists in this camp express concern for the use of psychotropics for relief of everyday stress symptoms when in fact the drug by providing only temporary relief may actually hinder the exploration of effective solutions to stress-provoking situations (Lennard and Epstein, 1970; Muller, 1973).

Those scientists assuming the "under-medicated" position (Burrell, 1972; Kallir, 1972) emphasize that few Americans use psychotropics regularly. One study found only 5% of the men and 10% of the women used psychotropics on a daily basis for at least two months (Mellinger et al., 1974). These scientists also argue that their surveys find the American public holds stoic attitudes towards psychotropic drug usage. For example, in their national survey 87% of the respondents thought will power was a better way of solving problems than tranquilizers (Manheimer et al., 1973).

Perhaps the best indice of whether or not the use of psychotropics is becoming a social problem is to review the number of cases of accidental deaths, poisonings and suicides occurring from these drugs. The National Institute on Drug Abuse monitors the emergency room occurrences of drug problems in 24 major cities in the U.S. Of the top 26 problem drugs in the U.S. the majority are psychotropic drugs available by prescription. The most frequent drug reported in emergency episodes involved a minor tranquilizer-diazepam or Valium. Another study reports that 20% of all admissions to a large urban hospital involve serious drug abuse the majority of these patients abusing legally available drugs, in most cases psychotropics (Maronde et al., 1972).

SOURCE OF PSYCHOTROPIC DRUGS

Even though the prescription psychotropics are listed as Controlled Substances according to the Drug Control Act of 1970 (most stimulants and sedatives are Schedule II; minor tranquilizers, Schedule IV) most drug users report little difficulty in obtaining prescriptions for psychotropics. The majority of users report the general practitioner as the source of psychotropics (Manheimer et al., 1972; Cooperstock and Sims, 1971). Even if the user develops additional sources for psychotropics as dependency increases, the initial source of the drugs is most likely to have been a physician (Whitlock, 1970). In addition to obtaining a prescription from physicians, users also report obtaining prescriptions from other medical personnel such as dentists and veterinarians.

The significance of obtaining a psychotropic drug via a prescription is twofold. First, prescription psychotropics users tend to use psychotropics for a longer period of time, more consistently, and more frequently than users who had to resort to other sources. (Mellinger, Balter, & Manheimer, 1971). Second, the use of psychotropic drugs obtained from a physician's prescription is likely to be perceived by the user and his/her family and friends as legitimate and therefore necessary.

THE ROLE OF THE PHYSICIAN IN PSYCHOTROPIC DRUG USE

The American physician plays a vital role in the psychotropic drug use of this country. Three areas will be discussed: (1) the limited knowledge about psychotropic drugs accessible to physicians, (2) the use of prescription-writing as a means of coping with patients and (3) the problems of multiple and refill prescribing practices.

LIMITED KNOWLEDGE ABOUT PSYCHOTROPIC DRUGS

Psychotropic medications have been on the market for approximately twenty years with new drugs appearing every year. Physicians trained prior to 1958, may have had limited formal training with these drugs and may rely upon informal sources such as information from detail men and word-of-mouth reports from colleagues. General practitioners (who are the specialist most frequently prescribing psychotropics) report that data supplied by drug companies represent a major source of drug information for them (Johnson, 1972). The amount of time

physicians spend per week discussing drugs with detail men has been increasing (Bauer and Wortzel, 1966). A survey of medical schools indicated that only 20 percent included formal courses on clinical psychopharmacology while the remaining medical schools had less than ten hours devoted to the subject (Bauer and Wortzel, 1966). Two recent studies have documented the limited knowledge that physicians have concerning psychotropic drugs (Weiner and Schumacker, 1976; Gottlieb, Nappi, and Strain, 1978).

Physicians who rely upon detail men, the Physicians' Desk Reference (PDR), or drug advertisements in medical journals for their information about drugs receive limited if not biased data because all these sources are prepared by the pharmaceutical companies which are dedicated to increasing sales of these products. Advertisements found in medical journals have been strongly criticized for their encouragement of psychotropic use for resolving tension of everyday life (Lennard and Epstein, 1970; Seidenberg, 1975) and for their stereotypical portrayal of women needing psychotropic medications to relieve nervous tension more frequently than men (Prather and Fidell, 1975; Seidenberg, 1975).

USE OF PRESCRIPTION-WRITING AS A MEANS OF COPING WITH PATIENTS

The writing of a prescription for a psychotropic may be influenced by a variety of factors. For example, one study found that physicians who did not tend to prescribe psychotropics frequently vs. those physicians who did write prescriptions had a better education and perceived the patient as a whole entity (Joyce, Lost and Weatherall, 1967). Physicians report writing a prescription for a psychotropic under these circumstances: the physician has difficulty relating to and talking with the patient (See Cartwright, 1974); the physician did not know what else to do for the patient or was pessimistic about other treatment (Shader, Binstock and Scott, 1968); or the patient reported only vague symptoms (Cartwright, 1974). One writer has suggested that writing a prescription serves as a means for the physician to terminate an office visit. This act then satisfied both psysician and patient that some service was performed by the physician (Muller, 1972). And finally, physicians are often under pressure to prescribe psychotropics for their family and friends. This situation is particularly difficult because failure to write the prescription or to recommend the refill may result in social ostracism: (In my research, a physician commented he found it difficult to refuse to write a re-fill prescription for a psychotropic when his medical partner had written the original prescription).

THE PROBLEM OF MULTIPLE AND REFILL PRESCRIPTIONS

The physician can contribute to the potential for psychotropic misuse/abuse through multiple prescribing, prescribing excessive dosages, and by continuously refilling prescriptions. Multiple prescribing occurs when a patient receives a variety of psychotropic prescriptions from one or several physicians. The situation is compounded if the various involved physicians fail to verify whether or not the patient has received other prescriptions for psychotropics or if the patient conceals such information from the physicians. The potential for over-use, drug dependence or drug interactions increase with multiple prescribing. Estimates of the frequency of multiple prescribing are difficult to ascertain because physicians do not have an adequate method of determining what other prescriptions have been written. (cf Maronde, 1972).

Prescribing excessive dosages is the situation when the physician orders a prescription larger in quantity of dosage than what might be considered safe or is more than the amount or dosage actually required for the patient. One study indicates that this practice among physicians is not uncommon and was most likely to occur with psychotropics-sedatives and tranquilizers (Maronde et al., 1971). Repeat or refill prescriptions can represent serious misuse potential dependency if the patient continues to seek a refill and the physician continues to grant the refill without verification that the medication is indeed still required. Psychotropic refills represent a special problem because the possibility of dependency occurring increases as the need for stronger dosages increases with continuous and prolonged usage. Perhaps the most serious misuse of refills occurs with the minor tranquilizers which are on Schedule IV of the Controlled Substances List. A physician can write a prescription for up to 5 refills in six months without any additional contact with the patient.

The pressure exerted by the patient upon the physician to refill a psychotropic may be very intense particularly if the patient has developed any kind of dependency upon the drug-physiological and/or psychological. One physician described the refill dilemma as representing a collusion between physician and patient. The patient feels he needs the medication and the physician believes he cannot refuse the request without replacing the prescription with some other remedy. The physician, unable to suggest a viable alternative orders another refill (Balint, 1970).

DIFFICULTY IN ASCERTAINING SAFETY OF PSYCHOTROPIC DRUGS

The safety of drugs is difficult to ascertain: often drugs placed on the market as innocuous, later prove to have serious side effects or difficulties that only emerge after prolonged usage or after a history of use in society. Newly introduced psychotropics are continually subject to this problem. One can note, for example, the hazards of barbiturates or amphetamines that were delineated only after their introduction in the market.

The safety of drugs is first ascertained with so-called controlled experiments involving animals and/or humans. Using controlled experiments can measure physiological tolerances of drugs and measure "safety margins"; however, these experiments do not take into account the behavioristic or human factors which affect usage. The patient ingesting a psychotropic medication rarely uses the drug as precisely or methodically as the patient in the controlled setting. Other factors may affect the "safety" of the drug such as the patient's health, nutritional patterns, fatigue level, use of other medications, consumption of alcohol, etc. Thus, to assert a drug is "safe" based upon controlled experiments can be misleading.

PROBLEMS WITH SPECIFIC CATEGORIES OF PSYCHOTROPIC DRUGS

1. Sedatives

The sedative-hypnotics have the highest usage among elderly people, ages 60 and over. Further information is needed to answer such questions as: Do the elderly need sleeping aids because of insomnia? Or does their pain prevent sleep? Do the elderly actually require as much sleep as younger people? Do nursing and convalescent homes routinely administer sleeping aids as a means of controlling or of coping with patients? Does the use of sleeping aids represent a tendency towards boredom?

2. Stimulants

The majority of the stimulants available on the market (Eskatrol, Dexamyl, Biphetamine, Dexedrine, Pondimin, Didrex, Tenuate) are listed in the PDR for the treatment of obesity. Yet, the weight loss claim of these drugs in the PDR include cautions such as "possible effect for short term weight reduction adjunct with regimen based on caloric restriction." "Limited usefulness of agents of this class should be measured against possible risk factors inherent in their use such as described above."

If the pharmaceutical companies in the PDR state the lack of evidence for the long range usefulness of stimulants in controlling obesity, why are these drugs still manufactured? It is well documented that these drugs are sought by street users and are highly dangerous and addictive substances, yet pharmaceutical firms are still allowed to manufacture these drugs at a rate that is higher than their use would demand. Why?

3. Minor Tranquilizers

The use of minor tranquilizers, especially, diazepam or Valium is becoming so popular that the brand name Valium has become synonymous with tranquilizer. Valium is so widely used one writer refers to the presence of a Valiumania (Cant, 1976). Throughout the medical community as well as the general public is the belief that Valium is "safe." Yet this term is misleading. Safe for the medical community may mean that Valium is safer than other medications prescribed for the same indication such as sedatives or barbiturates or safe for medical personnel may mean safe as long as prescribed or directed. And safe can also

mean the drug is considered safe as evidenced through controlled experiments. The problems with labelling a drug “safe" is that possible misuses, abuses, or side effects may be overlooked. For example, if Valium is safe, how can one account for Valium being the number one drug used by persons reporting to emergency rooms for drug problems? Valium does not continue to be "safe" wher taken in conjunction with alcohol or other drugs, or in large quantities, or for prolonged time. Yet, the general public and the medical community tend to ignore these warnings and maintain the perspective that Valium is safe.

To illustrate, in a recent study 50 Valium users (who averaged taking 16 mg. per year for an average of 26 months) described their side effects and symptoms with continuous use of Valium. Forty percent of the physicians reviewing the patients' records rated them as "moderately addicted." When physicians were informed that the drug was Valium, only 10 perent rated the same patients as having "moderate addictions." In fact, some physicians stated, "Oh, it's only Valium." (Maletzky and Klotter, 1976). In other words, physicians changed their evaluations of symptoms when they knew the drug was Valium.

Drug Evaluations (published by AMA) also refers to the word "safety" in discussing diazepam in the section on anti-anxiety drugs:

Overdose with benzodiazepines is less likely to result in coma, circulatory failure and death than overdosage with barbiturates or sedative-hypnotics. Indeed the wide margin of safety of the benzodiazepines virtually precludes their successful use for suicidal purposes. (412)

Does the above description sound like a drug responsible in 1976-77 for 900 deaths and 54,400 emergency room visits?

The Physicians' Desk Reference advocates the use of diazepam or Valium for the treatment of alcoholism at the same time pointing out that the drug should not be consumed with alcohol.

The Physicians' Desk Reference does elaborate various warnings about the use of diazepam which do not appear to be recognized by physicians. Does the following warning about Valium use (listed in the Physicians' Desk Reference) represent a drug, one would consider to have a wide margin of safety (as described by the AMA)?

Withdrawal symptoms similar to those of barbiturates and alcohol following abrupt discontinuance of diazepam.

In summary, the general public as well as the medical community has accepted a belief that Valium is "safe" without taking into account the inherent dangers of use of this drug in combination with alcohol or other psychoactive drugs, or for prolonged lengths of time, or in large quantities.

SUGGESTIONS FOR MEMBERS OF CONGRESS CONCERNED WITH PRESCRIBING PRACTICES OF PSYCHOTROPICS

1. Advocate that medical schools provide more extensive courses on psychopharmacology for medical students and refresher courses for practicing physicians concerning psychopharmacology, the treatment of stress, drug interactions, and drug side effects,

2. Sponsor information available to consumers on the use and misuse of psychoactive drugs, particularly minor tranquilizers. Specifically discuss the notion that Valium is not safe under all circumstances,

3. Provide information accessible to medical personnel on the various warnings, indications and counterindications of drugs-information not sponsored by the pharmaceutical industry,

4. Require labelling of all psychotropic medications-sedatives, tranquilizers, and stimulants to include the following warnings:

(a) Do not consume with alcohol

(b) Do not take in conjunction with other medications including overthe-counter varieties without checking with your physician

(c) Do not take for long periods of time without consultation with physician.

5. Investigate the feasibility of moving minor tranquilizers to Schedule IV. 6. Investigate the reasons for the continued production levels of amphetamines in spite of evidence of their limited effectiveness in controlling obesity.

7. Investigate feasibility of establishing a central drug record bureau to check for multiple prescribing of psychotropic drugs.

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