ficially and incorrectly identified these legitimate drugs as "soft" and other illicit drugs, which may in fact be less hazardous to mind and body, as "hard." I think it is time we view the "drug problem" in this country as an interrelated phenomenon that has roots in many areas of our lives. Thank you.

I would be happy to answer any questions any members of this committee might have.

Mr. NELLIS. Thank you, Mr. Pekkanen. In accordance with the chairman's instructions and because there are three more suspensions after the one that just concluded, we will take a recess until the committee members return.

[Recess.]

Mr. WOLFF. The committee will come to order.

I continue to have to apologize for my earlier absence from this hearing. I did not want to have you people come in here and then cancel the hearing today because of the pressure of other business in the House. However, we just had five votes and we anticipate another seven votes. I must say that it is kind of difficult to do both jobs at the same time. I might tell both of you gentlemen that we have been conducting an investigation in the environs of New York on the prescribing, the overprescribing, and treatment that is afforded in some of the adult homes and the confusion that exists in some of these adult homes today in the prescribing of various of these psychotropic drugs.

I wondered if you, Mr. Pekkanen, had any experience in this connection in the writing of your article on the "American Connection." Did you look into this area at all?

Mr. PEKKANEN. No. Congressman, I did not. I did not specifically look into the practice of nursing homes and I really have no specific knowledge on what goes on there.

Mr. WOLFF. Dr. Rucker, would you have any information on that? Dr. RUCKER. Yes; I have one unreported study that a master's student did on drug use in nursing homes under my direction several years ago. Before beginning the study the student prepared a model formulary for three therapeutic categories, one of which was psychoactive preparations, and the model formulary included 61 preparations. Then we had access to a firm which serviced 11 nursing homes exclusively no other business was transacted. We compared the model formulary to the drugs prescribed during the preceding 5 months as well as the inventory, and there was a redundancy factor of 75 percent with respect to the relationship between the formulary and the drugs actually prescribed during that 5-month period.

If one makes the assumption that the drugs that were in inventory had been prescribed some time during the period prior to the 5-month survey, the redundancy factor increased to approximately 80 percent. Therefore, in one survey, we see that people in nursing homes were not receiving very discriminatory treatment, at least with respect to therapeutic criteria relative to the most appropriate medications.

Mr. WOLFF. One aspect that we have developed in the course of this investigation has been the employment by the various homes of a particular physician to service the home and the individual clients or the patients in these homes who had their own doctors as well. That goes to the redundancy of the prescribing-of two doctors prescrib

ing for the same patient and the actual dispensing of the drugs themselves is done by, in some cases and one of our investigators is here right now-done by someone who cannot even read, who is someone who is totally without language capability. Now that, to my mind, is a serious problem and it indicates the fact that there is less than judicious care being rendered some of those people.

The basic reason why this hearing has been held and why we have started to look into this question is the feeling on the part of many of the people on this committee that there exists an even larger licit drug population than there is an illicit or illegal one. I wonder if you would, Dr. Rucker, care to comment upon that.

Dr. RUCKER. Well, several years ago I made a statement to the effect that based upon my discussion with people across the country that approximately two-thirds of the problem of abuse was indeed within the licit area that you are concerned about. The basis for that statement was simply discussion with physicians and other practitioners across the United States where the range went from 0 pertaining to one instance here in Washington, D.C., to more than 90 percent, and I endeavored to average those various impressions.

I think it's more critical, however, for the committee to consider the fact that we all lack the kind of data base that would give you the precision that you would like to have before the Congress makes judgments about any remedial program. Without a comprehensive data base, all remedial efforts are suboptimum. In fact, I have some data here that I obtained from a professor at the University of Pittsburgh back in 1966 I believe. This computer printout represents the prescribing by one physician for one patient as dispensed by one pharmacy during 1 year. Without a model information system, though, we have no way of appraising the dimensions of those problems.

Mr. WOLFF. As well, in that particular category, is the question of control of these substances, in having some centralized reporting agency to give you the data base. Within certain communities we find that people who are within the licit drug abuse pattern are using illicit methods in order to beat the system, whereby they get two prescriptions or three prescriptions and then take them to two or three different pharmacies to have them filled.

Dr. RUCKER. While you were gone I outlined a model information system that would close that information gap so the patient could not shop from pharmacy to pharmacy, physician to physician, or area to area. These professions would have the ability to monitor the use of drugs throughout the United States based upon a clearinghouse mechanism involving some 8 or 10-perhaps 40 or 50-regional locations where the professions would have access to patient profiles and would be able to monitor and hopefully control that situation.

Mr. WOLFF. Of course, that almost gets us to 1984 and I think that's something about which a great many people are concerned. Under the freedom of information law that exists today your whole medical profile then would be available to anyone who sought to get the information through that data bank.

Dr. RUCKER. That's a very relevant question but, again, you were not here when I drew the double line the double line there on the bulletin board suggests that the ability to monitor that problem from a control

point of view would be limited because professional criteria would govern the release of the data.

I think there's an intermediate point that society should consider as represented by this concept of a national clearinghouse for prescription records based upon regional coordination and professional control within the regional areas.

Mr. WOLFF. Mr. Pekkanen, would you comment on the question of the licit as opposed to the illicit market?

Mr. PEKKANEN. Yes. I think certainly if you include alcohol in the licit, there's just no question that the overwhelming drug problem in this country is from licit sources. Even exclusive of alcohol and just including prescription, licit prescription drugs, it's been my impression certainly that that is a larger problem than the so-called illicit problem of heroin, cocaine, and other illegal drugs. In other words, the numbers of people reached by the problem of misuse or abuse of licit drugs is a larger number.

I think one problem we often have is that the problem of licit drug abuse or overdose is often hidden. In other words, because often it relates to middle-class people and often they are treated by their physician or in a hospital setting in which their drug problem is not reported to police as it might be in the case of an illicit drug, therefore, I think there is a submerged problem that goes on that doesn't really become as visible. The instances you can think of are the HaightAsbury instances of LSD and hallucinogens. That was very visible to all of us. Yet the other kind of problem, which is quieter, which I refer to as the gray market of abuse, goes on and is not quite as visible to us, but it exists and I think in large numbers.

Mr. WOLFF. Now we have been trying to cut off the supply of most of the drugs that are abused and cause dependency in the United States through agreements with foreign nations and the like. This gray market, however, that you talk about is a very real one in providing not only for the people to whom or for whom these drugs are intended, but for the family members as well. That open medicine cabinet provides a very ready access for the young people to be able to use it as a source of supply in trading for other drugs.

How do we close that gap? How do we close this gap that exists today between the real need and abuse. There is a very real need— at one time I was tempted to say there's really no good drug, and then I caught myself and said, "You can't say that because there's a very real need for many of the drugs that are within this licit market that accomplish great benefits to mankind." Without them, perhaps mankind could not exist as it exists today. But it is the ancillary use or the ancillary areas that are involved that we are trying to find some way or means of controlling.

Now the one method that Dr. Rucker has clearly indicated certainly is something that should be given consideration. But, we are faced with another problem. Even though there are lists of controlled substances, much of what is done within the dispensing area and in the control of the prescription writer and the like are within the province of the State governments where you have your State boards operating. These are not within the province of the Federal Government.

Therefore, although we can take a lead, we cannot make that determination since under the police powers the States have the ability to exercise the control.

I wonder if you have any suggestions, having been out in the field and looked at this, looking at the trees distant from the forest, whether or not you can give us a layman's view of a better approach than that that has been articulated to this committee.

One fellow comes in and says "Put everybody in jail," but we wouldn't have enough jails. We would have to have the straight people in the jails and everybody else on the outside. Where do we go from here?

Mr. PEKKANEN. That's a very, very difficult question. I think obviously it gets very narrow because I think it comes down essentially to the physician because he's the basic conduit through which the drugs are distributed.

I think one of the fundamental problems I found in my interviewing of medical school teachers who teach psychopharmacology and I think are well equipped to understand the problems is that you have a very difficult problem in getting sufficient and solid indications for psychoactive drugs. For antibiotics you can take a culture and you can more precisely isolate the problem and therefore prescribe a drug which more precisely attacks the problem.

Psychoactive drugs are almost by their nature vague and often people articulate a sense of loneliness or depression, and what I'm really trying to say is that the symptoms are often vague and the prescription that responds to that is often not well thought out and vague, and I think, in part, that has to do with the fact that it's the nature of the beast, and the other part has to do with the fact that I do not think physicians are well equipped by their training, education, or by the data they have at their hands to really make careful, thoughtful prescriptions regarding phychoactive drugs, and I think there are a lot of other pressures that I spoke about which are the demands of patients themselves and physicians are put in a difficult economic bind at time by patients who want a drug, and a physician realizes that if he does not prescribe that drug, that patient may well leave him and therefore he's losing a source of income. I don't mean to make physicians out that they are simply looking at their patients as a source of income, but I think it's a real problem that can happen.

I think as the studies I have seen seem to indicate, that as physicians know more about drugs their prescribing habits are improved. In other words, I believe the figure is 85 percent of psychoactive drugs are prescribed by general practitioners, yet a proportion of psychiatrists will prescribe less drugs than their numbers indicate, and psychiatrists in my view seem to know probably more about psychoactive drugs than the other branches of medicine.

So I think it's a very, very complex, interrelated problem in terms of education, patient demands. If there were a magic bullet solution, I would like to know it, but I don't think there is. I think it's in large part a societal problem."

Mr. WOLFF. Dr. Rucker, has medicaid contributed to the spread of the so-called licit market for drugs? As a medical economist, I just

wonder whether or not you could give us your opinion on that? In other words, if I could paraphrase that for a moment, with the ability of people to gain certain medical services under medicaid, have we increased the availability of drugs to the consumer? Have we made it easier, for example, for the physician to treat a problem with a palliative rather than a cure? Maybe that's two separate questions.

Dr. RUCKER. That's a very complex question, but I think one bit of evidence can be cited. There are, of course, other dimensions to the problem. In reviewing the proportion of inferior drugs carried by 52 large private hospitals

Mr. WOLFF. Excuse me for a moment, but could you define what you consider inferior drugs?

Dr. RUCKER. Yes; we employed five independent measures of therapeutic discrimination. The first one pertained to the FDA list of little or no therapeutic gain, and that measure is somewhat different than the other standards. The second area pertained to the U.S.P. list of drugs that never got on the U.S.P. because they were regarded as dangerous or ineffective products. In addition, we reviewed the Medical Letter and dichotomized the drugs that they reviewed into useful preparations or not necessarily recommended. So we used the Medical Letter analysis to prepare another list of products that were questionable or inferior. In addition, we reviewed the DESI list of the FDA and found some 190 preparations that were regarded as ineffective not possibly ineffective or probably ineffective, but just ineffective. The final measure was a list, of 1,530-some combination products that, based upon the judgment of our staff, had little or no redeeming therapeutic utility.

On the basis of those 5 independent measures of negative therapeutic discrimination, we evaluated 52 large hospital formularies. In measuring the proportion of those inferior products carried in these hospitals, we found out that the average-the median-performance level was 20.2 percent. In examining the 9 medicaid formularies that could be studied-although there were 12 in our survey, we had to disregard 3 because the scope of benefits were in question-we found the median performance level of inferior preparations carried was not 20 percent, but very close to 40 percent.

Then the question becomes: What proportion of those psychoactive preparations were really represented within our area of negative discriminators? I have tried to provide you with some suggestion that this problem is not insignificant in the tables submitted with my testimony today.

Based upon that limited evidence, I would have to say your hypothesis has merit and indeed further investigation might prove that it is sustainable.

Mr. WOLFF. I know at one point in your testimony you did indicate that you found a relationship existing between physicians and the pharmacies in certain institutions. Am I correct in that? Was that what you were saying? I believe in the first part of your testimony you said something like that.

Dr. RUCKER. I think you may have reference to the fact that the pharmacy and therapeutics committee, which is the decisionmaking body pertaining to the list of drugs that will be approved for the