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formulary, in every instance I'm aware of and based upon the survey as well, is dominated by prescribers in contrast to dispensers. Usually the pharmacist serves as the executive secretary, and the typical modal arrangement was that there would be one pharmacist to eight physicians on the committee.
Mr. WOLFF. Going a step further, we have had some testimony to the effect that there have been some tie-ins between some members— and I would hope that we clearly define the fact that we are not using any broad-brush approach and in no way are we attempting to categorize the medical profession, but just those aberrations that exist within the profession that are causing a problem for the overall picture. I think one of the greatest problems we have today is the fact that people generalize a little bit too much.
Dr. RUCKER. I don't have access to Dr. Maronde's testimony of a month or two ago, but his previous findings indicated that perhaps 3 to 4 percent of the physicians accounted for 50 to 70 percent of the irrational prescribing within his particular study environment, and I would guess that's probably true in most places.
But again, nobody has the information system to enable us to identify the parameters of that problem.
Mr. WOLFF. What I was getting at is, in the course of any studies that you have made, have you found any collusive relationship between doctors and pharmacists!
Dr. RUCKER. Between the community pharmacy and the physicians ? Mr. WOLFF. Yes. Dr. RUCKER. No. I have never pursued that line of inquiry. I can cite you one example that did occur.
Mr. WOLFF. I don't think we should take one example and then use that as any delineator.
Mr. Pekkanen, could you comment on that?
Mr. PEKKANEN. Yes. When I was investigating for the book on the drug industry, I did run into examples of that. I don't know how widespread they are nationally, but I certainly heard suggestions and accusations of that nature. I think my feeling was from—and I'm working from memory now—that it was not terribly widespread, but it does exist. I also did find in some instances at least, in one detailman who I interviewed at some length, some collusion which he admitted to between himself and some doctors as well. So I don't think it's simply between doctors and pharmacies. I don't think there's any question in my mind that those things exist, but I'm not sure of the dimension. Mr. WOLFF. Thank you. Counsel will proceed now to ask questions. Mr. NELLIS. Thank you, Mr. Chairman.
Dr. Rucker, not too long ago we had an interesting hearing on Valium and Librium. Certainly these are two of the most frequently prescribed drugs for outpatients; am I correct in that?
Dr. RUCKER. Yes; the last data I've seen, Valium was No. 1 and Librium was No. 7 and I'm sure they still have that approximate range.
Mr. NELLIS. In your opinion, what proportion of these prescriptions are for medical conditions that are questionable or even beyond official indications ? Do you have any explanation for the disparity that exists apparently between these prescriptions and the number of Valium and Librium that are consumed!
Dr. RUCKER. I have not conducted any investigations trying to answer that particular question. I can cite for you two references. Some time within the last 112 years, was a lengthy article in the New York Times Magazine section entitled “Valium-mania," I believe. This article indicated that only approximately 17 percent of the prescriptions for Valium were with reference to the medical conditions that were indicated. Another study by Waldren, which I cited in my testimony which I believe is reference No. 8, indicated that approximately 25 percent of the prescriptions for Valium and/or Librium met that standard. By definition, then, the other 75 percent did not.
Mr. NELLIS. Then we could conclude, at least from those two studies and I think it's fair to say from the investigations that we have conducted—that the vast majority of these so-called minor tranquilizers that are so popular are prescribed for other than medically indicated reasons ?
Dr. RUCKER. That seems to be the correct conclusion.
Mr. NELLIS. Reasons such as stress, anxiety, the problems of everyday living, and the question the chairman asked, the business of nursing homes attempting to better control their patients. That would be a reason for prescribing tranquilizers, wouldn't it?
Dr. RUCKER. Yes; there is some documentation in a book by Mendelson titled “Tender Loving Greed,” published in about 1974. I don't recall the details, but one chapter deals with the use of drugs in nursing homes.
Mr. NELLIS. Now, you identified three factors as leading to irrational-your term now—irrational prescribing: lack of information system, casual empiricism on the part of prescribers—that is, doctors, and the absence of a record system for evaluating prescribing and dispensing patterns.
How much can this problem be reduced by adherence to a computer system
such as the one you described ? Dr. RUCKER. In essence, I have made two proposals for helping to mitigate the problem, and if you accept my definition of the National Drug Foundation and the implications here of a comprehensive record system, it's my estimate that somewhere between 50 and perhaps 70 percent of the inappropriate prescribing could be controlled by these two factors alone.
Mr. NELLIS. Now, when you say "could be controlled,” are you referring to Government controls necessarily, or are you referring to physician control, self-control by physicians?
Dr. RUCKER. At this stage in the development of these two concepts, I envision minimum Government control and maximum professional control.
Mr. NELLIS. And I take it from that we can assume that it's your opinion at least that there is a minimum of professional control as to the psychotropics at the present time. Is that a correct assumption?
Dr. RUCKER. That's a reasonably accurate statement.
Mr. Pekkanen, have you in the course of your investigations and in the course of your articles and bookwriting run across any effective means that have been suggested to you by physicians or others for better prescribing practices, better prescribing habits? Is the medical
profession concerned, in your judgment as an outside observer, about the problems we are discussing here today?
Mr. PEKKANEN. Yes; I think virtually all the people I have talked to are very concerned about it, but I would think I would have to preface that by saying I'm talking generally to people who are professors at medical schools, people who obviously have an ongoing interest in the quality of medical care generally. As I indicated earlier, I don't see I think the problem is extremely complex. I do not see where there's
a single solution. I think there are some things that could be done. It seems to me a deemphasis on the way drugs are advertised—I think, in my view, the advertising frankly has improved over the last few years.
Mr. NELLIS. Are you talking about professional advertising in medical journals?
Mr. PEKKANEN. Yes; basically this is simply prescription.
Mr. NELLIS. You're not talking about commercial advertising of over-the-counter substances?
Mr. PEKKANEN. Right.
Mr. NELLIS. Let me ask you this: In your opinion, what's wrong with the kind, quality, and nature of the advertising done by pharmaceutical companies in professional journals?
Mr. PEKKANEN. My feeling is it's done far too commercially. It's really done—I realize they are selling a product and I realize they are entitled to earn a profit and to do as well as they can, but it seems to me we are not in a situation where it's "Let the buyer beware.” This is medicine. This is something which the average person is really not aware of the implications, and I don't think the pharmaceuticals should be sold in such a blatantly commercial way.
I could cite you some old ads that have been, I'm sure, gone over before. There was the environmental depression series that Rulen ran.
Mr. NELLIS. Excuse me, Mr. Pekkanen. We have seen many of those ads and they have been exhibited in our hearings. If I understand you correctly, you're saying that there's an element of commercialism which induces medical practitioners to prescribe these drugs where perhaps they oughtn't to; is that your point?
Mr. PEKKANEN. Yes; but I think that exists. I think it's also a problem of people demanding it. I don't think you should ever underestimate the patients come in the office wanting a psychoactive drug, for whatever reason, and I think what this meets with is, on the other hand, the information the physician is receiving through the detailman and through the advertising and promotion of the kinds of problems these drugs can be useful for, and I think what you have here is a kind of meeting of the minds, as it were. On the other hand, a patient with a vague complaint, and on the other hand, advertising promotion which is of a vague nature-environmental depression for the problems of not fitting into society is a more blatant one. These are not specific indications and the doctor's office is often not getting specific complaints and I think what you have here is a very gray, vague area and what is fostered is prescribing.
Mr. NELLIS. Thank you.
Mr. WOLFF. The committee is happy that one of our most illustrious members is with us today, Congressman Paul Rogers, who chairs the Subcommittee on Health.
Mr. ROGERS. Thank you, Mr. Chairman, and I'm sorry I was not here earlier. We had some bills on the floor.
What is the most significant concern you have about the psychotropic drug use in this Nation? I would ask each of you to just briefly tell me your main concern.
Mr. PEKKANEN. Well, if I had to say one main concern, I think it's simply that they are too widely prescribed, for lack of anything else.
Dr. RUCKER. Mine is a different concern. My main concern is that the decisions are not made by practitioners in an environment of enlightened neutrality. In other words, there's too much pressure from external forces trying to influence drug use -perhaps the patient, perhaps the third party, perhaps manufacturers. I'm willing to tolerate a given degree of flexibility in professional judgment if those decisions can be promulgated within an environment of enlightened neutrality. I don't think we have attained that objective and we don't make progress on minimizing the irrational prescribing of any drug until we can start to approximate that situation where the physician makes, in essence, a best judgment based upon independent interpretation of the facts.
Mr. ROGERS. Are physicians well trained enough to make the proper judgments in this area of neutrality in the drug field?
Dr. RUCKER. In my view, they are not, and there are many reasons contributing to that. For example, the complexity of drug nomenclature is so substantial that pharmacists trying to simply record the names of the drugs found on the 52 large hospital formularies, who have far more training in this area than physicians, had an error rate of somewhere between 5 and 10 percent. Yet they are the most highly trained professionals in our society. Even under controlled conditions, we still had an error rate of handling what supposedly is a very simple function.
Mr. ROGERS. Should some effort be made to increase the education of doctors in the medical schools in pharmacology?
Dr. RUCKER. That's a very legitimate question and I'm sure it would be useful, but a few moments ago I indicated in my view the two most critical variables for improving the quality of prescribing law not in the educational component which I would rank at maybe the 10- or 15-percent level, but the ability to develop an independent information system and, second, to develop a record base that would enable prescribers to make an intelligent judgment about the consequences of their decisionmaking. These two factors alone account for between 50 and 70 percent of the problem of inappropriate or irrational prescribing, and then we ought to start going down the list. In fact, it would
be very useful if you could get a group of experts to rank these variables relative to their potential significance. But my interpretation is as I have indicated.
Mr. ROGERS. After your study, would you have any estimate of how much overprescription is taking place in this Nation? Is there any estimate that you have seen given? I know that's a difficult question, but I just wondered if you had, in your studies, made any estimate.
Mr. PEKKANEN. As far as I know, I know of no hard numbers. You hear estimates made at 50 percent, for instance. Some psychopharmacologists believe that 50 percent of the psychoactive drugs in this country are unnecessary. Some people place it higher and some people place it lower. In many cases, it's a value judgment of what is appropriate.
Mr. ROGERS. Then until we begin to determine that pattern, perhaps computerize it, it will be difficult to get on top of the problem?
Mr. PEKKANEN. Yes; in my view it will. I would just like to add a comment to a previous question you asked about medical school training. I think one of the things that I found in talking to medical school people is that the basic training that a physician gets in prescribing is in his residency or internship, and the influence there is basically the senior resident; and as a medical school dean told me, he said, "It is very crucial.” That is the crucial aspect of his training. If he happens to be with a very cautious prescribing senior resident, he's likely to follow that pattern. On the other hand, if he's with somebody who's much more promiscuous in his prescribing of drugs, he's likely to adopt that pattern. So it's possible you could have two different medical students with two different senior residents who would come out with two different views of how to prescribe drugs.
I also think there's a lot of room for solid information, but I think habits are set early for prescribing and physicians usually maintain those habits by and large for a number of years.
Mr. WOLFF. Thank you, Mr. Rogers.
I'm prompted to ask Dr. Rucker, when you think about the recommendations made by Dr. Bourne, that of outlawing amphetamines made by Dr. Bourne, that of outlawing amphetamines and barbiturates, since they have very narrow
Dr. RUCKER. I would prefer to let those trained in clinical pharmacology and clinical pharmacy make that judgment. I don't think it's appropriate that I make that judgment. If you'll ask me from a personal point of view, I would include them in the system because if they are inappropriately used one can monitor that problem and take remedial action. If you outlaw them, then you drive the whole problem underground and when it surfaces it's often too late to correct it.
Mr. WOLFF. Thank you, Mr. Mann.
Mr. Mann. You referred earlier to what, in effect, was a climate of pressure or nonneutrality on a physician for the prescribing of these tranquilizer drugs. Does it not almost rise to a level of just order taking? The patient in effect tells the doctor what they want and that's what they get ?
Dr. RUCKER. Well, there is some evidence in the literature to indicate that the influence the patient has on the prescriber is not nearly as great as thought previously. I can cite the work of Dr. Peter Parrish who did a study of this problem in Great Britain. There are others who point out that when the patient violates the compliance instructions at the level of 40 and 50 percent, it's hard to substantiate the theory that the patient is bamboozling the physician to provide these medications. So there is some contravailing evidence and it's difficult to isolate those dimensions of patient influence on prescribing practices. It's a very critical question because if the problem is the patient, then we ought to develop remedial programs to pursue this source. But from a methodological point of view, it's very difficult to establish the extent and dimension of patient influence. Patients do, of course, account for some of the problem, especially when they go shopping from