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Second, it is now a clear majority of States-and I'm not sure how long it will be before all States will have a requirement for continuing education that is the equivalent of that which is required by State medical associations in order for recognition in continuing medical education. These are conditions for licensure.

Mr. MANN. There again, the AMA does not impose that type of requirement on a constituent body?

Dr. BOYLE. The AMA did take a leadership in this area, however, in that it's now about 12 years ago that we established what's known as the Physician's Recognition Award, which was one in which individuals were encouraged to engage in continuing education and encouraged to report this continuing education to the AMA and be so recognized. We also have been very actively involved in the process of evaluating and accrediting courses in continuing medical education to the extent that whereas approximately 13 years ago there were about 1,000 such accredited courses there are now over 8,000 such courses being conducted.

Mr. MANN. All right. Now, in like manner, you have established ethical standards which again come in the form of recommendations from AMA to constituent bodies, or are they a prerequisite for membership of a county association in the AMA?

Dr. BOYLE. Adherence to the code of ethics is presumed to be a prerequisite for membership. Unfortunately, Mr. Mann, the enforcement of the code of ethics in AMA or a State or local society becomes a very difficult thing for the simple reason that the instant that one attempts to discipline a physician based upon that code and in any way restrict his privileges as a member in the association once he'd been accepted, you find yourself in court. Not only do you find yourself in court but you lose.

Mr. PETERSON [interrupting]. Sometimes with Federal agenciesDr. BOYLE. And with Federal agencies, as well, the Federal Trade Commission.

Mr. MANN. In attempting to determine the role of AMA and the role that AMA might play with reference to psychotropic drug problems, am I to assume there's no way that the American Medical Association is going to impose any standards for the prescribing of psychotropic drugs through any type of mechanism?

Dr. BOYLE. We have no means at the moment of imposing a restriction on an individual physician's ability to practice. We certainly have the ability to provide recommendations to State and local societies with respect to how they go about evaluating the performance of their members and what they do if they observe aberrant behavior. Mr. MANN. But you have not done that with reference to the details of medical practice?

Dr. BOYLE. Wait a minute. You're talking about two different things.

Mr. MANN. I'm talking about another thing now.

Dr. BOYLE. You're talking about establishing standards of individual physician practice. I think that's something that we would oppose writing some kind of a cookbook which says for "x" disease you need "x" number of drugs.

Mr. MANN. That's what I'm getting at. There's no way you're going to get around to doing that. Does it appear unnecessary that the Fed

eral Government, for example, limit the time and size of prescriptions for psychotropic drugs to 50 pills or 60 pills for 30 days instead of 90 pills?

Dr. BOYLE. I think what you would be doing is to say the Congress of the United States is going to make the individual judgments that should be left to the physician who is taking care of an individual patient. There are some patients for whom that might be entirely appropriate. There are some patients for whom it would not be appropriate. There are some instances in which the mode of therapy or the kind of therapy you want to prescribe could all of a sudden very drastically change. I'll give you just one simple example, and that is that nowadays for the treatment of people with transient ischemia of the brain due to atherosclerosis in the neck, the primary mode of therapy is aspirin. You would have been laughed at if you said that 10 years ago. Many of these major drugs have sudden drastic change in their indication. Dylanton is one of them. I noticed in one of the documents that you were given today as part of testimony that there has been an almost tripling in the use of anticonvulsant agents, one of them being Dylanton, and one of the reasons is that Dylanton is now used for the treatment of heart arrhythmias and neuralgia. The dose and use of these drugs have drastically changed. I don't think the Congress would ever want to get into the position of making those judgments.

Mr. MANN. At the same time, I think there may be a general misapprehension about the effectiveness of the AMA with respect to the disciplining of their members or controlling medical practice in it to any degree. You're virtually powerless.

Dr. BOYLE. We can influence medical practice but as far as regulation, that is something that has already been preempted by the State. They license physicians. We do not. Now we have, I believe, in virtually every State in this country supported those changes in the medical discipline act which would make individual physicians more accountable. We have sought the means repeatedly to see to it that we were able to report without a fear of retribution to the regulatory agencies. We have supported legislation to give immunity to hospital committees, to medical society committees and individual physicians and other agencies in reporting so they would not become the victims of vicious suits when they try to act in the public good.

Mr. MANN. Thank you very much.

Mr. WOLFF. We'll have to suspend now to vote. When the committee resumes after the vote Mr. Rangel will assume the chair. [Recess.]

Mr. RANGEL. The hearing will resume. Mr. Gilman.

Mr. GILMAN. Thank you, Mr. Chairman.

Gentlemen, there was some testimony that was given earlier in which you stated that you didn't feel that overprescription by physicians was too great a problem. I have before me a March 2, 1978, article from the Los Angeles Times and I believe, Dr. Freedman, you're from California

Dr. BOYLE. No; I am.

Dr. FREEDMAN. I'm from Illinois.

Dr. BOYLE. I'm from Los Angeles.

Mr. GILMAN. In which they state that hundreds of California doctors have become the main illegal supplier of dangerous drugs to

thousands of young people across the State. The Times has foundincidentally, the title of this article is "California's New Drug Pushers." "The president of the State's division of medical quality estimates there are between 500 and 1,000 of these drug pusher doctors in California. They are illegally giving out close to a million pills a day and they do it by writing prescriptions for anybody who can pay their fees. They operate in almost every community. Many doctors know who they are but will not expose them, said Eugene Feldman, president of the division of medical quality. It's a brotherhood code. Turn your back or get sued, he told the Times. Although it's estimated that less than 2 percent of the State's doctors are involved, narcotic agents say doctors now illegally supply about 90 percent of all pharmaceutical drugs out on the street and some of these doctors earn $1,000 a day writing illegal prescriptions for anybody who can pay the $10 or $20 fee, preferably in cash, and if it's not cash it's medical and the taxpayer foots the bill."

Now, Dr. Boyle, you're from California. Were you familiar with this series of articles by the Los Angeles Times?

Dr. BOYLE. Yes, Mr. Gilman.

Mr. GILMAN. What has the AMA done about this kind of report? Dr. BOYLE. First of all, as far as the report is concerned the AMA has no need to become involved in that because the California State Medical Association is very actively involved.

Just to make a couple of observations one, Dr. Feldman is not noted for moderation in his statements. The California Medical Association as well as the Los Angeles County Medical Association has challenged Dr. Feldman to provide us with the information on which was the basis of these statements. We are aware of the fact that there are a small number of doctors in California, just as there are small numbers of doctors all over the United States in metropolitan areas, who are actively involved in this kind of illicit practice.

There was earlier this year in California, to the best of my knowledge, five physicians practicing in the San Fernando Valley area who were indicted for just that kind of practice. Wherever this is identified, these persons would be reported to the state board of medical quality assurance. In this instance, they should be reported to the State attorney general or to the local district attorney in the county in which they reside because that kind of practice is something which should be prosecuted, and whatever the penalties are they should be imposed. The State medical association is actively involved in trying to determine what is the validity of that statement and where these numbers come from. If Dr. Feldman is correct, then it means that the State board of medical quality assurance is just not doing its job because those people should be before the State board.

Mr. GILMAN. Well, I note in your opening statement you state that the AMA has a longstanding interest in the use of all drugs and that the AMA is concerned about the proper use of drugs and the proper proliferation of drugs and is trying to do something about it.

I have before me a NIDA report dated May 1978 entitled "Top 26 Problem Drugs in the United States, Based on Statistics," and I'm quoting from just a short paragraph: "Gathered in 24 cities between May 1976 and April 1977, the National Institute on Drug Abuse has developed the following national estimates on drug-related deaths in

emergency treatment for the 26 most abused drugs." There were an estimated 8,000 deaths in 284,000 emergency room visits related to drugs. Prescription information is included to put these statistics in perspective and I'm just going to quote a few of the statistics. They cite Seconal to have had some 7,400 emergency room visits with some 1.5 million estimated prescriptions in that year period and some 67 million estimated pills that were prescribed with about 1,100 emergency room visits per 10 million pills and resulting in some 37 deaths per 10 million pills.

With regard to benzodiazepines, Valium, 54,400 emergency room visits, some 900 estimated deaths for single and combination drugs, estimated deaths from single drugs were 50, some 57 million prescriptions in that 1 year period, and 3 billion-3.2 billion pills estimated to have been prescribed in that year period. Quaalude, some 5,500 emergency room visits, 100 estimated deaths, single and combination drugs, 1.3 million estimated prescriptions in the 1 year period.

Certainly you're probably familiar with these statistics. They seem to indicate to me that there's an overprescription and an overuse and it seems to me that the medical profession certainly should be doing more than it has been doing. What are you doing to prod your physicians, your State societies, to pay closer attention to this problem? Dr. BOYLE. First of all, if I may make a comment, that is, that the data that you're quoting does not relate actually to the total use of those medications.

Mr. GILMAN. No question. It's not the total use. I said it's gathered in 24 cities only.

Dr. BOYLE. I understand that. I'm not talking about that total. I'm talking about the total use of drugs in those cities. In Los Angeles, for example, I know from my children's experience that they could go out on any street corner and buy Secondal any time they want it and that's where the majority of those people who are drug overdosers occur from.

Mr. GILMAN. Then the Times tells us that the drugs out on the street, 90 percent of them are due to physicians.

Dr. BOYLE. We have challenged that data and the Times has not made that statement. Dr. Feldman, who is a member of the State board of medical quality assurance has made that statement, without any basis that we know of other than just to make that statement.

Mr. GILMAN. They recite, for example, in the Times, one doctor's impact can be staggering, according to court records, which show pills prescribed here sometimes wind up in the hands of large-scale dealers in Las Vegas, Seattle, Chicago, New York, and Miami, and they recite a few examples. A Los Angeles doctor working with a criminal syndicate wrote prescriptions for more than 1 million pills delivered to his confederates by the box load and they cite another example where nearly 200,000 pills were seized in the office of an Oakland doctor who confessed to indiscriminately and recklessly dispensing huge quantities of drugs over a 22-year period. A San Francisco physician was caught driving a panel truck load of 1.7 million amphetamines destined for the street. A west Los Angeles doctor sold thousands of prescription blanks to a dealer who filled them out and got the drugs and sold them to criminal syndicates in Las Vegas and New York. A

second San Francisco doctor wrote 5,000 prescriptions for 133,000 pills in a 90-day period, according to a Federal study of 13 San Francisco pharmacies.

It's true that it's not widespread, but cretainly even a limited number of your physicians doing this has a vast impact. What are you doing to try to discourage that kind of activity? What are you doing to police your own profession?

Dr. BOYLE. Mr. Gilman, those are criminal activities and those persons are criminals and should be treated accordingly. We support anybody who will prosecute those people in a criminal fashion. Those are criminal activities.

Mr. GILMAN. How are you supporting them? That's what we would like to know. How are you supporting them? How are you encouraging them? What steps has AMA undertaken? Can you detail the kind of steps or activity you have undertaken to attempt to have more effective policing of your profession?

Dr. BOYLE. Mr. Gilman, that is not policing of the profession. That is policing of individual behavior. Those guys are crooks and they need to be prosecuted just like any other crook.

Mr. RANGEL. Let me ask this then, if the gentleman will yield-
Mr. GILMAN. I would be pleased to yield.

Mr. RANGEL. I'm sorry.

Mr. GILMAN. That's all right.

Mr. RANGEL. The truth of the matter is, even if they were investigated by the California attorney general, even if they were indicted, you would not have a review as to their membership in the AMA, would you?

Dr. BOYLE. If they were convicted of a felony

Mr. RANGEL. I didn't say convicted.

Dr. BOYLE. They would lose their membership.

Mr. RANGEL. The fact is, you don't have any standards that supersedes those of the local medical association. So if 90 of these guys were pulled in off the streets and jailed awaiting trial, that would not adversely affect their membership in the AMA one way or the other. So when you say you encourage it, it means you don't put a bond up for

them, but what do you encourage? The guy's indicted.

Dr. BOYLE. Mr. Rangel, I think you would agree that each of these people is entitled to full administration of due process. You would agree that they need to be tried.

Mr. RANGEL. Right. So you don't do anything but let them get local due process?

Dr. BOYLE. You would agree that they will need to be tried in a local court and that they should not lose their privileges on the mere allegation of wrongdoing, but only after their innocence or guilt has been fairly determined.

Mr. RANGEL. Of course, I don't have any problem with the AMA. I know what your role is. They have a problem because they think you should police your members.

Mr. GILMAN. That's the second vote.

Mr. RANGEL. We will have to recess for 10 minutes and come right back.

[Recess.]

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