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peer pressures with the State and county and State organizations and by the time it reaches the AMA you don't see any unique responsibility to get the wrongdoers out of the profession; that is, local; and if somebody came to you with pictures of a doctor with a smoking gun, you'd say, "Very good. What State ?" And you look up the membership and refer it to the district attorney.
Dr. BOYLE. The same is true if you had evidence in the district of somebody who committed a murder in the State of Virginia. You would refer it to the State of Virginia to try it.
Mr. RANGEL. No, no; if he attacked me- it's a Federal offense. We have a Federal standard. You see, that's the difference.
Dr. BOYLE. Not you attacking somebody else.
Mr. RANGEL. It depends on who attacks here. You see, you don't have any Federal control over your profession and you don't want it, and that's not your job to advocate it, and we have a problem because we kind of think it's widespread since it's unusual to find overprescriptions in the profession, but there's such a small number of wrongdoers as opposed to the physicians that are doing right that unless we just give you newspaper stories you will refer it to the State and that's not our job. We're not State legislators. So perhaps you're helpless and I'm helpless because we don't have jurisdiction or we are not prepared to exercise it.
Dr. BOYLE. În the instance of really illegal activities, which is what Mr. Gilman was talking about, there are clearly agencies that have responsibility for that.
Mr. RANGEL. State?
Dr. BOYLE. Also the Drug Enforcement Administration of the Justice Department. There are agencies that have responsibility.
Mr. RANGEL. Well, perhaps we should have more then of a Federal presence, which I know is not what you want, but you can depend on it, just based on the record today; that since you don't have the resources nor do you see it as part of your mandate, that perhaps the Drug Enforcement Administration and other agencies are going to have to provide oversight. Since we can't refer it to the local district attorney where obviously there's no Federal code of ethics, and we have to rely on the Federal narcotics laws. So we can't take any
doctor's license away and we don't want to, but we have to do something rather than say it's a State problem.
Dr. BOYLE. That's a long step, I have to say. Also, I must point out that DEA can suspend the right of a physician to prescribe controlled substances, by suspending the DEA registration, if there is cause for such action. So, in fact, there is a significant Federal presence in this
Mr. GILMAN. Mr. Chairman, if I might just conclude, with your permission, Mr. Chairman, I'd like to request that the data that the AMA has available with regard to physicians' proprietary interest in pharmacies be made part of the record at this point in the record, and I'm going to ask Dr. Boyle if he would supply us with that information.
Dr. BOYLE. Such as we have, yes.
Mr. GILMAN. And, Dr. Boyle, when you provide us with the information of what the AMA is doing with regard to drug abuse and trafficking, would you spell out what committees you have, what national
planning you have, what programing you have, what investigations you have undertaken, what complaints you have made with regard to abuse and with regard to trafficking that you find within the profession and what you are doing to discipline the profession?
Mr. RANGEL. Without objection, so ordered.
Mr. DORNAN. If I can conclude quickly would that be the finale for today's hearing!
Mr. RANGEL. Well, I think counsel has some questions. Is this the first set of bells?
Mr. DORNAN. Yes; about 2 more minutes to the 10-minute bells.
Mr. DORNAN. Dr. Boyle, this subject is of intense interest to me for personal as well as professional reasons. I believe I have observed divorces among many friends brought about in great
measure by psychotropic drugs. Sometimes the divorces were rectifiable, but rarely. I have seen lives really torn asunder. As a sheer coincidence, the last 3 days I have had as a houseguest of my oldest son, a young lad who works in a pharmacy in West Los Angeles. It is one of the really highpowered pharmacies that's quadrupled its financial intake in only 8 years, all on legal prescription drugs, of course. It's a $1 million operation. While watching the Emmy Awards last night this young pharmacy employee who started out 5 years ago, delivery boy for the pharmacy and now has worked his way up to an assistant manager type, rattled off the prescription charts of one television performer after another as they appeared on the Emmy show. I began to question him on frequency of use by stars of certain drugs—particularly Valium—and he said, “Oh, Valium is definitely No. 1 with Hollywood people, the runaway favorite. Many of the show business people have insurance policies where they can get large prescription bottles for 50¢ or $1 where, without insurance, that same pill bottle that might otherwise cost $10, $12, or $15." This is just one testimony and example of heavy use in one profession. It all adds to my observation that drug use is the fifth horseman of the apocalypse, after war, famine, plague, and pestilence.
I have just returned from 3 weeks in the Soviet Union, which has about the opposite of our problem; that is, no good medicine at all. I'm just sickened that there isn't some reasonable midpoint that society might reach between the Soviet lack of good chemical use in their society and our American complete runaway legal prescription nightmare. This U.S. mess is particularly tragic, especially on the west side of Los Angeles, my district, where people can really afford to get stoned out of their gourds regularly and with so-called legal protection.
Doctor Boyle, do you see the time-worn challenge, "physician, heal thyself,” relevant here. Do you recognize a supraproblem in the United States--a really serious nightmare, as I do, or do you see it as just a minor problem that the AMA should address as briefly as possible?
Dr. BOYLE. I think, as we indicated earlier in our testimony, Mr. Dornan, that we recognize the fact that there are individuals who are
involved in the illicit drug trade and that those people should be prosecuted by whatever means are legally available. We recognize that there are individuals who misprescribe or overprescribe certain drugs such as psychotropic agents, and that those individuals we need to attempt to change their practice patterns by virtue of continuing efforts of local
peer pressure and continuing medical education. This applies in other areas of medical practice as well. Disabilities that can be caused by psychotropic agents are readily recognized by people because of their unique and specific effects on their behavior, but the disabilities that are attendant upon the misapplication of other agents might be more subtle and may not be as easily recognized. For example, the disability caused by the lack of potassium induced by the improper utilization of diuretic drugs.
So we believe these are serious problems that need to be addressed. The point we were trying to make earlier, however, is, it is not possible to simply take the totality of drugs prescribed divided by the population and come to a conclusion as to whether or not there is widespread, or lack of widespread, over- or underprescription of drugs.
Mr. DORNAN. I'd like to pursue that line of questioning when we come back.
Mr. RANGEL. I have just been advised by counsel that he's going to submit his questions, and if you want to submit yours we can adjourn
Mr. DORNAN. All right; I'll submit mine in writing also.
Let me thank the American Medical Association. The questions will be sent to you. It would be very helpful to us if you could give us some positive answers as to directions you can take to avoid legislative intervention. Thank you so much.
The meeting stands adjourned.
SUBMISSIONS FOR THE RECORD
MEDICAL AND CHIRURGICAL FACULTY
OF THE STATE OF MARYLAND,
Baltimore, Md., October 3, 1978. Hon. LESTER L. WOLFF, Chairman, House Select Committee on Narcotics Abuse and Control, Washington, D.C.
DEAR MR. WOLFF: We have read a “thumb-nail" report of the testimony before your committee by witnesses from the American Medical Association, among others, concerning overprescribing physicians. We are distressed that this article leaves one with the impression that the medical profession doesn't care very much about the problem of over- or mis-prescribing by physicians. Exactly the contrary is true. We believe the problem to be that the wrong people were on the carpet! While it is true the AMA cannot go into physicians' office, the county and state medical societies can—and we do.
While we cannot speak for other states, of course, we believe that Maryland is fairly typical of other state societies in attempting to keep a handle on the prescribing practices of physicians and to take appropriate action when there is evidence of deviation from the accepted norms of practice. Maryland is one of a handful of states that has promulgated regulations restricting the prescribing of amphetamines. These regulations are presently being revised by the State Department of Health and Mental Hygiene with the advice and cooperation of the Medical and Chirurgical Faculty. Cooperation with the Department and the Faculty continues through pharmacy surveys being forwarded to the medical society for review. The physician is contacted if he is prescribing amphetamines
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and asked for an explanation of diagnosis, backed up by documentation, for such prescribing. Prescribing of other classified drugs is also monitored and those physicians who cannot reasonably explain the use of such drugs are often referred for peer review of their entire practice. The next step, if the practice is found to be sub-normal, is referral to the Commission on Medical Discipline, a state agency for appropriate action in connection with medical licensure.
We don't have all the answers, and perhaps there are a few physicians who slip by without being recognized as poor prescribers ; but we believe this whole process to be educational in nature for physicians, and as protective of the public. We, too, support strict enforcement of the law, and cooperate with law enforcement authorities in identifying physicians who abuse the law.
We would be very happy to visit with your committee, to describe our procedures in more detail and to answer any questions you might have. We have many physicians in Maryland who freely give of their time and expertise to the problem of improper prescribing, and we are sure this is true in other states as well. Sincerely,
FRANCIS C. MAYLE, M.D.,
[Newsletter, PMA Vol. 20, No. 37, Sept. 25, 1978]
PHARMACEUTICAL MANUFACTURERS ASSOCIATION,
Washington, D.O. WOLFF HEARING ON OVERPRESCRIBING: FOUR HOURS WITHOUT A SINGLE ANSWER
If the House Select Committee on Narcotics Abuse and Control thought that last Wednesday's witnesses—a journalist, a pharmacologist, a psychiatrist and an AMA trustee could enlighten the Congress about "overprescribing" physicians, four hours of testimony proved otherwise.
"I will begin by stating my bias, and that is I believe we live in an overmedicated society," journalist John Pekkanen (author of "The American Connection”) began. “My area of special concern has long been legitimately prescribed psychoactive drugs." The rest of his testimony and answers did not live up to the committee's expectations. True, he said that the drug companies "court” the doctors. But, he continued, “The problem is extremely complex. Everybody I talked to is very concerned ... It's very difficult to determine precisely who needs psychoactive drugs. The symptoms are vague.” And, he stressed, “Never underestimate patient demands.'
Next came Dr. T. Donald Rucker, chairman of the Ohio State University pharmacology department, who bemoaned the lack of an adequate data base in 23 pages of testimony and tables.
The two American Medical Association witnesses, Daniel X. Freedman, University of Chicago psychiatry department chairman; and Joseph Boyle, Los Angeles internist and AMA trustee, warned about the complexity of easy accusations. “We do not believe that statistics regarding the total annual number of prescriptions written for a particular drug can really answer questions pertinent to whether there is overprescribing or misprescribing of that drug," Dr. Boyle said. "Higher than expected use of these drugs could also be attributed to increased access to health care now available under Federal programs such as Medicare and Medicaid or to the trend in treating mental illness in the community rather than in institutions. A greater willirgness among some groups to seek help can lead to increased uses of these drugs in certain populations. In any event, it must be remembered that conditions such as anxiety are often attributable to factors beyond the control of medicine, such as inflation, unemployment, family relationships and sbifting social values."
They explained what the American Medical Association has done to assure wise prescribing :
The AMA's Drug Evaluations, published in cooperation with the American Society of Clinical Pharmacology and Therapeutics, Dr. Boyle said, “is designed to provide practicing physicians with an up-to-date unbiased scientific evaluation of available drugs.” The section on psychotropic substances warns the physician to guard against "contributing to drug abuse through injudicious prescription practices or by acquiescerce to the demands of some patients for instant chemical answers to their problems.”
When it can be established that a physician or other prescriber is prescribing or dispensing drugs for non-medical use, appropriate actions should be taken to halt such activity. We support strict enforcement of the law.
AMA has been especially active in working to improve medical discipline at the state level. We have developed model state legislation on the subject of physician discipline.
The AMA supports efforts designed to eliminate improper prescribing, and we believe the principal means for achieving such a result is to provide unbiased, valid and current information to physicians on the risks and benefits of particular drugs in various treatment situations.
The AMA Archives of General Psychiatry over the past decade has published major controlled studies relating to the efficacy and side effects of psychotropic drugs. In addition major national surveys of prescription drug use have also been published in order to more reliably inform physicians con
cerning drug use.
Boyle: “Our function is to advise. We have no authority, we're not a regulatory agency; we can't go into the physician's office."
Lester Wolff (D-NY): "Are there ro AMA standards ?”
“You have not assumed real leadership,” Rogers told the AMA witnesses. “I want a letter from the AMA, telling us what it can and will do in regard to improper overprescribing."
AMERICAN MEDICAL ASSOCIATION,
Chicago, Ill., October 13, 1978. Mr. JOSEPH NELLIS, Chief Counsel, Select Committee on Narcotics Abuse and Control, Washington, D.C.
DEAR MR. NELLIS : In response to your letter of September 20, 1978, the American Medical Association submits its answers to the 10 questions that you posed in the letter. We request that our responses to these questions be published in their entirety in the record of the hearing held on September 19, 1978.
We are currently reviewing the transcript of the September 19, 1978 hearing and will submit the additional material requested at the hearing as soon as it is available. Sincerely,
JAMES H. SAMMONS, M.D.
1. Question. Does AMA as an organization invest pension, other insurance, or any other funds in the stock of pharmaceutical manufacturers? If so, please detail such transactions and state your views as to whether this might constitute a conflict of interest.
Answer. As of August 31, 1978, AMA's investment position in pharmaceutical company stock was as follows:
All stock Drugs and market value pharmaceuticals
AMA including current working funds.
$51, 808, 000
The above tabulation indicates that pharmaceutical stocks account for none of AMA's investments. Investments in AMA's employee pension plan, the AMA sponsored membership retirement plan (MRP) and the Education and Research Foundation (ERF) are controlled by banks and other professional investment