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The use of Valium as a form of social control
THE
USE OF VALIUM AS A FORM SOCIAL CONTROL
OF
KEVIN KOUMJIAN Health
and Medical
Sciences
Program.
University
of California,
Berkeley. U.S.A.
Abstract-How is the use of Valium, an anti-anxiety drug, a form of social control’? This paper describes how drug treatment of anxiety is a process which redefines social problems as medical problems and, by providing symptomatic relief from stress, discourages approaches which attempt to make more structural changes in society. A major cause of this ‘medicalization’ of anxiety and tension is attributed to attitudes and beliefs which support the use of Valium. These attitudes and beliefs are presented as: (1) the individualization of anxiety. (2) a reductional view of non-specific or psychosomatic symptoms. and (3) a belief that Valium has a specific effect in reducing anxiety without inducing any significantly undesirable changes in physiology. social interaction or subjective experience. Drug companies and the conditions of modern medical practice are examined as two factors which may promote these beliefs.
INTRODUCTION
Use of the minor tranquilizer diazepam (better known by its trade name Valium) is now a widespread phenomenon in American society and has raised questions concerning medicine’s position as an institution of social control. Critics point out that treatment with anti-anxiety drugs such as Valium provides only symptomatic relief from anxiety and does not address the social origins of stress. One major cause of this ‘medicalization’ of anxiety and tension has been attributed to the attitudes and beliefs promoted by drug company advertising and the conditions of modern medical practice. These attitudes and beliefs could influence patients to: 1. Define social problems related to family, work and other spheres of social life, as medical problems; 2. Seek the medical solution for such problems (i.e. Valium), which is often merely treatment of symptoms, and 3. Become dependent upon the medical solution because the social problem is not addressed and symptoms recur. This article attempts to provide an analysis which will elucidate the social process outlined above.
THE EXTENT OF VALIUM USE AND SOME PROBLEMS IT PRESENTS
Diazepam (trade name Valium) is one particular drug among a larger class of drugs known as the minor tranquilizers. It has been chosen as the focus of this study because it is a prototype of its class, and it is the most widely prescribed drug in American medicine today [l]. Although this study concerns one particular drug, most issues presented here concern the entire group of minor tranquilizers, especially Valium’s immediate class, the benzodiazepines. The first benzodiazepine marketed was chlordiazepoxide (trade name Librium) in 1960 and this was soon followed by the introduction of Valium in 1963. The benzodiazepines and especially Valium were promoted as specific ‘anti-anxiety’ or ‘anxiolytic’ drugs which brought drug treatment of anxiety into a new 245
era. In comparison with earlier forms of sedative drugs, Valium was welcomed because: (1) it showed less of a sleep producing effect, (2) it was clearly safer in overdose, (3) it was thought to be less prone to the development of tolerance in users, (4) it was thought to be less liable to induce dependence, and (5) it was found to be effective in reducing certain parameters of symptoms associated with anxiety. In the years following the arrival of the benzodiazepines, prescriptions for the drugs rose at such a high rate that by 1972 Valium had become the most frequently prescribed drug in the United States. and Librium (Valium’s sister drug) had become the third leading prescription drug [I]. (America was not alone; statistics from Western European nations showed similar results [Z].) In 1978. approximately 68 million prescriptions were filled for the minor tranquilizers, of which 44.6 million were for Valium [l]. The extent of the use of minor tranquilizers in American society has been studied through national surveys and prescription drug data. Based on these studies it has been estimated that one in ten adults in the United States use Valium or Librium during any 3 month period 131. During a typical year it is estimated that 150/, of Americans use a minor tranquilizer of some kind [4]. A more conservative estimate maintains that ten million Americans used benzodiazepine anti-anxiety drugs in 1978 [S]. The typical user takes minor tranquilizers for a period varying from a few days to a few months. However, the use of these drugs on a chronic basis has become an occurrence of great magnitude. In a national survey reported in 1973 it was estimated that 4’i/ of the general American adult population had used a minor tranquilizer on a daily basis for longer than 6 months during the previous year. An additional 1’5; used a minor tranquilizer for periods varying from 2 to 5 months [4]. Chronic use of Valium has only recently been recognized as a major health problem. For many years it was commonly believed that Valium had a very IOW addictive potential, however this belief in recent years has been disputed by addiction researchers and by the U.S. Food and Drug Administration. In 1976, Maletsky and Klotter reviewed 27
KEVIN KOUMJIAN
246
articles attesting to Valium’s freedom from addictive properties, and concluded that none of the trials of withdrawal were done with systematic observations and no data regarding tolerance had been collected. In their own study they found strong evidence of both tolerance and withdrawal symptoms characteristic of addictive drugs [6]. The following are withdrawal symptoms from Valium: anxiety, depression, tremors, sweating, cramps, dizziness, nausea, vomiting, weakness, crawling sensations in the skin, sensations of pins and needles in the skin, depersonalizations, seizures, paranoia, panic, and psychosis. Most documented cases of sudden withdrawal reactions have occurred in patients who took excessive amounts of these drugs for months or even years [6-9-j. However, some recent cases have been reported in patients who have taken doses at the upper end of the therapeutic range (30-40 mg/day) [l&13]. These findings prompted the U.S. Food and Drug Administration to issue new warnings in the labeling of all benzodiazepines [14]. In addition to the physical dependence, other reports indicate that Valium also produces a psychological dependence which leads to chronic use for many patients [lS]. Vaiium is a drug which in just 17 years of availability has become a part of daily hfe for an extensive number of Americans. In this relatively short history, the full social significance of its use has not been assessed. However, an analysis and critique of the social context which promotes the use of Valium and of the impact which the prescription of Valium has on society are emerging. This critique remains controversial, but it cannot be dismissed. THE SOCIAL IMPACT OF VALIUM
FROM A
PERSPECTIVE WHICH RECOGNIZES MEDICINE
AS AN INSTITUTION
OF
SOCIAL CONTROL
medicine
as an institution of social control
The social process involved in the prescription and use of Valium forms a particular subsystem within the larger institution of medicine. Therefore, in order to understand the social effects of anti-anxiety medication, it is necessary to outline the broad social activities performed by American medicine. As a social institution, medicine performs activities within the sphere of life which a particular society defines as relevant to health and illness. Recently a number of social scientists have recognized that the institution of medicine has taken on functions of sociai control [16-203. Thus, often moral and valueladen issues are judged by whether they are ‘healthy’ or ‘unhealthy’ under the presumption that medical science offers an expert and objective position. However, medical decisions often do carry moral and value laden judgments and as a social institution, the judgments usually reinforce the norms of society. The notion of social control is often mistakenly dismissed as an overly simplistic concept. However, it should be clear that medicine is not a narrowly defined institution [18, pp. 7-81 and that it has become involved in social control as a result of a web of social changes. These changes include people’s attitudes towards health and illness, new medical technologies and information, and economic and political
factors states:
which influence
health
issues. As I. K. Zola
This [expansion of medicine] is not occurring through the political power physicians hold or can influence, but is largely an insidious and often undramatic phenomenon accomplished by ‘medicalizing’ much of daily living by making medicine and the labels healthy and ill relevant to an
ever increasing part of human existence 119, p. 487.1. The use of Vu&urn as a jbrm
of social control
The prescription and use of Valium can be viewed as a form of social control by demonstrating. first. a redefinition of social problems as medical problems and, second, the social effects of treating anxiety in a medical context. The process ofredejinition. Anxiety is a term which has broad applications in the sense that there are both ‘normal’ states of anxiety which everyone experiences and ‘psycho-pathological’ states of anxiety which are considered to be indications of poor mental health. Generally, anxiety is thought of on a scale in which ‘normal’ or ‘healthy’ anxiety is less than ‘unhealthy’ anxiety but there is no clear point at which either the doctor or the patient can draw a line between the two states. Even with objective scales developed to measure signs and symptoms of anxiety [21] there is a fundamental problem. These scales tend to measure rather non-specific and superficial items which ignore the origins of anxiety. The clinician often recognizes that a significant level of anxiety exists yet must rely upon subjective impressions in determinjng whether the level of anxiety is healthy or unhealthy for a particular patient. This unclear middle ground requires that the definition of healthy versus unhealthy anxiety be made by a consideration of the individual’s social functioning. Thus, the individual’s abilities to live up to personal ideals, social expectations, or the physician’s judgment are factors in a pseudo-objective diagnosis, which leads to the prescription and use of Valium. The evidence that this redefinition process has taken place is based on the increased number of people who go to a doctor with frankly social problems such as loneliness or marital discord, the increased use of minor tranquilizers observed during periods of increased social stress [22], and the distribution of users of minor tranquilizers among different social groups (discussed below). Social efjits. The possible social effects of treating anxiety through medical sedation have been outlined by Ingrid Waldron: It [prescription of Valium] focuses attention on individual malfunction and alleviation of symptoms of distress, rather then on seeking to understand and deal with the problems and their causes. As a consequence, social and economic problems are dealt with in the framework of a medical model of the relief of individual distress rather than in the social and political context of cooperative efforts for social change. Medicalization of these problems reduces pressures for social change and this outcome is advantageous for those who profit from the existing order [22. p. 433 In considering the social effects of medication it is imperative to identify the rate of use among different social concrete example of Waldron’s argument
anti-anxiety variations in groups. One applied to a
Valium as social control particular
social group is the case of nursing homes for the elderly in which “oversedation has long been recognized as a service to the caretaker and a disservice to the patients” [23]. In relation to broader social groups, minor tranqujlizers are used more commonly among women than men and among older compared to younger people. Regarding socioeconomic status, significant differences have not been found in the prevalence of use. If a person is a user of a psychotherapeutic drug, however, the probability of frequent and long term use is greater in lower socioeconomic groups [4]. How the use of drugs such as Valium might affect social interactions is another important question. The subtle effects on social life produced by regular use of a minor tranquilizer like Valium are difficult to assess. These effects are difficult to measure because the observer must witness the actual social interactions as they take place rather than relying on subjective interpretation of drug effects. The difficult nature of such research has left us with little documented evidence of the social effects of Valium. In 1971, Dr. Henry L. Lennard called for research into “the whole array of drug effects upon the individual, his family, and all of the social networks within which the drugged individuals interact” [24]. At the present, this important field of research has not yet received adequate attention. Attitudes and beliqfS which support the use of Valium in social control A system of attitudes and beliefs exists which supports the use of Valium as a form of social control. Critics of this system challenge the validity of three pervasive assumptions which may promote the use of the drug: (I) that anxiety originates from individual malfunction and that treatment of symptoms of anxiety therefore alleviates the problem; (2) that many different problems can be reduced to a single category, which is then treatable with Valium; (3) that treatment with Vahum has a specific effect in reducing anxiety without altering other aspects of physiology, subjective experience and social interaction. These beliefs contribute to the med~calization of anxiety because they define anxiety as a medical problem and leave the diagnosis and treatment of anxiety in the hands of medical professionals. These three beliefs will be analyzed below. Anxiety as an individual’s problem. People who use anti-anxiety drugs usually are experiencing very high levels of psychic stress [2.5,26]. The fact that intrapsychic stress is a very important clinical problem is not in question. However, problems of stress are often construed to be completely intra-psychic at the exclusion of recognizing the social reiations which contribute to the problem. Thus often when the primary cause of stress is a social condition in which the person lives, it is interpreted to be a personal shortcoming either in terms of the individual’s responsibility for self care or as a physiological problem which he or she cannot aiter. When primary origins of stress are investigated, one finds that patients taking tranquilizers have very diflicult social problems characterized in part by isolation and frustrating, unfulfilled life situations [22, p. 41; 25, pp. 163-164]. From this point of view, stress is
247
only a word to connect the direct effects of social agents on the person’s body and mind 1273. One reason why social origins of stress are often overlooked is because people take their social problems to doctors. The doctor may then concentrate on the symptoms of anxiety, thereby reinforcing the belief that the origin of anxiety is within the individual [25, p. 1643. A reductionist ciew of non-spec& symptoms. The indications for the use of Valium are very broadly stated on the product label. There are some specific uses of Valium (for example, in the treatment of status epilepticus), but the very non-specific uses proposed are:
I. for the symptomatic relief of tension and anxiety states resulting from stressful ~jrcumstan~s or whenever somatic complaints are concomitants ofemotionalfactors. It is useful in psychoneurotic states manifested by tension, anxiety, apprehension. fatigue. depressive symptoms, or agitation PI. This implicit belief that Valium can be effective in so many varieties of human experience is probably a result of an emphasis on finding specific medical causes of disease. The tendency to attempt to define a specific agent of disease is one which has permeated scientific medicine, and led to many successful discoveries. The doctrine of specific causation has befuddled physicians and patients who are faced with ‘psychosomatic’ or ‘non-specific’ medical symptoms, This void in the practice of medicine is often filled by the readily available use of Valium. In effect, nonspecific diagnoses are legitimjzed by a specific form of treatment. Statistics on the indications for which Valium has been prescribed reflect this phenomenon, They are: mental disorders, 30%; mus~uloskeletal, IT”/0; circulatory, 16% ; geriatric, 8% ; medical/surgical aftercare. 7%; gastrointestinal. 6%; genito-urinary, 3%; and others, 7% [29]. The most striking effect of this process of reducing non-specific complaints to treatment with a particular agent is provided by research which shows that doctors tend to change diagnoses to match the diagnoses for which new drugs are available [29]. Clearly. the belief in Valium as effective in so many non-specific diseases legitimizes its frequent use. The following report illustrates this process: It appeared that the patients who were given these drugs [Valium and Librium] did not have specitic illnesses, but were usually treated for situationai or chronic unchanging problems. When asked specifically. the prescribing doctors admitted that they were giving the medication in a spirit of *‘what else can you do. you have to give them something [30].” Belief in Valium’s specijicity. The belief that Valium has a specific effect in reducing anxiety without inducing any significantly undesirable changes in physiology, subjective experience. or social interaction would also contribute to the abundant use of Valium. This belief, although not held by sophisticated observers of drug action, is often implicit in the way drugs are advertised and in the remnants of the traditional conception of drug action as a ‘magic bullet‘ wherein a given chemical agent is believed to seek out a specific target in the organism [31]. This notion has
248
KEVIN KOUMJIAN
recently been strengthened by a report that ‘Valium receptors’ have been identified in the brain [32]. Another factor which has helped Valium to achieve its commonly held recognition as a safe drug is in its comparison with earlier sedative drugs, including the barbiturates and meprobamate, which were both clearly unsafe and addictive. However, reports are now mounting concerning the insidious effects which Valium has upon its users. The most significant are tolerance and addiction. Other common adverse effects include drowsiness (which is dose related), muscular incoordination, slurred speech, and spotty memory. Additional, but less common effects are excitement, hostility, hallucinations and delusions, depressed feelings with suicidal ideas, headache, dizziness, decreased sex drive, dry mouth, constipation, and slow urination [33]. The fact that Valium is not a ‘magic bullet’ is shown by this array of adverse effects. Even Valium’s impact on anxiety is not a clearly defined action. Much of its effect is accomplished by influences other than the drug. A study of patients with minor emotional problems displayed a placebo response of 50’1; and an active response of 75% [34]. Furthermore, the effects of Valium are so diffuse that one authority stated that “to make a single ‘yes’ or ‘no’ statement as to drug efficacy in some situations may boil down to the clinician’s judgment of the relative value of various modes of evaluation [35]“. It is unknown what other effects Valium may have upon the individual’s social interaction and subjective experiences. It is, however, easy to speculate that the response will vary from individual to individual since Valium is a drug which leaves much leeway for cognitive interpretation. Since it is difficult to generalize about cognitive effects, research on Valium has generally ignored in-depth reports of subjective experiences in favor of more easily quantifiable measures. The danger in this approach is that other important factors, such as whether the patient feels dependent upon the use of Valium and whether he or she has been able to identify or work to change the sources of stress, may be ignored. Factors trol
which promote
the use of Valium in sociul con-
In 1972 the state of South Carolina banned benzodiazepines from the state Medicaid formulatory for budgetary reasons. In six months 3574 of the benzodiazepine users had received an alternative sedative prescription but 65% of the users were no longer on medication (and no significant changes in the health of patients was reported) [36]. In another case, a rigorous information campaign on the problems in using tranquilizers reduced the number of prescriptions by 33% in one clinic [37]. These experiences raise an important question-if Valium is not fundamental to the care of many patients, what promotes the beliefs, outlined earlier, which lead to the frequent use of Valium? Drug company promotion. Hoffman-La Roche, the producer of Valium and Librium, depends heavily upon the successful marketing of minor tranquilizers. By 1971, it was estimated that Valium and Librium had been worth over $2 billion in sales. Approxi. mately, one fifth of this revenue was remvested m
sales promotion through drug detail men. advertising and ‘public service projects’ [38]. The effectiveness of drug advertising is evident in the following statistics: SO’)rence for drug information which contains descriptions of drugs paid for by the companies [40]. Advertising for minor tranquilizers has been very explicit in its message to use drugs in controlling social conflict. One example, which appeared in 1969. was an ad promoting the use of a minor tranquilizer for producing a “less demanding and complaining patient” [22, p. 413. Another pictures a worried young college woman and conveys the message that Librium can be of some help in solving the problems created when “exposure to new friends and other influences may force her to reevaluate herself and her goals,” and “newly stimulated intellectual curiosity ma) make her more sensitive to and apprehensive about unstable national and world conditions” [31, p. 311. Today the drug companies are much more subtle in their promotion of drugs for social problems. One such subtle campaign is an educational program entitled, ‘Consequences of Stress‘ and sponsored by Hoffman-La Roche. This program drew the following response from J. Richard Grout, Director. Bureau of Drugs, of the U.S. Food and Drug Administration: We are not
entirely comfortable about this program [because it is difficult to distinguish between drug promotion and legitimate support of medical education]. The program is aimed at stress, and it has the potential of subtly conveying the message that tranquilizers should be prescribed for many patients whose internal discomfort is much closer to that accompanying the normal pressures of life rather than the medical disorders for which tranqullizers are indicated [ 141.
The conditions of modern medictrl practice. The doctor makes the final judgment about whether to prescribe Valium and is therefore the principal object of attention for the drug company, the government agencies which hope to control overuse, and the patients who often want ‘something’ for their distress. Yet two major factors which often determine the physician’s decision to prescribe more than these external influences are lack of time and lack of training in the social context of medicine. According to one survey, 507: of medical visits lasted less then 15 min, with only 20% lasting over 30 min 125. p. 1641. One easy way for a doctor to end an interview is to write a prescription. The evidence that lack of training in the social aspects of medicine and a hesitancy to use time consuming psychotherapy contribute to increased prescription writing can be inferred from statistics which show that psychiatrists account for less than 17% of all of the prescriptions for minor tranquilizers [3]. These statistics are explained by the tendency for psychiatrists to use psychotherapy and to hold a less symptom oriented view of anxiety. CONCLUSION
This article has presented an analysis of the use of Valium as a means of social control. some attitudes
Valium
as social control
and beliefs which may work to support the use of Valium, and two factors which promote the use of Valium. It is essential to understand that these components all interact within one social system. Therefore, it becomes clear that the use of Valium as a form of social control is not usually done in an overtly coercive fashion. Rather, dominant attitudes and beliefs concerning the realm of medicine (which in American treatment
society includes anxiety) and the strategy of (Valium) pervade both ends of the doctor-
patient relationship as well as the larger systems within which individuals act. Furthermore these attitudes and beliefs are strengthened by interests which benefit from this social arrangement. Therefore drug companies (which reap profits) and doctors (whose practice is simplified by this process) actively promote the use of Valium. Also patients, as members of a technologically oriented society, may demand Valium due to their acceptance of the pervading assumption that anxiety is a medical problem requiring a technological remedy. The result of this approach to anxiety is that human conflicts arising from the relation between individuals and the social system become objectified and are controlled without a resolution of the structural conflicts involved. This mechanism preserves the existing social order but at several costs. It may harm individuals due to adverse side effects, addiction
and/or the continuation of a living situation in which the person is not satisfied. Also alternative modes of therapy and social changes which address the more fundamental causes of anxiety are discouraged by this more direct and specific cure provided by medical science. REFERENCES
1 Despite these high levels of use reported in 1978. it should be pointed out that between 1973 and 1978 total prescriptions for all minor tr~nquiIizers including Valium fell somewhat. The reasons for this decline are not entirely clear but may involve concern about addiction. Narional Prescriprion Audit, Therapeutic Category Report, 19641978, IMS America. Ambler. PA 19002. survey of the extent 2. Balter M. B. rr ai. Cross-national of anti-anxiety sedative drug use. N. En&. J. Med. 290, 769. 1974. Pat3. Weise C. E. and Price S. F. The Benzodiazepines: ferns of Use. Addiction Research Foundation. Toronto, Canada, 1975. 4. Parry H. J. er ul. National patterns of psychotherapeutic drug use. Archs gen. Psychiat. 28, 769, 1973. Disease and Therapeuric index. Drug File, 5. Narional Jan.-Dec.. 1979, IMS America, Ambler, PA 19002. 6. Maletzky B. M. and Klotter J. Addiction to diazepam. Int. J. Addictions ii, 95-l 15, 1976. 7. Preskorn S. and Denner L. J. Benzodiazepines and withdrawal psychosis. J. Am. Med. Ass. 237, 36, 1977. 8. Dysken M. W. and Chan C. H. Diazepam withdrawal psychosis, a case report. Am. J. Psychiat. 134, 573, 1977. 9. Covi L. et ul. Length of treatment with anxiolytic sedatives and response to their sudden withdrawal. Acta psvchiui. sound. 49, 51, 1973. 10 Pevnick J. S.. Jasinski D. R. and Haertzen C. A. Abrupt withdrawal from therapeutically administered diazepam. Archs yen. psychiat. 35, 995, 1978. 11 Rifkin A., Quitkin F. and Klein D. Withdrawal reaction to diazepam. J. Ani. Med. Ass. 233, 2173, 1976.
249
of diazepam. J. Ani. Mud. Ass. 12. Haskell D. Withdrawal 233, 135, 1975. dependence: frequent or 13. Ayd F. J. Benzodiazepine infrequent. 1311.Drug Ther. Newskerr. 13. 8. 1978. 14. Grout J. R. Dir. Bureau of Drugs, USFDA (testimony). Subcommittee on Health and Scientific Research. U.S. Senate, Sept. 10, 1979. Research Foundation, (testi15. Glaser F. B. Addiction mony). Subcommittee on Health and Scientific Research, U.S. Senate, Sept. 10, 1979. notes on the 16. Conrad P. The discovery of hyperkinesii: medicalization of deviant behavior. Sot. Probl. 23, 12. 1975. B. and Ehrenreich J. Medicine and social 17. Ehrenreich control. In The Cultural Crisis of Modern Medicine (Edited by Ehrenreich J.). Monthly Review Press. New York, 1978. B. The Euploitution of l/118. Waitzkin H. and Waterman ness in Capitalist Sociefy. Indianapolis. Bobbs-Merrii. 1974. 19. Zola I. K. Medicine as an institution of social control. Social. Rev. 20. 487, 1972. 20. Zola I. K. In the name of health and illness: on some socio-political consequences of medical influence. Sot. Sci. Med. 9, 83. 1975. 21. Hartlage L. C. Common approaches to the measurement of anxiety. Am. J. Psychiar. 128, 1145. 1972. of Valium, Librium. 22. Waldron I. Increased prescribing and other drugs-an example of economic and social factors in the practice of medicine. Inr. J. Hlrlt Seru. 7, 41, 1977. in older patients. 23. Butler R. N. Overuse of tranquilizers Int. J. Ay. Hum. Dec. 7, 2, 1976. 24. Lennard H. L. Mystification und Drug Misuse, p 16. Jossey-Bass, San Francisco. CA, 197 1. of the masses? 25. Lader M. Benzodiazepines-opium ~euroscifJ~~ce 3, 16 I. 1978.
26. Mellinger G. D. er a/. Psychic distress, life crisis and use of psychotherapeutic medications. Archs yen. psy chiur. 35, 1045, 1978. 27. Berliner H. S. and Salmon J. W. The hohstic health movement and scientific medicine. Sot. Rec. 9, 31. 1979. 28. Product label for Valium, Hoffman-La Roche. 1979. drugs in use today. the role 29. Blackwell B. Psychotropic of diazepam in medical practice. J. Am. Med. Ass. 225. 1638. 1973. 30. Pursch J. A. (testimony), Subcommittee on Health and Scientific Research, U.S. Senate, Sent. 10. 1979. 31. Lennard H. L. er al. Hazards implicit in prescribing psychoactive drugs. Science 169,438. 1970. 32. Iverson L. Anti-anxiety receptors in the brain? Nrrrtrrr 266,678, 1977. Drug.\. 33. Goldberg M. and Egleston Cl. Mind Iyffuenciny p. 179. P.S.G.. Littleton, MA. 1978. of psychotherapeutic drugs in 34. Wheatley D. Evaluation general practice. R. Sot. Med. 65, 3 17, 1972. D. J. and Shader R. I. Benx~dia;epines in 35, Greenblatt Ctinicai Practice, Chap. 4. Raven Press, New York. 1974. _.
R. L. Medical practices 36. Keller M. H. and McCurdy without anti-anxiety drugs. Read before the 125th convention of the Am. Psychiat. Ass., Dallas, May 3, 1972. 37. Kaufman A. et al. Tranquilizer control. J. Am. Med. Ass. 221, 1504, 1972. 38. Ball R. The secret life of Hoffman-La Roche. Forrun*, pp. 130-134. 162-171. 1971. habits of physicians. Drzccl 39. Miller R. R. Prescribing Inteil. C/h. Pharm. 7, 492 and 557. 1973. and 8. 81. 1974. of the Pharmaceurical Industry, /Y?1---73 40 Examinurion Subcommittee on Health, Committee on Labor and Public Welfare, U.S. Senate. U.S. Gov. Prmt. Office. Wash.. D.C.. 1974.
USE OF VALIUM AS A FORM SOCIAL CONTROL
OF
KEVIN KOUMJIAN Health
and Medical
Sciences
Program.
University
of California,
Berkeley. U.S.A.
Abstract-How is the use of Valium, an anti-anxiety drug, a form of social control’? This paper describes how drug treatment of anxiety is a process which redefines social problems as medical problems and, by providing symptomatic relief from stress, discourages approaches which attempt to make more structural changes in society. A major cause of this ‘medicalization’ of anxiety and tension is attributed to attitudes and beliefs which support the use of Valium. These attitudes and beliefs are presented as: (1) the individualization of anxiety. (2) a reductional view of non-specific or psychosomatic symptoms. and (3) a belief that Valium has a specific effect in reducing anxiety without inducing any significantly undesirable changes in physiology. social interaction or subjective experience. Drug companies and the conditions of modern medical practice are examined as two factors which may promote these beliefs.
INTRODUCTION
Use of the minor tranquilizer diazepam (better known by its trade name Valium) is now a widespread phenomenon in American society and has raised questions concerning medicine’s position as an institution of social control. Critics point out that treatment with anti-anxiety drugs such as Valium provides only symptomatic relief from anxiety and does not address the social origins of stress. One major cause of this ‘medicalization’ of anxiety and tension has been attributed to the attitudes and beliefs promoted by drug company advertising and the conditions of modern medical practice. These attitudes and beliefs could influence patients to: 1. Define social problems related to family, work and other spheres of social life, as medical problems; 2. Seek the medical solution for such problems (i.e. Valium), which is often merely treatment of symptoms, and 3. Become dependent upon the medical solution because the social problem is not addressed and symptoms recur. This article attempts to provide an analysis which will elucidate the social process outlined above.
THE EXTENT OF VALIUM USE AND SOME PROBLEMS IT PRESENTS
Diazepam (trade name Valium) is one particular drug among a larger class of drugs known as the minor tranquilizers. It has been chosen as the focus of this study because it is a prototype of its class, and it is the most widely prescribed drug in American medicine today [l]. Although this study concerns one particular drug, most issues presented here concern the entire group of minor tranquilizers, especially Valium’s immediate class, the benzodiazepines. The first benzodiazepine marketed was chlordiazepoxide (trade name Librium) in 1960 and this was soon followed by the introduction of Valium in 1963. The benzodiazepines and especially Valium were promoted as specific ‘anti-anxiety’ or ‘anxiolytic’ drugs which brought drug treatment of anxiety into a new 245
era. In comparison with earlier forms of sedative drugs, Valium was welcomed because: (1) it showed less of a sleep producing effect, (2) it was clearly safer in overdose, (3) it was thought to be less prone to the development of tolerance in users, (4) it was thought to be less liable to induce dependence, and (5) it was found to be effective in reducing certain parameters of symptoms associated with anxiety. In the years following the arrival of the benzodiazepines, prescriptions for the drugs rose at such a high rate that by 1972 Valium had become the most frequently prescribed drug in the United States. and Librium (Valium’s sister drug) had become the third leading prescription drug [I]. (America was not alone; statistics from Western European nations showed similar results [Z].) In 1978. approximately 68 million prescriptions were filled for the minor tranquilizers, of which 44.6 million were for Valium [l]. The extent of the use of minor tranquilizers in American society has been studied through national surveys and prescription drug data. Based on these studies it has been estimated that one in ten adults in the United States use Valium or Librium during any 3 month period 131. During a typical year it is estimated that 150/, of Americans use a minor tranquilizer of some kind [4]. A more conservative estimate maintains that ten million Americans used benzodiazepine anti-anxiety drugs in 1978 [S]. The typical user takes minor tranquilizers for a period varying from a few days to a few months. However, the use of these drugs on a chronic basis has become an occurrence of great magnitude. In a national survey reported in 1973 it was estimated that 4’i/ of the general American adult population had used a minor tranquilizer on a daily basis for longer than 6 months during the previous year. An additional 1’5; used a minor tranquilizer for periods varying from 2 to 5 months [4]. Chronic use of Valium has only recently been recognized as a major health problem. For many years it was commonly believed that Valium had a very IOW addictive potential, however this belief in recent years has been disputed by addiction researchers and by the U.S. Food and Drug Administration. In 1976, Maletsky and Klotter reviewed 27
KEVIN KOUMJIAN
246
articles attesting to Valium’s freedom from addictive properties, and concluded that none of the trials of withdrawal were done with systematic observations and no data regarding tolerance had been collected. In their own study they found strong evidence of both tolerance and withdrawal symptoms characteristic of addictive drugs [6]. The following are withdrawal symptoms from Valium: anxiety, depression, tremors, sweating, cramps, dizziness, nausea, vomiting, weakness, crawling sensations in the skin, sensations of pins and needles in the skin, depersonalizations, seizures, paranoia, panic, and psychosis. Most documented cases of sudden withdrawal reactions have occurred in patients who took excessive amounts of these drugs for months or even years [6-9-j. However, some recent cases have been reported in patients who have taken doses at the upper end of the therapeutic range (30-40 mg/day) [l&13]. These findings prompted the U.S. Food and Drug Administration to issue new warnings in the labeling of all benzodiazepines [14]. In addition to the physical dependence, other reports indicate that Valium also produces a psychological dependence which leads to chronic use for many patients [lS]. Vaiium is a drug which in just 17 years of availability has become a part of daily hfe for an extensive number of Americans. In this relatively short history, the full social significance of its use has not been assessed. However, an analysis and critique of the social context which promotes the use of Valium and of the impact which the prescription of Valium has on society are emerging. This critique remains controversial, but it cannot be dismissed. THE SOCIAL IMPACT OF VALIUM
FROM A
PERSPECTIVE WHICH RECOGNIZES MEDICINE
AS AN INSTITUTION
OF
SOCIAL CONTROL
medicine
as an institution of social control
The social process involved in the prescription and use of Valium forms a particular subsystem within the larger institution of medicine. Therefore, in order to understand the social effects of anti-anxiety medication, it is necessary to outline the broad social activities performed by American medicine. As a social institution, medicine performs activities within the sphere of life which a particular society defines as relevant to health and illness. Recently a number of social scientists have recognized that the institution of medicine has taken on functions of sociai control [16-203. Thus, often moral and valueladen issues are judged by whether they are ‘healthy’ or ‘unhealthy’ under the presumption that medical science offers an expert and objective position. However, medical decisions often do carry moral and value laden judgments and as a social institution, the judgments usually reinforce the norms of society. The notion of social control is often mistakenly dismissed as an overly simplistic concept. However, it should be clear that medicine is not a narrowly defined institution [18, pp. 7-81 and that it has become involved in social control as a result of a web of social changes. These changes include people’s attitudes towards health and illness, new medical technologies and information, and economic and political
factors states:
which influence
health
issues. As I. K. Zola
This [expansion of medicine] is not occurring through the political power physicians hold or can influence, but is largely an insidious and often undramatic phenomenon accomplished by ‘medicalizing’ much of daily living by making medicine and the labels healthy and ill relevant to an
ever increasing part of human existence 119, p. 487.1. The use of Vu&urn as a jbrm
of social control
The prescription and use of Valium can be viewed as a form of social control by demonstrating. first. a redefinition of social problems as medical problems and, second, the social effects of treating anxiety in a medical context. The process ofredejinition. Anxiety is a term which has broad applications in the sense that there are both ‘normal’ states of anxiety which everyone experiences and ‘psycho-pathological’ states of anxiety which are considered to be indications of poor mental health. Generally, anxiety is thought of on a scale in which ‘normal’ or ‘healthy’ anxiety is less than ‘unhealthy’ anxiety but there is no clear point at which either the doctor or the patient can draw a line between the two states. Even with objective scales developed to measure signs and symptoms of anxiety [21] there is a fundamental problem. These scales tend to measure rather non-specific and superficial items which ignore the origins of anxiety. The clinician often recognizes that a significant level of anxiety exists yet must rely upon subjective impressions in determinjng whether the level of anxiety is healthy or unhealthy for a particular patient. This unclear middle ground requires that the definition of healthy versus unhealthy anxiety be made by a consideration of the individual’s social functioning. Thus, the individual’s abilities to live up to personal ideals, social expectations, or the physician’s judgment are factors in a pseudo-objective diagnosis, which leads to the prescription and use of Valium. The evidence that this redefinition process has taken place is based on the increased number of people who go to a doctor with frankly social problems such as loneliness or marital discord, the increased use of minor tranquilizers observed during periods of increased social stress [22], and the distribution of users of minor tranquilizers among different social groups (discussed below). Social efjits. The possible social effects of treating anxiety through medical sedation have been outlined by Ingrid Waldron: It [prescription of Valium] focuses attention on individual malfunction and alleviation of symptoms of distress, rather then on seeking to understand and deal with the problems and their causes. As a consequence, social and economic problems are dealt with in the framework of a medical model of the relief of individual distress rather than in the social and political context of cooperative efforts for social change. Medicalization of these problems reduces pressures for social change and this outcome is advantageous for those who profit from the existing order [22. p. 433 In considering the social effects of medication it is imperative to identify the rate of use among different social concrete example of Waldron’s argument
anti-anxiety variations in groups. One applied to a
Valium as social control particular
social group is the case of nursing homes for the elderly in which “oversedation has long been recognized as a service to the caretaker and a disservice to the patients” [23]. In relation to broader social groups, minor tranqujlizers are used more commonly among women than men and among older compared to younger people. Regarding socioeconomic status, significant differences have not been found in the prevalence of use. If a person is a user of a psychotherapeutic drug, however, the probability of frequent and long term use is greater in lower socioeconomic groups [4]. How the use of drugs such as Valium might affect social interactions is another important question. The subtle effects on social life produced by regular use of a minor tranquilizer like Valium are difficult to assess. These effects are difficult to measure because the observer must witness the actual social interactions as they take place rather than relying on subjective interpretation of drug effects. The difficult nature of such research has left us with little documented evidence of the social effects of Valium. In 1971, Dr. Henry L. Lennard called for research into “the whole array of drug effects upon the individual, his family, and all of the social networks within which the drugged individuals interact” [24]. At the present, this important field of research has not yet received adequate attention. Attitudes and beliqfS which support the use of Valium in social control A system of attitudes and beliefs exists which supports the use of Valium as a form of social control. Critics of this system challenge the validity of three pervasive assumptions which may promote the use of the drug: (I) that anxiety originates from individual malfunction and that treatment of symptoms of anxiety therefore alleviates the problem; (2) that many different problems can be reduced to a single category, which is then treatable with Valium; (3) that treatment with Vahum has a specific effect in reducing anxiety without altering other aspects of physiology, subjective experience and social interaction. These beliefs contribute to the med~calization of anxiety because they define anxiety as a medical problem and leave the diagnosis and treatment of anxiety in the hands of medical professionals. These three beliefs will be analyzed below. Anxiety as an individual’s problem. People who use anti-anxiety drugs usually are experiencing very high levels of psychic stress [2.5,26]. The fact that intrapsychic stress is a very important clinical problem is not in question. However, problems of stress are often construed to be completely intra-psychic at the exclusion of recognizing the social reiations which contribute to the problem. Thus often when the primary cause of stress is a social condition in which the person lives, it is interpreted to be a personal shortcoming either in terms of the individual’s responsibility for self care or as a physiological problem which he or she cannot aiter. When primary origins of stress are investigated, one finds that patients taking tranquilizers have very diflicult social problems characterized in part by isolation and frustrating, unfulfilled life situations [22, p. 41; 25, pp. 163-164]. From this point of view, stress is
247
only a word to connect the direct effects of social agents on the person’s body and mind 1273. One reason why social origins of stress are often overlooked is because people take their social problems to doctors. The doctor may then concentrate on the symptoms of anxiety, thereby reinforcing the belief that the origin of anxiety is within the individual [25, p. 1643. A reductionist ciew of non-spec& symptoms. The indications for the use of Valium are very broadly stated on the product label. There are some specific uses of Valium (for example, in the treatment of status epilepticus), but the very non-specific uses proposed are:
I. for the symptomatic relief of tension and anxiety states resulting from stressful ~jrcumstan~s or whenever somatic complaints are concomitants ofemotionalfactors. It is useful in psychoneurotic states manifested by tension, anxiety, apprehension. fatigue. depressive symptoms, or agitation PI. This implicit belief that Valium can be effective in so many varieties of human experience is probably a result of an emphasis on finding specific medical causes of disease. The tendency to attempt to define a specific agent of disease is one which has permeated scientific medicine, and led to many successful discoveries. The doctrine of specific causation has befuddled physicians and patients who are faced with ‘psychosomatic’ or ‘non-specific’ medical symptoms, This void in the practice of medicine is often filled by the readily available use of Valium. In effect, nonspecific diagnoses are legitimjzed by a specific form of treatment. Statistics on the indications for which Valium has been prescribed reflect this phenomenon, They are: mental disorders, 30%; mus~uloskeletal, IT”/0; circulatory, 16% ; geriatric, 8% ; medical/surgical aftercare. 7%; gastrointestinal. 6%; genito-urinary, 3%; and others, 7% [29]. The most striking effect of this process of reducing non-specific complaints to treatment with a particular agent is provided by research which shows that doctors tend to change diagnoses to match the diagnoses for which new drugs are available [29]. Clearly. the belief in Valium as effective in so many non-specific diseases legitimizes its frequent use. The following report illustrates this process: It appeared that the patients who were given these drugs [Valium and Librium] did not have specitic illnesses, but were usually treated for situationai or chronic unchanging problems. When asked specifically. the prescribing doctors admitted that they were giving the medication in a spirit of *‘what else can you do. you have to give them something [30].” Belief in Valium’s specijicity. The belief that Valium has a specific effect in reducing anxiety without inducing any significantly undesirable changes in physiology, subjective experience. or social interaction would also contribute to the abundant use of Valium. This belief, although not held by sophisticated observers of drug action, is often implicit in the way drugs are advertised and in the remnants of the traditional conception of drug action as a ‘magic bullet‘ wherein a given chemical agent is believed to seek out a specific target in the organism [31]. This notion has
248
KEVIN KOUMJIAN
recently been strengthened by a report that ‘Valium receptors’ have been identified in the brain [32]. Another factor which has helped Valium to achieve its commonly held recognition as a safe drug is in its comparison with earlier sedative drugs, including the barbiturates and meprobamate, which were both clearly unsafe and addictive. However, reports are now mounting concerning the insidious effects which Valium has upon its users. The most significant are tolerance and addiction. Other common adverse effects include drowsiness (which is dose related), muscular incoordination, slurred speech, and spotty memory. Additional, but less common effects are excitement, hostility, hallucinations and delusions, depressed feelings with suicidal ideas, headache, dizziness, decreased sex drive, dry mouth, constipation, and slow urination [33]. The fact that Valium is not a ‘magic bullet’ is shown by this array of adverse effects. Even Valium’s impact on anxiety is not a clearly defined action. Much of its effect is accomplished by influences other than the drug. A study of patients with minor emotional problems displayed a placebo response of 50’1; and an active response of 75% [34]. Furthermore, the effects of Valium are so diffuse that one authority stated that “to make a single ‘yes’ or ‘no’ statement as to drug efficacy in some situations may boil down to the clinician’s judgment of the relative value of various modes of evaluation [35]“. It is unknown what other effects Valium may have upon the individual’s social interaction and subjective experiences. It is, however, easy to speculate that the response will vary from individual to individual since Valium is a drug which leaves much leeway for cognitive interpretation. Since it is difficult to generalize about cognitive effects, research on Valium has generally ignored in-depth reports of subjective experiences in favor of more easily quantifiable measures. The danger in this approach is that other important factors, such as whether the patient feels dependent upon the use of Valium and whether he or she has been able to identify or work to change the sources of stress, may be ignored. Factors trol
which promote
the use of Valium in sociul con-
In 1972 the state of South Carolina banned benzodiazepines from the state Medicaid formulatory for budgetary reasons. In six months 3574 of the benzodiazepine users had received an alternative sedative prescription but 65% of the users were no longer on medication (and no significant changes in the health of patients was reported) [36]. In another case, a rigorous information campaign on the problems in using tranquilizers reduced the number of prescriptions by 33% in one clinic [37]. These experiences raise an important question-if Valium is not fundamental to the care of many patients, what promotes the beliefs, outlined earlier, which lead to the frequent use of Valium? Drug company promotion. Hoffman-La Roche, the producer of Valium and Librium, depends heavily upon the successful marketing of minor tranquilizers. By 1971, it was estimated that Valium and Librium had been worth over $2 billion in sales. Approxi. mately, one fifth of this revenue was remvested m
sales promotion through drug detail men. advertising and ‘public service projects’ [38]. The effectiveness of drug advertising is evident in the following statistics: SO’)
entirely comfortable about this program [because it is difficult to distinguish between drug promotion and legitimate support of medical education]. The program is aimed at stress, and it has the potential of subtly conveying the message that tranquilizers should be prescribed for many patients whose internal discomfort is much closer to that accompanying the normal pressures of life rather than the medical disorders for which tranqullizers are indicated [ 141.
The conditions of modern medictrl practice. The doctor makes the final judgment about whether to prescribe Valium and is therefore the principal object of attention for the drug company, the government agencies which hope to control overuse, and the patients who often want ‘something’ for their distress. Yet two major factors which often determine the physician’s decision to prescribe more than these external influences are lack of time and lack of training in the social context of medicine. According to one survey, 507: of medical visits lasted less then 15 min, with only 20% lasting over 30 min 125. p. 1641. One easy way for a doctor to end an interview is to write a prescription. The evidence that lack of training in the social aspects of medicine and a hesitancy to use time consuming psychotherapy contribute to increased prescription writing can be inferred from statistics which show that psychiatrists account for less than 17% of all of the prescriptions for minor tranquilizers [3]. These statistics are explained by the tendency for psychiatrists to use psychotherapy and to hold a less symptom oriented view of anxiety. CONCLUSION
This article has presented an analysis of the use of Valium as a means of social control. some attitudes
Valium
as social control
and beliefs which may work to support the use of Valium, and two factors which promote the use of Valium. It is essential to understand that these components all interact within one social system. Therefore, it becomes clear that the use of Valium as a form of social control is not usually done in an overtly coercive fashion. Rather, dominant attitudes and beliefs concerning the realm of medicine (which in American treatment
society includes anxiety) and the strategy of (Valium) pervade both ends of the doctor-
patient relationship as well as the larger systems within which individuals act. Furthermore these attitudes and beliefs are strengthened by interests which benefit from this social arrangement. Therefore drug companies (which reap profits) and doctors (whose practice is simplified by this process) actively promote the use of Valium. Also patients, as members of a technologically oriented society, may demand Valium due to their acceptance of the pervading assumption that anxiety is a medical problem requiring a technological remedy. The result of this approach to anxiety is that human conflicts arising from the relation between individuals and the social system become objectified and are controlled without a resolution of the structural conflicts involved. This mechanism preserves the existing social order but at several costs. It may harm individuals due to adverse side effects, addiction
and/or the continuation of a living situation in which the person is not satisfied. Also alternative modes of therapy and social changes which address the more fundamental causes of anxiety are discouraged by this more direct and specific cure provided by medical science. REFERENCES
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