Initial information sources about valium.

Increased use of Valium during the past two decades has resulted in Valium being the most commonly prescribed drug in the United States (Blackwell, 1973). Increased stress placed upon individuals in today's society has pressured them into seeking alternatives that will aid with the relief of stress, anxiety and tensions. One alternative has been use of Valium. This investigation was designed to evaluate from what initial information source Valium users learn of the drug and initiate its use. The conceptual framework for the study was based upon the "demon theory," that the organism is sick because it has been invaded, damaged, or depleted by a foreign element or demon (French, 1977). Stress is the conceptual element that has invaded and damaged the organism. Stress, moves the organism away from homeostasis for a time and with sufficient force to prohibit the organism from reestablishing balance easily. An organism must be able to adapt to a disturbing force such as stress, by bringing the disturbance under control (assimilation) with such help as Valium or by modification to meet the new demands (accommodation). The instrument used was a questionnaire designed by the investigator. The principle analysis was frequency distributions and percentages. The most common initial information source and supplier of Valium was a physician or supervised assistant. The reasons for using Valium were obtained from the initial supplier by detailing pertinent information about the physical and emotional symptoms manifested by the individual. Additional findings such as dose, frequency, Valium use, use of other medications, current suppliers or sources, and the need for Valium were shown to be individualized according to present manifestations, adaptation and coping mechanisms. Further study is recommended with a larger sample from other areas and differing sub cultural groups to evaluate the reliability of the instrument.

INITIAL INFORMATION SOURCES ABOUT VALIUM by Tanya Fern Robison A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah March 1982 ~1982 Tanya Fern Robison All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Tanya Fern Robison This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. R.N. , 7 /1 !~·o /a / Sue E. Huether, R.N., Ph.D. THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Utah: I have read the thesis of Tanya Fern Robison in Its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate SchooL R. N •. , M. S. Member, Supervisory Committee Approved for the rvtajor Department Linda K. Amos, Ed.D., F.A.A.N. Chairmanl Dean Approved for the Graduafe Council ABSTRACT Increased use of Valium during the past two decades has resulted in Valium being the most commonly prescribed drug in the United States (Blackwell, 1973). Increased stress placed upon individuals in today's society has pressured them into seeking alternatives that will aid with the relief of stress, anxiety and tensions. One alternative has been use of Valium. This investigation was designed to evaluate from what initial information source Valium users learn of the drug and initiate its use. The conceptual framework for the study was based upon the -"demon theory," that the organism is sick because it has been invaded, dam­aged, or depleted by a foreign element or demon (French, 1977). Stress is the conceptual element that has invad­ed and damaged the organism. Stress, moves the organism away from homeostasis for a time and with sufficient force to prohibit the organism from reestablishing bal­ance easily. An organism must be able to adapt to a dis­turbing force such as stress, by bringing the disturbance under control (assimilation) with such help as Valium or by modification to meet the new demands (accomodation). The instrument used was a questionnaire designed by the investigator. The principle analysis was frequency distributions and percentages. The most common initial information source and supplier of Valium was a physi­cian or supervised assistant. The reasons for using Valium were obtained from the initial supplier by detail­ing pertinent information about the physical and emotion­al symptoms manifested by the individual. Additional findings such as dose, frequency, Valium use, use of other medications, current suppliers or sources, and the need for Valium were shown to be individualized accord­ing to present manifestations, adaptation and coping me­chanisms. Further study is recommended with a larger sample from other areas and differing subcultural groups to evaluate the reliability of the instrument. v This thesis is dedicated to my loving husband, Bill, whose constant support, patience and caring made this work possible. CONTENTS ABSTRACT ..•. ACKNOWLEDGMENTS . Chapter I. INTRODUCTION. Purpose • . . . . .. ..• Significance of the Research •• II. REVIEW OF THE LITERATURE Valium. . . Reasons for Use . . .• ... Information . . . . . . . . . • . Initial Source/Supplier of Information. . Summary . . • . . . . . . . ... III. CONCEPTUAL FRAMEWORK . iv ix 1 5 5 6 7 8 11 12 13 15 Summary . . . . .• ••..•..•. 20 Objective . . . . . . .. 21 Research Questions. ....• • . 21 Operational Definitions of Terms. 21 IV. METHODS AND RESEARCH DESIGN. Design of the Research .. Sample • . . . . • • . . Cri teria for Inclusion Instrument. . . . . . . . . . Procedure . . . . • . . . . . v. FINDINGS AND DISCUSSION. Sample. . • • Questionnaire Statistics. . Data Analysis Data Analysis Discussion of Return •• and Findings. Findings. . . 23 23 23 23 24 24 26 26 26 26 27 27 35 VI. APPENDIX: REFERENCES SUMMARY AND IMPLICATIONS ... 48 Rationale and Objective . . . . 48 Sample and Methods . . . . . . . . 49 Findings. . . . . . . .. ... 49 Limitations of Study. .. ....... 51 Implications for Further Research . . . . . 52 Implications for Nursing Practice . . . . . 64 QUESTIONNAIRE. 55 63 viii ACKNOWLEDGMENTS The author is indebted to the thesis committee mem­bers, Dr. Sue Huether, Ms. Suzie Tarmina and Dr. Taylor A. Jeppson for their time, assistance and guidance during the preparation of this research. Appreciation is given to all the participants, without whom the study could not have been accomplished. A special thanks is given to Mr. William S. Linford, Mrs. Evadeen Robison, and Mr. Duane Robison for their patience, understanding and constant support throughout the formation and writing of this manuscript. CHAPTER I INTRODUCTION A modern epidemic of drug use has occurred in tOday's society. Due to increased demands placed upon individuals by employment agencies, government regula­tions, families, peers, and religious beliefs, many individuals, rich, poor, black, white, male, female, have turned to drugs to obtain some solace from fears and stress. "Pharmaceutical revolutions have been of great help in the prevention, diagnosis and treatment of human disease (Wolfson, 1970, p. 465). Pharmaceuti­cal companies furnish information not only to medical professionals, but also to lay individuals. This is accomplished through. explicit advertising in both pro­fessional and lay journals. Inadvertently the following misconception is developed by readers of the magazines: that all problems either large or small could be handled or solved by the use of a drug (Wolfson, 1970). This assumption that all problems can be handled or solved with drugs is an extremely common belief in today's so­ciety, and has concerned many within the health care disciplines. 2 Valium abuse, use is a concern today_ With a great­er number of individuals turning to drugs for relief of stress and anxieties, different sources have been sought to eliminate the feelings. As the demand for chemicals has grown, Valium, a minor tranquilizer, has been placed on the market with the intention of relieving anxieties and tensions, and providing relaxation. Through adver­tisements, family, friends and medical professionals, Valium has become the wonder drug, with "seven million prescriptions annually" (Blackwell, 1973, p. 1638). Valium provides an individual with a feeling of relaxa­tion, relief from tension, anxiety and stress, and calm­ing without demonstrating unpleasant side-effects. "This satisfying psychological effect encourages con­tinued use of the drug and thus supports a substance­dependent population and contributes to a public health hazard of unthinkable proportions~f (Shulman, 1978, p. 370). As the use of drugs increased to aid in the re­lief of displeasing conditions, and as satisfying feel­ings are experienced "the patient becomes accustomed to a rapid and effective relief by taking pills and his inherent stress response capability becomes atrophied" (Shulman, 1978, p. 372). When this occurs a chronic condition of drug dependency develops and the patient seeks and selects the medication again and again. "At this time continual prescribing is no longer therapeutic" 3 (p. 372). When this chronic condition develops drug use increases to the point of abuse in order to produce changes in behavior and mood. At this stage, the indi-vidual may not be successful in obtaining an adequate amount of prescription drugs and obtains them from illi-cit secondary sources. How do people first learn about Valium, and what is the initial source for obtaining the drug? "Valium is the most widely and frequently prescribed drug in the united States (Holliste, 1977, p. 44) and is also a unique drug . overcompliance rather than noncom-pliance is often observed wi th diazepam (Valium)" (Pakes, 1979, p. 863). The drug is well known among medical professionals and the general public. Increased advertisements in both professional and lay journals, and increased Valium prescribing by physi-cians have contributed to an accelerated knowledge and use of Valium. "It is conservatively estimated that Roche Labs have spent well over $400 million . . . including journal advertising, detail men and other promotional devices ... to ingrain Valium on the mind of practicing physicians and their patients" (Pekkamen, 1975, p. 18). Initial sources for Valium use other than those pre-viously mentioned may be "borrowing or requesting drugs from friends and family (particularly mothers), illegally purchasing drugs from street sources, stealing prescrip- tion pads from physicians offices, and stealing from friends' medicine cabinets" (Prather & Fidell, 1978, p. 878). Such initial sources can be misleading or decep­tive to the user if the philosophy that many problems can be relieved with drugs such as Valium is upheld. The individual initially taking the drug can be put in a vulnerable or difficult position, by not knowing the true cause of the problem, action of the drug or side effects. Therefore, an individual needs to gain suffi­cient and accurate knowledge about Valium before actual consumption occurs. By doing so, many dilemmas can be avoided, such as overdose, suicide or addiction. 4 Valium, a minor tranquilizer has become a widely known drug during the past decade, sought by many to de­lineate or alleviate stress, fears, and tensions. Indi­viduals learn about/of Valium through many diversified sources. The sources range from physicians to street peddlers, depending on the individual needs, alterna­tives, coping mechanisms and finances. Initial infor­mation sources for Valium need to be identified and con­trolled in order to decrease the frequency with which Valium is being obtained and abused/used. Also, in iden­tifying initial sources of information of Valium, appro­priate measures can be taken to educate the supplier about usage, action, and side-effects of Valium, coping mechanisms other than drugs, and support systems for an 5 individual, who is distressed by psychological and social problems. Purpose The purpose of this study was twofold: first, to determine from what initial information source Valium users learned of the drug, and second who provided the initial dose of Valium. Significance of the Research The significance of this investigation for nursing was to identify initial information sources and provid­ers of Valium. After identification has been made through experimental studies, nurses can aid in expe­diting decreased use of Valium by assisting the individ­uals to develop other coping skills, and resources, and to apply them when needed, as an alternative to the use of chemicals, such as Valium. CHAPTER II REVIEW OF THE LITERATURE "Americans nearly doubled their consumption of pre­scription drugs during the ten year period ending in 1973" (Rucker, 1974, p. 888). Why have individuals in­creased drug use? Individuals believe certain chemicals will aid and assist coping mechanisms when stressful so­cial and psychological conditions occur. "Certain medi­cations often make us forget our pressures, often re­lieve us of stress. They enable us to cope oftentimes helping us to temporarily escape reality" (Johnson, 1978, p. 745). An individual's personality, needs, coping style, skills and feelings are factors which influence the individual's attitude and belief regarding usage of drugs to solve problems. Many stresses and fears arise from the unknown or from an inability to deal appropri­ately with daily experiences or problems. An inability to cope with today's pressures has led many individuals to artificial supports such as drugs, with the result that many feel most or all of their problems can be alle­viated with drug use (Wolfson, 1970). 7 Valium Valium was introduced in 1963, at a time in which individuals needed help coping with increasing tensions, anxieties, stress and fears. From 1963 until now Valium has become the most widely prescribed and used drug in the world (Waldrom, 1977). In 1973, "Valium accounted for half of all psychotropic drugs used and for approxi-mately 70 million prescriptions that year" (Palmer, 1979, p. 7). Advertising by the Roche company, the manufac-turers of the drug, clearly facilitated the escalation of Valium sales. In 1973, the last year for which fig-ures are available, Valium's wholesale sales exceeded $225 million. This does not include sales to the military, which are substantial. From the wholesale fig­ures, one can infer that retail sales were in the neighborhood of a.half billion dollars in 1973. That's about half the total u.s. tran­quilizer market. This is approximately 80 million prescriptions, ••• enough to supply 20 a year to every adult and child in the country (Pekkanen, 1975, p. 18). In 1976, "Valium was the most widely prescribed drug in the United States" (Hollister, 1977, p. 44), and "has been the most frequently prescribed drug in the United states since the early 1970's" (Pakes, 1979, p. 863). A number of issues have contributed to the use of the drug. Valium is universally available. Socioeconomic stresses in all cultures have continued to increase, mass advertising of the drug is widely disseminated, and 8 treatment by prescription drugs has increased during the past decade. In Utah alone, "from January I, 1978 to June 30, 1978 Valium ranked fourth amoung all drugs pre­scribed. One hundred and ninety-one thousand, four hundred and ninety-nine Valium pills were dispensed. From July I, 1978 to December 31, 1978 the quantity dis­pensed increased from 37,091 to 228,590" (Utah Drug Frequency List, 1978, p. 1). The figures indicate that a large amount of Valium is still being prescribed, and does not include the number of Valium pills that are illegally traded or sold on the black market. Reasons for Use Valium is widely prescribed and heavily sought by lay individuals, because of the effectiveness in reliev­ing signs and symptoms of everyday pressures, stress, and tensions. As pressures, and stress increase, secon­dary to the demands of today's society, individuals seek ways of eliminating or maintaining physical and emotional health. A physician is one source that an individual can turn to for assurance that "something will be done and that • something' is tangible, the benefits are real, if only temporary" (Hollister, 1976, p. 47). Johnson (1978) stated that physicians are pressured by patients to prescribe medication for the slightest ailments, and will prescribe a mild drug to appease a patient to 9 prevent the patient from finding another physician who will prescribe a drug. At first Valium works beauti­fully. "It may lift depression, calm fears, and re­lieve anxiety" (Nyswander, 1975, p. 152). With positive effects demonstrated by Valium, many individuals seek continual usage which eventually leads to abuse and de­pendency. Sutker, Archer and Allain (1978) stated, "chronic drug use is associated with exaggerated need to attenuate unpleasant internal states, or, conversely, to seek out external sources of stimulation" (p. 1377). If the needs or states are not met with non-chemical variants then chemicals or drugs will be sought to alle­viate unpleasant behavior, attitudes and fears. "This efficacy to alleviate unpleasant factors with chemicals or drugs such as Valium, becomes well-accepted as evi­denced by patients' regular request for a new supply" (Maletzky, 1976, p. 97). The requests become more and more frequent as individuals become more dependent upon Valium. Frequent requests are often encouraged by both emotional and environmental factors which exist in to­day's high pressure society. Since Valium is widely known and often prescribed, it has become known and used "as a substitute for deal­ing directly with social and psychological problems" (Waldrom, 1977, p. 37). Hollister (1977) noted that "this has become the major criticism of the widespread 10 use of Valium"{p. 38). Edwards (1974, p. 822), stated nthat help should not be equated with 'prescribing', be­cause providing drugs often creates more problems than it solves." Not all physical, emotional or psychologi­cal discomfort can or should be handled with drugs. More time should be spent in educating individuals about behavior modification and personal coping mechanisms which can eliminate or greatly decrease the use of drugs. Elizabeth Johnson (1978, p. 747) noted, "we need to un­derstand feelings, culture and aspirations. We need to understand coping patterns or lack of coping abilities. Many people can live with reality because of the support from someone who cares and will help through the days ahead." Most health professionals prescribe Valium or other chemicals when lack of time, understanding or inability to control the situation exists. "If no other steps have been taken to determine and to resolve the underly­ing causes of symptoms, then a situation could result where the patient becomes accustomed to a rapid and ef­fective relief by taking pills and his inherent stress response capability becomes atrophied" (Shulman, 1978, p. 372). Hence, the individual becomes accustomed to the effect desired, and overcompliance results because the individual has obtained an effect that is needed and desired. 11 Waldrom (1977) found that only one-quarter of new prescriptions for Valium were for patients diagnosed as anxious or psychoneurotic. The greatest use of Valium was for diagnosed somatic conditions. Blackwell (1975) noted that thirty percent of the population studied used Valium for mental disorders and the remainder for "psy­chosomatic" conditions. Valium has a number of differ­ent actions and has been prescribed for problems other than anxiety relief. Valium having these varying degrees of uses, has become overly used and prescribed which may produce physical dependence if used over a prolonged period. "This drug is now the most widely used agent in the medical practice and each year the prescribing of the drug has increased at the rate of around seven million prescriptions" (Blackwell, 1977, p. 1638). Information There was little information in the literature re­garding patient education about the use of Valium. What the physician thinks his patients need to know, want to know, and ought to know about the use of drugs should be communicated by the physician (Hollister, 1977, p. 57). Many people do not wish to be informed and choose to have the physician make the decision. An­derson (1977) determined that physicians should sit down with the patient, explain the need, use and dose of 12 medication. However, Johnson noted that patients are in the office for such a short time that they hardly hear any directions. This means the patient must make assump­tions about what he or she thought the physician said, which may result in improper and noncompliant use of the drug. Initial Source/Supplier of Information "In 1974 psychiatrists were responsible for a mere 10% of the total prescriptions ... , while almost 70% were written by general practitioners ... family physi­cians, internists, gynecologists, and pediatricians~ (Palmer, 1979, p. 7). The majority of investigators sup­port that "Valium is over prescribed by neurologists, psychiatrists and general practitioners, for patients often in lieu of attempts to resolve those underlying problems" (Waldrom, 1977, p. 37). The indication that physicians commonly initially prescribe Valium is supported in the literature. "Stu­dies now indicate that on the average each physician visit results in one prescription (Cooperstock, 1978, p. 2), and thi s one prescr iption of an "anx iety drug pro­vides the assurance that the doctor will do something and that this I something 1 is tangible, the benefits are real, if only temporary" (Hollister, 1977, p. 47). The 13 findings of Prather and Fidell (1978) support the prev­ious statement that physicians contribute to Valium abuse/use. Physicians contribute to psychotropic mis­use/ abuse in at least three ways: a) multiple prescrib­ing, b) excessive dosages, and c) repeat prescriptions. Multiple prescribing occurs when an individual receives a variety of psychotropic prescriptions from one or several physicians at the same time. Minimal literature was available representing re­search pertaining to determining initial information sources of Valium. The vast majority of researchers described neurologists, general practitioners, and psy­chiatrists as prescribing Valium and thus the biggest offenders of increased Valium abuse/use. Little re­search has been done to identify other factors contri­buting to Valium abuse. Prather and Fidell (1978, p. 878) stated "other sources of psychotropic drugs include stealing prescription pads from a physicians office, borrowing or requesting drugs from friends and family, illegally purchasing drugs from street sources, and stealing drugs from a friend's medicine cabinets." No other research findings support the statements. Summary Many aspects of Valium have yet to be researched. While many articles have reported Valium use, abuse, and 14 misuse, few empirical studies of the initial information sources of Valium exist. Specific knowledge of how one gains access or came in contact initially with the drug Valium could expedite the control of Valium, hence decreasing the catch 22 effect of minor tran­quilizer use, i.e., the more they are given, the more they seem to work, the more they are prescribed" (Blackwell, 1975, p. 31). The general public needs "to understand alternative methods of coping patterns and/or lack of coping abili-ties. Many can live with reality because they know there is someone who cares and will help them through the days ahead" (Johnson, 1978, p. 747). Others are alone, and have no one to aid with increased anxiety, tensions, stresses, or fears. Therefore, artificial means (drugs) are sought to alleviate a distraught time in life. Many times drug induced problems and depen-dency problems can be prevented by helping people cope with problems without turning to artificial supports and experiences. People can help people best if they learn to relate effectively, interact compassionately and honestly, and draw strength from relation­ships they build with each other. Preven­tion in the form of caring, as the hand of one who reaches out to touch another can be a single step (Johnson, 1978, p. 747). The physician, nurse, family members or friends can all aid in expediting decreased use of Valium by aiding the individual to use personal coping skills when needed in order to decrease the use of chemicals such as Valium. CHAPTER III CONCEPTUAL FRAMEWORK The conceptual framework for this study was based upon the classical theory of disease which is in essence a "demon theory.rr rrThe organism is sick because it has been invaded, damaged, or depleted by a foreign element or demon" (French, 1977, p. 27). French (1977) noted that man is sick because there is something in the body that does not belong, or is sick because something has been removed from the organism that is necessary to life. Clearly the concept of disease, that some outer or ex­ternal factor caused a deficiency is applicable to this research. Usually, the extraneous element, stress or anxiety, leads an organism to find some type of solution. Often the type of help results in the use of a drug such as Valium. French (1977) stated that stress can be defined as anything that moves the organism away from homeostasis for a time and with sufficient force to prohibit the organism from reestablishing balance easily. Thus a symptom is any maneuver the organism uses to compensate for this imbalance. An organism must be able to adapt 16 to disturbing forces, either by bringing the disturbance under control or by modifying to meet the new demand. There are generally two types of stress reactions: transient stress and disease stress. French (1977) stated the transient stress reaction involved a rever­sible deviation from the organism's normal state, for example, the organism returns to normal once the stress is gone. A disease state causes irreversible changes and the organism cannot return to normal once the stress is eliminated. Health could therefore be defined as how the organism responds to stress, once confronted. Organisms must realize that some stress is essen­tial for health, and must find ways of reacting and responding to the stress without losing balance. As pressures and stress increase secondary to the demand placed upon the organism by the environment (such as, government regulations, family, peers, religious beliefs and society), ways are sought or explored to regain a "normal" level of functioning. If the organism is un­able to respond adaptively to the stress, then three options result. French (1977) stated the first option was that the organism can ignore the stress, which is dangerous. Second, sufficient energy can be used to op­pose the stress directly and thus maintain balance, and third a "balance bargain" can result which is reorgani­zation where a force that was initially experienced is 17 either neutralized or experienced as useful or even es­sential. Balance bargains can be hazardous, and usually do not work. Once the balance bargains are exhausted, treatment is sought. The focus of this investigation was the identifi­cation of initial information sources of Valium, infor­mation provided by initial supplier and reasons for use. Specific knowledge of how access is gained or contact is made with Valium could expedite the control of Valium. Organisms need to understand and realize that some stress is essential for health. Increased stress placed upon organisms by the environment and society, could cause stress, anxiety, and tensions. Greenblatt and Shader (1974) believed stress, an­xiety and tensions could elicit both psychic and somatic manifestations. Common psychic signs include excessive worry, overconcern, tension, irritability and inability to concentrate. Somatic manifestations include agita~ tion, restlessness, difficulty falling asleep,. tremor, breathlessness, tachycardia, palpitations, headache, nausea, chest pain, diarrhea and urinary frequency. An organism can manifest both psychic and somatic signs. "Occasionally, a patient will complain only of somatic symptoms with no overt manifestations of psychic anxi­ety" (Greenbladt & Shader, 1974, p. 1077). The organism is ill because some force has changed 18 the life pattern and something was removed or altered causing a deficiency or void in the organism. With a deficiency or void, stress, anxiety or tensions occur because homeostasis has been disrupted and altered. Al­tered life styles cause an organism to compensate for the imbalance, and psychic or somatic symptoms occur. The organism then tries to adapt to the symptoms and re­turn to a normal balance or steady state ("a state in which energies are continually used to maintain the re­lationship of the parts and keep them from collapsing in decay" [Laszlo, 1972, p. 37]). If all modes are exhaus­ted and if stress is severe or prolonged, a normal level of functioning ceases to exist. "The organism must re­sort to expensive measures to maintain balance" (French, 1977, p. 29). Either a physical disease, social factor, environ­mental factor or psychopathological condition can be the invading foreign element that has created stress in an organism. If the organism exhausts all modes for main­taining a normal balance, the organism tries to find other systems that could aid the assimilation or accomo­dation. With increased use of chemicals and drugs during the past decade, the world has become a pill-taking so­ciety, and a modern epidemic of drug use has occurred. Due to increased stress, anxiety and tension placed upon 19 individuals by different governing agencies, many indi­viduals have turned to drugs to obtain some solace from their fears and stress. Inadvertently a misconception by individuals has developed which states, "all problems either large or small can be handled or solved by the use of a drug" (Wolfson, 1970, p. 465). Therefore, a great number of individuals turn to drugs for relief of stress and anxieties. As the demand for a drug to re­duce stress and anxieties grew, Roche developed a minor tranquilizer called Valium. Valium was placed on the market with the intention of relieving anxieties and ten­sions, and provides an individual with a sense that the effect so greatly desired was obtained, without demon­stration of unpleasant side-effects. As drugs are in­creasingly used to aid in relief of displeasing condi­tions and as satisfying feelings are felt "the patient became accustomed to a rapid and effective relief by taking pills and his inherent stress response capabili­ties became atrophied" (Shulman, 1978, p. 372). Once Valium is used and becomes part of the coping pattern of an individual continual usage is sought. Individuals learn about Valium through many diver­sified sources, ranging from physicians to street ped­dlers, depending on the individuals' needs, alterna­tives, coping mechanisms and finances. Prather and Fidell (1978) stated some individuals feel the physi- cians were the initial source or supplier of drugs, and obtaining the drug from a physician rather than any other source, usage would appear to be more legitimate in the eyes of family and friends. Hopefully the use of Valium supplied by a health care professional would only be used during the transient stress stage. If prescribed or used longer "the organism cannot return to its original state and its adaptability decreases" (French, 1977, p. 30). When an organism continually sought and took a drug, such as Valium, "as a substi­tute for dealing directly with social and psychological problems or stress" (Waldrom, 1970, p. 38), use/abuse and loss of reestablishing balance can occur. There­fore, the organism remained sick because something was removed from the organism that is essential to life. Summary 20 The classical theory of disease which is in essence a "demon theory" was an appropriate framework for this study. Individuals are limited by different economical, social, physical, psychological and environmental fac­tors. Increased pressures eventually lead to increased stress, tensions and anxiety. When an individual is stressed by excess or deprivation the organism becomes sick and seeks ways of adapting and bringing the distur­bance under control to meet new demands. During the 21 past decade individuals have sought Valium from whatever sources available, because Valium produces an effect that is desirable to an individual's physical and emo-tional systems. Consequently, the simple need manifes-ted by the individual grew to a complex demand, of con-tinual drug usage on a permanent or prolonged basis. Determining initial information sources about Valium could expedite the control of Valium, allowing other me-chan isms such as personal coping skills to be employed to respond to stress, anxiety or tensions. Obiective < The objective of this research was to determine from what initial information source Valium users learned of the drug and received an initial supply. Research Questions 1. What is the initial source of information about Valium given to Valium users? 2. Who supplied the initial dose of Valium? 3. What information about Valium was provided by the initial supplier of the drug? 4. Why do abusers/users use Valium? Operational Definitions of Terms Initial Source: The first source of information a Valium user/abuser learned about the drug. Initial Supplier: The initial person who actually supplied the first Valium pill. Valium (Diazepam): A drug classified as a minor tranquilizer, and most frequently prescribed to treat anxiety, stress and tensions. 22 Information: Facts or descriptions about Valium communicated by word of mouth, newspaper or magazine ar­ticles, newspaper or magazine ads, or billboards. Abusers/users: When an individual takes thirty or more milligrams of Valium per day, "obtains drugs (Valium) on his own initiative rather than on the basis of professional advice" (Rappolt, 1974, p. 232). CHAPTER IV METHODS AND RESEARCH DESIGN Design of the Research The design was descriptive and employed a question­naire technique. Data pertinent to the research ques~ tions were collected. Sample The sample was drawn from people who were currently using Valium or had taken Valium by physician prescrip­tion within the past twelve months. The subjects were selected from the files of two family physicians, in the Salt Lake City area. Data were collected from May 1, 1981 through August 1, 1981. Criteria for Inclusion To be included in the sample, the individual had to: 1. Be currently taking Valium or have taken Valium in the past twelve months. 2. Be currently under the supervision of a health care professional. 3. Agree to participate as a subject by answering and returning the questionnaire. Instrument 24 The instrument utilized was a questionnaire (Appen­dix A) designed by the investigator. The questionnaire given to the subjects consisted of seven demographic questions, and 24 items of single and multiple answers. The demographic questions assessed sex, age, race, religion, education, occupation and income. The items of single or multiple choice addressed the four research questions of initial source of information of Valium, information provided by the initial supplier and reasons users/abusers use Valium. The instrument was tested in a pilot study. The questionnaire (Appendix A) was administered to a group of colleagues. These individuals agreed that the ques­tionanire was clear and concise, and covered the informa­tion sought concerning initial information sources of Valium and its use. Procedure The questionnaire was mailed to subjects who had met previous criteria. A self-addressed envelope accom­panied the questionnaire with directions to complete and return the questionnaire to the investigator within ten days. Through answering and returning the questionnaire, 25 subjects agreed to participate. If the questionnaire was not returned after twenty days, a postcard reminder was sent. CHAPTER V FINDINGS AND DISCUSSION Sample From May 1, 1981 to August 1, 1981 a total of 62 questionnaires were distributed to men and women selec­ted from the files of two family physicians in the Salt Lake City area. ,To participate, the subjects must have been currently taking Valium or have taken Valium in the past twelve months, and have been currently under the supervision of a health care professional. Questionnaire Return A total of 24 questionnaires were initially returned by mail to the investigator. Seven questionnaires were returned after a postcard reminder, yielding a 50% over­all response. Statistics The principle analysis of the data was accomplished by frequency distributions and percentages. Means, me­dians and modes were calculated from the demographic data, variables assessing initial sources of information, information provided by the supplier, the use of Valium, and additional findings. Data Analysis Data were analyzed under five subheadings: 1. Demographic information. 2. Initial source of information about Valium for the person who has used, or is using, Valium. 3. Information about Valium provided by the ini­tial supplier of the drug. 4. Abusers/users of Valium. 5. Additional findings. Data Analysis and Findings Demographic Data Sex, age, race, religion, education, occupation 27 and income were the demographic variables statistically analyzed. Twenty-two (71%) of the subjects were women and nine (29%) were males. Ages of the subjects ranged from 20 years to over 60 years. Age was further subdi­vided into a younger group (20 years to 49 years) of 18 subjects (58%) and an older group (50 years and older) of 13 subjects (42%). The majority of participants were Caucasian (30, 97%) and of Mormon religious preference. Educational preparation ranged from 11 (36%) subjects completing post high school vocational education to 9 (30%) having completed higher degrees. There were 17 28 (55%) professionals and 9 (30%) blue collar workers. The range of responses for income included 16 (52%) sub­jects whose income was less than $14,000. and 12 (39%) subjects whose income was more than $15,000 per year. Initial Information Source Nine questions (See Appendix A) addressed the ini­tial source of information about Valium. The majority of subjects initially learned about/of Valium from physi­cians (25; 80%), with 3 (10%) learning about the drug from family members, and 2 (7%) from newspaper or maga­zine articles. The physician or supervised assistant commonly provided the initial dose of of Valium, 29 (93%), whereas, 2 subjects (7%) obtained the initial dose from family members. Most subjects, 26 (84%) used Valium for the first time because the physician or supervised assis­tant said it would help the diagnosed problem. Also, 26 (84%) subjects stated that the first Valium pill was provided without requesting the drug. Eleven (35%) sub­jects claimed to still be receiving Valium from the ini­tial supplier, whereas 20 (65%) subjects were not. Se­ven (23%) subjects visited the initial supplier quarter­ly and 6 (20%) yearly. Twenty-seven (88%) subjects took Valium for the original reasons while 3 (10%) individuals took Valium for other reasons. 29 Information Information about Valium provides a direct under­standing about the drug, the actions, use, and side­effects. When Valium is prescribed or given to an indi­vidual the initial supplier needs to identify different reasons for using Valium in order to aid the individual with an understanding of why the drug is needed. Seven­teen (55%) subjects stated that the initial supplier iden­tified different reasons for using Valium, while 19 (64%) subjects responded that the initial supplier identified the appropriate action of Valium for the specific com­plaint. In order to reestablish balance and aid the indi­vidual in returning to homeostasis as quickly as possi­ble alternatives other than a chemical or drug need to be explored. If a drug is finally provided, adequate facts must be made available to the client. Sixteen (52%) of the subjects stated no other alternatives were explored before Valium was given, whereas 13 (42%) said other alternatives were explored, including Valium. A number of facts were given to the majority of subjects while three subjects stated no facts about Valium were provided at the time the drug was supplied (See Table 1) . Use/Abuse Twenty-eight (91%) subjects took Valium initially Table 1 Facts About Valium Made Available By Initial Source of Information Choices Frequencies Amount and frequency of use. 18 Reasons why you need to be taking Valium. 15 Refills, how often and how many. 14 Potential side-effects, such as fatigue and sleepiness. 13 Special instructions regarding caution in using alcohol when taking Valium, i.e., operating heaving equipment and driving. 11 If Valium can be taken with other drugs. 10 What Valium should do for you, changes you may experience. How long you should be taking Valium. None of the above Others No response 9 6 3 2 1 30 31 because a physici~n or supervised assistant prescribed the drug to treat the problem. Twenty-four (78%) sub­jects stated that anxiety, stress, or tension was commu­nicated as the problem, emotional withdrawal and depres­sion was the diagnosis for ten subjects, six subjects had insomnia and one presented with stomach disorder (See Table 2). Half of the subjects, 15 (40%), were taking Valium for anxiety, tension or stress, and the other half for somatic symptoms (See Table 3). There were multiple answers to the questions presented on Tables 2 and 3. Additional Findings Dose and Frequencies. Dose and frequencies reflec­ted misuse, overuse or disuse of a drug. Thirteen (43%) of the subjects had been taking Valium for three years or less, while 18 (58%) subjects had been taking Valium for three years or more. The majority of subjects (15, 49%) took one tablet at a time: 19 (62%) took a 5 milli­gram dose and 11 (36%) of the 19 took only 5 milligrams once a day. Ten (33%) subjects took one Valium during a 24 hour period, 4 (23%) took two (5 mg each) or 10 milligrams, during 24 hours, 3 (10%) took four (5 mg each), or 20 milligrams during a 24 hour period, 2 (7%) took 6 (5 mg each) or 30 milligrams during a 24 hour period, and 10 (33%) subjects failed to respond to the Table 2 The Diagnosis for Which Valium Was Originally Supplied Symptom Frequencies Anxiety, tension, stress Emotional withdrawal, depression Seizures Hostility, anger Insomnia High blood pressure A musculo-skeletal problem A heart-circulatory disorder A urinary problem A stomach disorder Alcoholism Other 24 10 6 5 5 4 3 3 2 1 o o 32 33 Table 3 Reasons Why Subjects Initially Took Valium Symptoms Frequency Percentage Psychological Problems Anxiety, tension, stress 15 49% Emotional withdrawal, depression 0 Hostility, anger 0 Somatic Problems A musculo-skeletal prob-lem 1 3% A stomach disorder 1 3% A urinary problem 0 A heart-circulatory dis-order 0 High blood pressure 0 Seizures 0 Other Insomnia 3 10% Unknown 2 7% No response 6 19.4% 34 question. Other Medications Valium is also indicated for the treatment of non psychological problems. It has been proven to be effec­tive in a number of physical disorders: musculoskeletal disorders, circulatory disorders, insomnia and others. Valium can and usually is prescribed prophylactically. Therefore an individual may be taking a number of medi­cations in conjunction with Valium. Thirteen (42%) sub­jects were taking one to three medications excluding Valium. Twenty-seven (88%) subjects were taking no ad­ditional tranquilizers when using Valium. Current Source and Supply Seventeen (55%) subjects could not refill a Valium prescription without communicating with the physician or supervised assistant. Also, two-thirds of the respon­dents had to be seen by a physician or supervised assis­tant for an episodic visit before the prescription could be refilled. Twenty (65%) of the subjects received Val­ium from only a physician or supervised assistant and were currently under the medical supervision of a physi­cian or supervised assistant. Need for Valium As stated previously, individuals often receive 35 drugs for the treatment of health problems before other alternatives are explored. Individuals may feel that a drug such as Valium is not helping to cope with the exis­ting problem and become noncompliant. Twenty-four (78%) of the subjects expressed an ability to cope with prob­lems with alternative measures not needing Valium to manage everyday pressures. Seventeen (55%) of the 31 participants indicated a belief of being able to cope without Valium. Discussion of Findings Demographic Data The majority of subjects were female. This supports Hollister's (1977) findings who noted that more women were treated with Valium because women see physicians more often than men. The predominant age group was between 20 and 49 years of age. This finding was similar to Cooperstock (1979) who indicated that people in their middle years tend to receive the highest proportions of tranquilizers. The predominant religion of Valium users/abusers in this study was Latter-Day Saints, the predominant religion for the population sampled. All participants except one were Caucasian, the predominant ethnic group in utah. The majority of the participants completed post high school vocational education which agreed with national 36 statistics identifying Utah as one of the main states in which students are educated beyond high school. Over half the users/abusers of Valium were white collar work­ers who made less than $14,000 annually. The findings of Parry (1968) and Cooperstock (1978) were contradictory. Cooperstock (1978) indicated drug use among the non­employed was higher than among the employed. Parry (1968) found that the drug use of people making more than $10,000 annually was slightly higher than subjects mak­ing less than $10,000 per year _ In summary the demo­graphic data profile for Valium users/abusers was female, Caucasian, middle aged, of the Mormon faith with a post­high school vocational education .who was classified as a white collar professional making under $14,000 annual­ly. Initial Information and Source of Valium These findings showed that the majority of subjects received an initial dose and prescription from a physi­cian, and that usually Valium was prescribed appropriate­ly_ The findings may reflect a function of the popu­lation. The sample was obtained from subjects who were currently under the direct supervision of two general practice physicians. Also, the majority of the subjects in the practices were LDS. 37 Many individuals belonging to the Mormon faith value health; are systematic, organized, and encouraged to maintain a healthy, active body. In order to stay healthy and active a physician is sought if a physical or emotional conflict occurs in life. A physician is felt to be one source that an individual can trust to assure that something can and will be done to solve a health problem. Therefore, the subjects comply with rules and regulations recommended and established by the physician, as an authority figure. Hence, if a physi­cian determines that a drug such as Valium would be of benefit for a particular condition, the individual would tend to comply according to the rules provided by the physician. Conforming to the rules and regulations set forth by a physician could account for the fact that Valium is one of the unique drugs used with overcompli­ance rather than noncompliance. This study supports other findings of Parry (1968) and Palmer (1979), that the physician was the initial supplier and/or prescriber of Valium. Initial informa­tion sources, such as a physician, could affect the lives of an individual. The initial source or supplier of a drug such as Valium should provide sufficient time to effectively diagnose and prescribe adequate treatment. With increased patient loads and time pressures, a phy­sician might feel it takes less time to write a 38 prescription than to explain why no medication is neces­sary (Johnson, 1978). Valium has been popularized and often prescribed for the management of social and psychological problems (Waldrom, 1977). "This has become one of the major cri­ticisms of the widespread use of Valium. It has kept the physician and the individual from learning how to deal and/or cope with social and psychological factors" (Hollister,1977 p. 44). Health care professionals should evaluate the individual's problems, guiding the treatment through proper communication channels. Before any medication is prescribed all other alternatives and support systems should be exhausted. Nolan (1976) be­lieved a patient's needs could be met by a doctor's sym­pathetic attention rather than the prescription of a. drug. This study did not support the physicians explor­ing other alternatives besides the prescription of Vali­um. An additional finding included continual physician communication with Valium users to evaluate the progress of emotional and environmental factors. This could indi­cate that the population studied seek and listen to authority figures such as physicians and are organized and systematic. Knowing when and when not to prescribe a drug is a component of prescribing responsibility in addition to providing adequate information necessary for a particular individual. An individual needs to be aware of the health problem and ask pertinent questions about the condition and the role the drug plays in affecting 39 a lifestyle. These findings did not indicate the ini­tial supplier of Valium provided adequate information about/of Valium. The physician did identify pertinent facts such as why the drug was necessary, amount and fre­quency of use, refills, potential side-effects and how Valium should be taken. No research has been conducted identifying the specific information given by the ini­tial supplier to the individual. Continual communication between the individual and supplier may eliminate the use of Valium and support the seeking of behavior modification skills and adequate coping mechanisms. Over half the participants could not refill a Valium prescription without first communicating with the physician or supervised assistant, indicating a form of Valium supervision and monitoring. Use of Drug The findings verify that Valium was initially pre­scribed as a substitute for dealing directly with indi­vidual social and psychological problems such as stress, anxiety, and tension, and that participants were taking Valium for the same reasons. Valium was also initially prescribed for the treatment of abdominal and musculo- 40 skeletal disorders, dysmenorrhea, and insomnia. Cooperstock (1978) stated that in chronically ill patients psychotropic drugs were primarily used with pa­tients who had a primary diagnosis of ischemic heart disease, neurological diseases, and musculoskeletal dis­orders. Hollister (1977) indicated that only about thirty percent of all the prescribing of minor tranqui­lizers, particularly diazepam, was for anxiety and in­somnia. The remaining seventy percent was for musculo­skeletal disorders, psychophysiologic disorders and an­xiety secondary to other medical problems. The inci­dence of prescribing Valium increased for patients with chronic cardiovascular disease or chronic gastrointes­tinal disturbances (Hollister, 1977). Waldrom (1977) found that only one-quarter of new prescriptions for Valium were for patients diagnosed as anxious or psychoneurotic. Much of the prescribing of Valium was for diagnosed somatic conditions. Blackwell (1975) found thirty percent of the population studied showed Valium was indicated for mental disorders and the remainder were conditions that could be labeled as "psy­chosomatic." Valium has a number of different actions and has commonly been prescribed for uses other than an­xieties. The varying justifications for Valium use may be a factor related to drug dependency, misuse or abuse, with physical dependence when used over a prolonged 41 period. There was little information in the literature re­garding patient education about the use of Valium. What the physician thinks his patients need to know, want to know, and ought to know about the use of drugs should be communicated by the physician (Hollister, 1977). Many people do not wish to be informed and choose to have the physician make the decision. Anderson (1977) determined the physicians should explain the need, use and dose of medication. However, Johnson (1978) noted that patients are in the office for such a short time that any directions are hardly heard. Patients must make assumptions about what was said by the physician which may result in improper compliance and use of the drug. Use/Abuse Valium is often prescribed as a substitute for the direct management of social and psychological problems which the patient manifests to the physician (Waldrom, 1977). Most physicians do not have the time to help an individual develop coping skills, therefore a drug such as Valium is prescribed. Relief is readily available merely by taking medication. This leads to a situation where the patient becomes accustomed to rapid and effec­tive relief and the inherent stress response becomes atrophied (Shulman, 1978). When patients regularly 42 requested new supplies of Valium, (Maletzky, 1976), other forms of therapy need to be developed before dependency or abuse occurs. These findings indicate that Valium was initially prescribed by physicians as a means of coping with social and psychological problems, and that participants are now taking Valium for the same reasons. Therefore, Valium has been well-accepted and no other forms of therapy identified or utilized. Continual pre­scribing and use of Valium could and does lead to abuse and dependency. Valium dosage and frequences should not be the same for each individual, as individual needs are different. Hollister (1973) stated that some patients take Valium in anticipation of going to a dentist while others take it for angina. There is no set rule that says so many milligrams of Valium should be given for an existing con­dition. Dosage and frequencies vary, and physicians learn to recognize and identify individuals who need higher and lower amounts adjusting the drug accordingly. Hol­lister (1977) proposed that a large number of patients could determine personal dose needs and develop appro­priate dose schedules. The Presidents Advisory Commis­sion on Narcotics and Drug Use defined drug abuse as when a person takes drugs on his own initiative rather than on the basis of professional advice (Rappolt, 1974). The definition implies self dosaging as abuse. A high dose of Valium is 40 milligrams or more per day (Hollister, 1977), and a more stringent requirement of 30 milligrams or more per day was defined as abuse for this study_ The majority of the sample took well below 30 milligrams of Valium per day_ Four of the 31 subjects were taking an addictive dose (See Figure 1). The average amount of Valium taken at one time was five milligrams and that five milligrams was taken once during a 24 hour period. Wolfson (1970) and Rappolt (1974) defined drug abuse as drugs taken to produce changes in mood and behavior, the initiation of drugs (Valium) by the individual rather than through profes­sional advice, or the acquisition of drugs (Valium) through illicit channels. None of the above criteria was supported by this study. 43 An individual, specifically one who has multiple health problems, or an older individual may be "taking two pills for blood pressure, one for heart, one for diabetes, a dyspepsia potion, and alternating consti­pation and diarrhea pills" (Anderson, 1977). Multiple drug use presents one of the most significant problems in medicine today. Blackwell (1973) found sixty-four percent of Valium was prescribed in combination with other drugs. Fourty-two percent of Valium users in this sample were also taking other medications. Hollister (1977) proposed that individuals taking Valium almost til ,r=.o... tJ'\ or-f r-I r-I or-f = Q.) tJ'\ ro til 0 0 120 l-l.l'i Minimum E2 Moderate E3 Severe 0 No Response 40 35 30 25 20 15 5 10 15 20 25 30 Number of Subjects Figure 1. Minimum, moderate and severe usage of Valium. 44 45 certainly were taking drugs in rotation with Valium. In order to prevent drug abuse, maintain adequate control, and provide proper therapy, there must be a continual communication between the individual and the supplier. "Some people are prone to become dependent on chemicals. Under special situational conditions anyone can become addicted" (Hollister, 1977, p. 53). Therefore, contin­ual evaluation and monitoring greatly facilitates the prevention of addiction or abuse. Constant monitoring and routine evaluation by the supplier is also necessary to understand and evaluate the adequacy of coping abilities and patterns. Many individuals can be gradually withdrawn from Valium as the individual learns how to cope with decreasing use of chemicals/drugs and gradually regains a previous le­vel of effective functioning. Research of Valium has addressed only the subjects of use, overuse, misuse and abuse. No work could be identified which addressed the idea of whether individ­uals need Valium to cope with everyday pressures and stresses. If an individual manifests signs of stress to a physician, and the physician believes Valium could benefit the individual, then the individual is presumed to need Valium and cannot function adequately without it. The opposite was found in this investigation. Three-fourths of the participants felt they did not need Valium to cope with everyday pressures. Over half of the subjects stated they could manage without Valium. This finding confirms that physicians are prescribing Valium to individuals who believe they do not need the drug for stress management. Therefore, the physician 46 is providing the individual with the possibility of ad­diction, overuse, or abuse. This may suggest that over­use may be mainly accounted for by the factors that rein­force the prescribing habits of the physician. Conceptually, an individual becomes sick because something has been removed from the organism that is necessary for homeostasis. Stress, anxiety, and ten­sion was the "demon" which caused the organism to move away from homeostasis. Usually, a symptom such as a headache, nausea, or diarrhea is the maneuver an organ~ ism uses to compensate for this imbalance. The organism tries to adapt itself to the disturbing forces, and looks for a modificiation to meet the new demand. When the organism tries to adapt to the disturbing forces, without adequate and professional help the imbalance can and often does continue. Therefore, a physician is sought, hoping that homeostasis can be reestablished. If the organism responds to stress, with the help of a physician, in an adaptive and flexible way without los­ing balance, a constant steady state can be obtained readily. But if the stress is prolonged and severe 47 enough, the organism may never regain a previous level of functioning (French, 1977). Valium should be used only for the acute temporary condition thereby allowing the organism to adapt itself to disturbing forces by assimilation or accomodation. If Valium is used for pro­longed periods without adequate supervision then the organism may not return to an original state, decreas­ing adaptability. Also, if Valium is given over a pro­longed period the organism continues to seek the satis­fying psychological and physical effect, which encoura­ges continued use of the drug. Continued use of the drug prevents the organism from effectively responding in a flexible and adaptive manner, hence an unhealthy response to stress can result in decreased adaptibility. Lehman (1967) stated the longer the patient is on the antianxiety drug, the more dependency is produced and consequently the ability to withstand stress is reduced. Increased dependency upon a chemical results in misuse, overuse, and abuse of the chemical or drug. CHAPTER VI SUMMARY AND IMPLICATIONS Rationale and Objective Increased use of Valium during the past two decades has made Valium the most commonly prescribed drug in the United States (Blackwell, 1973). With increased pres~ criptions and increased advertising by Roche Company, Valium became a familiar word. Lay and professional journals are filled with articles about the pros and cons of Valium. Individuals are seeking Valium from phy­sicians, family, friends and street sources, which re­sulted in 70 million prescriptions being written during 1972 at an estimated cost of around $200 million (Black­well, 1973). Research (Hollister, 1977; Waldrom, 1977; Prather & Fidell, 1978; Maletzky, 1976; Cooperstock, 1979) was published regarding Valium and its use, overuse, mis­use, and abuse. Traditionally a chemical/drug such as Valium was obtained from a health care provider. With increased changes placed upon the individual by society, and increased drug abuse/use the tradition of obtaining Valium from a health care provider soon decreased. Individuals who had read and heard about Valium turned to the drug to gain solace from stress, tension and an­xieties, and obtained Valium from any source or suppli­er. The purpose of this investigation was to determine from what initial information source Valium users learned of the drug and initiated its use. Sample and Methods The sample included subjects who were currently using, or have taken, Valium within the past twelve months. Therefore, 31 individuals from two family physicians practicing in the Salt Lake City area com­prised the sample. 49 Data were collected from May 1, 1981 through August 1, 1981, and were acquired through a questionnaire pro­vided each participant. The principle analysis of the data was frequency distributions and percentages. Fur­ther statistics of some categories could not be accom­plished due to lack of sufficient sample size. Findings The demographic data revealed that the majority of users of Valium were Caucasian and members of the Church of Jesus Christ of Latter Day Saints. Eighty percent of the participants were women ranging in age from 20 to 49 years. The most common education was post high school vocational, with the majority being professionals 50 making less than $14,000. annually. Valium users initially learned about Valium from a physician. The physician provided the individuals with the first or initial dose of Valium given or pro­vided without the individual's request. When the indi­vidual did request Valium it was from a physician or supervised assistant, rather than a family member, friend, or street source. The first Valium dose was ob­tained after one office visit to acquire the initial prescription. Over half of the participants did not obtain Valium from their initial supplier but from ano­ther source, which could signify that the original source or supplier has changed. Eighty-seven percent of the individuals were still taking Valium for the same reason initially prescribed. Valium was initially taken by the participant be­cause the physician or supervised assistant suggested it would help the condition. The reasons for taking Valium were the same as those initially communicated to the supplier. The conditions included emotional prob­lems and physiologic system disorders. The reasons for taking Valium, duration, potential side-effects, dose and frequency, refills and special instructions regard­ing caution with alcohol ingestion were facts frequently stated by the supplier to the recipient. Other concepts described within the study were the 51 use of other medications, current sources, and the need for Valium. The most common dose of Valium was 5 milli­grams which was usually taken once during a 24 hour per­iod. Valium was often used in conjunction with several other medications. In order to replenish the supply of Valium, the user had to be currently under the supervi­sion of a physician or supervised assistant, and had to communicate with that health care provider before Valium could be refilled. The average time allotment for sup­ply replenishment was monthly. Surprisingly, subjects felt that Valium was not needed to cope with everyday pressure and could manage effectively without the use of Valium but still continued to obtain the drug. Limitations of Study Generalizability of the findings is limited pri­marily because of insufficient sample size and the bias of the population sampled, i.e., those from physician office files. A larger sample size would tend to as­sure increased statistical power, validity, and relia­bility of the findings. Another limitation was the lack of variety of so­cial, economic, religious and cultural backgrounds. A large proportion of the sample indicated a preference for the Mormon religion. This factor may not have re­flected typical responses for initial information 52 sources of Valium and its use because of the stigma that is placed upon an individual when emotional conflicts occur. Further investigation using a larger sample of men and women who represent a variety of social, econo­mic, religious and cultural backgrounds needs to be ob­tained in order to procure accurate and reliable data. An additional limitation was the topic. Valium in recent years has received a large amount of negative criticism. Therefore, Valium users do not like to ad­mit use for fear of being categorized as a potential Valium abuser. This phobia of being accused as a drug abuser can interfere with the truthfulness of the re­sponses and failure to return questionnaires. Implications for Further Research The first need for further research is that the investigation be repeated, replicating and extending, with larger numbers of subjects from differing locali­ties and subcultural groups. Ideally, the large sample size should represent men and women from a variety of social, economic, religious and cultural backgrounds. Every effort should be made to ensure a response rate of at least 75%. The questions in the instrument need to be shor­tened, more precise, and structured for simple answering 53 avoiding the multiplicity problem particularly found in items 16, 17 and 19 of the questionnaire. These items include: a) facts about Valium made available by the initial source, b) initial information communicated to supplier by the subject and c) present problems for Val­ium use. Another possibility is to investigate what the in­dividual expected of the health care professional when help was sought in obtaining relief from stress, anxi­ety or tension. As noted in the literature, little, if any, research has been done to see if drugs are ini­tially sought when stress develops. "Chances are that instead of the prescription what the patient really needed was ten minutes of her doctor's sympathetic atten­tion" (Nolan, 1976, p. 94). Implications for Nursing Practice The purpose of this study was to identify from what initial information source Valium users learned of the drug and its use. The questionnaire was construc­ted using the concepts of initial information source, information, use/abuse, dose and frequencies, other me­dications, current source or supplier, and present need of Valium. In the analysis of the data the majority of findings were found to be in accordance with some of 54 the research reviewed in the literature. These findings can be applicable to any health care professional who is concerned about the use of Valium and the role it plays in an individual's life. The nurse, as a part of the health care team and a health care professional could utilize these findings for selecting therapeutic alternatives other than chemicals/drugs, which are frequently prescribed. With the awareness of the emotional aspects of stress and the role stress plays within a system, the nurse could provide optimal combinations of care, help, support, counseling and information. When, as deter­mined by the nurse, an individual is having difficulty coping and adapting to a disturbing situation, the nurse could offer new ways of coping and adapting to the prob­lem. In conclusion, the role of providing care, under­standing and support is extremely important in helping the individual cope with existing stresses from today's society. Often a health care professional, such as a physician, does not have adequate time to reinforce cop­ing mechanisms, therefore a drug is provided. A nurse has the time and ability to analyze, plan, implement, and evaluate the needs of an individual, in order to help that individual return to a homeostatic state. APPENDIX QUESTIONNAIRE 56 PLEASE CIRCLE THE APPROPRIATE ANSWER OR ANSWERS, OR FILL IN THE BLANK: 1. Sex a. Male b. Female 2. Age a. 15-20 years b. 20-29 years c. 30-39 years d. 40-49 years e. 50-59 years f. 60 years or older 3. Race a. Caucasian b. Spanish c. Negroid d. Jewish e. European f. Other 4. Religion a. Mormon b. Catholic c. Protestant d. Jewish e. Other 5. Education a. 0-6 years b. 7-9 years c. 10-12 years d. Completed post high school vocational education e. Graduated from four years of College f. Completed Master's education g. Completed Doctoral education 6. Occupation a. Professional b. Managerial c. Clerical, sales d. Housewife 57 e. Farmer, farm laborer f. Craftsman, foreman g. Other Manual, service h. Other ---------------------------------------------- 7. Income a. Under $5,000. b. $5,000. - $9,999. c. $10,000. - $14,000. d. $15,000. - $24,000. e. Over $25,000. 8. How did you initially learn about Valium? a. Magazine ad b. Magazine or newspaper article c. Billboard d. Physician e. Nurse f. Social worker g. Family member h. Friend i. Street source j . Other 9. Who provided your initial dose of Valium? a. Physician or supervised assistant b. Family member c. Friend d. Street source e. Other 10. When you first used Valium it was because: a. You requested it b. It was given to you without your request 11. Did you initially request Valium from a: a. Physician or supervised assistant b. Family member c. Friend d. Street source e. Other ---------------------------------------------- 12. You used Valium for the first time because: a. A family member gave it to you b. A friend gave it to you c. A physician or supervised assistant gave it to you. d. A street source gave it to you. e. Other ---------------------------------------------- 13. The reason why you took your first Valium was be­cause: 58 a. Family member or members said it would help you b. Friends suggested that you try Valium, to help you. c. Newspaper or magazine articles stated that Valium is helpful with the problem that you have. d. Physician or supervised assistant suggested it would help your condition. 14. Did the initial source or supplier of Valium iden­tify different reasons for using Valium? a. Yes b. No 15. Did the initial source or supplier of Valium iden­tify which action of Valium was appropriate for you and your specific condition? a. Yes b. No 16. Which of the following facts about Valium were made available to you by your initial source of informa­tion about Valium (Circle more than one if appro­priate) . a. Reasons why you need to be taking Valium. b. What Valium should do for you, changes you may experience. c. How long you should be taking Valium. d. Potential side effects, such as fatigue, and sleepiness. e. If Valium can be taken with other drugs. f. Amount and frequency of use. g. Refills, how often and how many. h. Special instructions regarding caution in using alcohol when taking Valium, i.e., operating heavy equipment and driving. i. None of the above j. Others --------------------------------------------- 59 17. Which of the following did you communicate with the person who initially gave you Valium (Circle more than one if appropriate) a. Anxiety, tension, stress b. Emotional withdrawal, depression c. A muscular-skeletal problem d. A urinary problem e. A stomach disorder f. A heart-circulatory disorder g. Hostility, anger h. High blood pressure i. Alcoholism j. Seizures k. Insomnia 1. Other ---------------------------------------------- 18. Were other alternatives besides Valium explored be­fore Valium was given to you? a. Yes b. No 19. Why are you now taking Valium? a. Anxiety, tension, stress b. Emotional withdrawal, depression c. Hostility, anger d. A muscular-skeletal problem e. A urinary problem f. A stomach disorder g. A heart-circulatory disorder h. High blood pressure i. Seizures j. Insomnia k. Other ---------------------------------------------- 20. How long have you taken Valium? a. 0-3 months b. 4-6 months c. 7-12 months d. 1-2 years e. 3-4 years f. 5-10 years g. 11-15 years h. Greater than 16 years 21. What color(s) of Valium pill do you take? a. White b. Yellow c. Blue 22. How often do you take Valium? a. Once a day b. Twice a day c. Three times a day d. Four times a day e. Five times a day f. Six times a day g. More than six times a day 23. How many Valium pills do you take at one time? a. One-half b. One c. Two d. Three e. Four f. Five or more 24. How many Valium pills do you take during a 24-hour period? a. One b. Two c. Three d. Four e. Five f. Five or more 25. How many drugs/medications are taken daily not counting Valium? a. 0 b. 1-3 c. 4-6 d. 7-10 e. 11 or more 26. How many pills are taken daily not counting Valium pills? a. 0 b. 1-3 c. 4-6 d. 7-10 60 e. 11 or more 28. How many office visits did you have with a physi­cian or supervised assistant before obtaining your first Valium pill (If does not apply to you, go to number 29). a. 0 b. 1 c. 2 d. 3 e. 4 f. 5 g. 6 or more 61 29. How often do you visit the person who supplied your initial dose of Valium (to obtain more Valium)? a. Twice a week b. Weekly c. Every two weeks d. Monthly e. Quarterly f. Every six months g. Yearly h. Never 30. Do you still obtain Valium from the person who pro­vided you with your first Valium pill? a. Yes b. No 31. How many times can the current prescription be re­filled without communicating with the physician or supervised assistant? a. 0 b. 1 c. 2 d. 3 e. 4 f. 5 g. 6 or more 32. How often do you replenish your supply? a. Twice a week b. Weekly c. Every two weeks d. Monthly e. Quarterly f. Every six months g. Yearly h. Other ---------------------------------------------- 33. How many different individuals, including your physician, currently supply you with Valium? a. 0 b. I c. 2-3 d. 4-6 e. 7 or more 62 34. Are you currently under the supervision of a physi­cian or supervised assistant? a. Yes b. No 35. Do you take Valium for reasons other than those initially prescribed? a. Yes b. No 36. Do you need to use Valium to cope with everyday pressures? a. Yes b. No 37. Do you believe you could manage without Valium? a. Yes b. No REFERENCES Anderson, R.E. & Carter, I.E. 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