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Running head: WHERE THE LINE SHOULD BE DRAWN

Where the Line Should be Drawn: The Prescription of Anxiety Medication

Jordan Stewart

First Colonial High School

Legal Studies Academy

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Abstract

This paper is focused on the overprescription of anxiety medications. It begins by describing the

difference between anxiety and stress as the two are commonly confused. Then it clarifies what

characteristics demonstrate the need for a prescription and the types of drugs prescribed to treat

an anxiety disorder. Along with this, statistics on drug abuse in the United States are presented to

help portray the severity of this issue and how it is rapidly growing. To support these statistics

case examples are given as a graphic means of the severity. The paper then moves into the

current laws towards prescription medications in Virginia, how this compares to other places,

and solutions to help with the growing overprescription issues.

Keywords: overprescription, anxiety medications, difference, drug abuse, severity, solutions

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Where the Line Should be Drawn: The Prescription of Anxiety Medication

What is the Difference between Stress and Anxiety

Similarities

Although commonly confused with one another, the difference between stress and

anxiety is shockingly prominent. They are confused due to the way they are used

interchangeably when describing feelings and emotions to others. Since both may have similar

symptoms on the body such as increased heart rate, panic attacks, spike in blood pressure, and

many other physical effects, it may be difficult for an uninformed individual to differentiate the

two (Moss).

Differences

The biggest difference between stress and anxiety is the catalyst. Stress is a response to a

threat or a situation, real or perceived, by the body. It is characterized by the bodys reactions

such as increases in cortisol, adrenaline, and other pertinent hormones (B. Simmons-Becil,

Personal communication, November 25, 2016). These reactions are what lead to the symptoms of

chronic fatigue, crying, overeating, undereating, infections, and other prominent physical effects

that are able to be noticed by an individual and those around them ("How Is Anxiety Different

from Stress? - Stress and Anxiety," 2016). The strongest identification of stress is that the threats

are present in a certain moment with a specific cause, which can be a result of multiple factors

that build up and may last for a substantial time, or be over in a quick moment. In order to relieve

stress, the situation that is causing it either needs to be resolved or perceived differently to

decrease the stress response. Anxiety, on the other hand, is a reaction to the stress experience

that, converts fear into feelings by causing a person to feel anxious about being anxious
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("Stress," n.d.). Everyone experiences anxiety in different ways with physical symptoms as well.

Some may report feelings of edginess, anger, or crying, but most common are shortness of

breath, chest pain, heart palpitations, increase in sweating, stomach pains/cramps, and GI

responses including vomiting and diarrhea (B. Simmons-Becil, Personal communication,

November 25, 2016). Those with anxiety face symptoms that are much more severe and

debilitating. It derives from uneasiness, fear and worry. There are many signs for anxiety such as

that the symptoms persist even after the stressors are gone. Some people have difficulty

navigating their day to day life because, a flat tire for you or me might just be an aggravation,

but for someone with poor coping mechanisms, a flat tire might incite a crying fit with heart

palpitations and feelings of suffocation (B. Simmons-Becil, Personal communication,

November 25, 2016). Reactions such as these demonstrate how there is not one singular common

cause of anxiety. Everyone experiences it at some point in their life and it is individual meaning

it will affect everyone at different degrees of severity.

Importance

As stated before, in order to resolve stress the stressor either needs to be removed or

perceived differently. Unfortunately, anxiety does not have this pinpoint cause and cannot be

controlled easily, which is why it is considered a legitimate mental disorder. Neither of these can

be dealt with if it is unsure as to which a person has, and if stress and anxiety are not handled

appropriately it can negatively impact the person who has it and those around them. Psychiatrist

Bethanie Simmons-Becil, who specializes in depression, anxiety, and medication management

explains that, Children learn how to handle their stress and anxiety from those that are around

them, and if a child has a parent that cries, gets angry, throws things, and/or yells when they are
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anxious, then the child will often have the same reactions to stress (B. Simmons-Becil, Personal

communication, November 25, 2016). Additionally, if a parent has a high level of anxiety on a

constant basis, often children will pick up these same habits and be anxious much of the time as

well. Unfortunately, as children have not developed the ability to fully articulate their emotions,

they will not be able to explain these feelings as well as an adult.

Another important point is how anxiety is caused by a lack of coping mechanisms, and if

a person does not learn to deal with situations, then it will be a lifetime struggle for them to

manage it. Individual therapy, specifically cognitive behavioral therapy (CBT) is the best

treatment for anxiety (B. Simmons-Becil, Personal communication, November 25, 2016). CBT is

an, action-oriented form of psychosocial therapy that assumes that maladaptive, or

faulty,thinking patterns cause maladaptive behavior and negative emotions

("Cognitive-behavioral Therapy | Definition of Cognitive-behavioral Therapy by Medical

Dictionary," n.d.). Treatment for this therapy focuses on altering a persons thoughts and how a

situation is perceived in order to change a persons emotional state. The desired outcome is that a

client learns how to recognize anxiety before it becomes severe, and utilize learned coping

mechanisms to deal with anxiety before physical symptoms arise (B. Simmons-Becil, Personal

communication, November 25, 2016).

When Medication Should be Prescribed

Why it Should be Prescribed

Although the end goal of a client should be to hold the ability to manage their stress and

anxiety on their own, anxiety medication may be a good temporary solution. These medications

should only play a role when the effects of anxiety begin prohibiting daily functions. If it is
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causing insomnia, paralyzing fear, or other debilitating factors, then medication will help to push

these aside so the fundamentals of coping may be built before taking all these factors on.

Generally, medications are solely designed to address physical symptoms. The type of

medication prescribed can play a major role into the effectiveness of therapy on an individual to

eventually manage themselves (Fenton et al.).

Types of Anxiety Medications

Antidepressants are used to influence neurotransmitters such as dopamine, which controls

the pleasure sensors, and serotonin, which stabilizes mood. This medicine does not target

specific anxiety attacks as they can take up to several weeks to begin working and therefore

causes withdrawal symptoms such as dizziness, nausea, headaches, and other effects when time

comes to edge off the medication ("How Antidepressants Are Used to Treat Anxiety," n.d.).

Ironically, these symptoms often cause stress and anxiety resulting sometimes in patients going

right back onto medication.

Buspirone is a long term medication prescribed for anxiety and works toward balancing

uneven chemicals in the brain that may result in the tension and fear that cause the anxiety

("Buspirone: Uses, Dosage, Side Effects," n.d.). Common symptoms of this product include

dizziness, uneasiness, upset stomach, and other physical side effects that often times are cause by

the anxiety people on this medication are attempting to rid.

Benzodiazepines have addictive qualities that lead it to be, a large contributor to the

controlled substance abuse epidemic in the United States (B. Simmons-Becil, Personal

communication, November 25, 2016). For this reason it should not be prescribed to anyone with
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past substance abuse issues. Also, it can only be prescribed for short term use to help with acute

anxiety cases as a form of sedation ("Generalized Anxiety Disorder," n.d.).

Risk of Starting Abuse

A shocking 90% of prescription drug abuses begin in the teenage years, and currently 1 in

6 teenagers has reported using prescription drugs to either get high or alter their mood in some

way ("Legally Dead | Exploring The Epidemic of Prescription Drug Abuse," n.d.). Considering

that anxiety medications hold the purpose of changing mood, it is no doubt to the dangers of

having an immense amount of them being prescribed. In 2011 reports found that 1 out of every 5

Americans is on a psychiatric medicine, and from 2001 to 2010 there was a 100 percent

increase in the number of children under age 10 taking antipsychotic medications ("Americas

startling Use of Mental-illness Drugs: By the Numbers, A Nation of Pill-Poppers," 2011).

Examples of Wrongful Prescriptions

This case was filed after the death of an eleven year old boy by the name of David Glenn

Noll. The suit deals with the medical malpractice apparent by the boys doctors, Dr. Rahal and

Dr. Jaffe, when treating the patient. Davids mom took him to the doctor because he was

experiencing neck pain and discomfort behind one ear caused by a swollen gland. The two were

told by Dr. Jaffe that these symptoms were simply caused by a virus and recommended Tylenol;

however, after leaving the hospital the two shortly returned because David said his head was

very sore, which the doctor concluded was due to a tick bite on his head, and sent them back

on their way with no change in diagnosis or prescription. Two days later, Davids condition

continuously worsened, so his mother then took him once again to Dr. Jaffe, who decided at this

point David had the measles yet prescribed him no further medication. Unfortunately, Davids
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condition once again kept worsening, so his mother called the pediatrician's office where Dr.

Jaffe worked and spoke to Dr. Rahal on the telephone. She provided him with her childs

symptoms and prior diagnosis, and Dr. Rahal, over the telephone, prescribed the boy medication

to try and prevent the vomiting David was experiencing. The next day, it was once again obvious

that David was becoming sicker, and so he and his mother went back to the doctors office. This

time the two saw Dr. Rahal in person for the first time, but during the visit David collapsed and

began convulsing. He was rushed to the hospital and died from Rocky Mountain spotted fever,

just eight days after his initial visit. (Noll v. Rahal)

While many elements of this case do not relate to what has been mentioned, some aspects

clearly demonstrate the issues dealing with prescriptions of anxiety medications. No medication,

despite the reason, should be prescribed on the phone, even if it is a refill. In most situations a

patient can wait until office hours to receive medication, and if not, then they should take

themselves to an urgent care or emergency room facility. Another point is that the second doctor

did not consult with Davids first doctor before proceeding to treat him. Although this may be

difficult in some situations, the two worked in the same office and it was obvious David had

been seen several times and was still having issues, which should raise a few warning signs. In

situations where a doctor may feel that it is imperative to immediately prescribe medication, the

doctor should then schedule an appointment to follow up with the patient as soon as possible to

prevent missing certain symptoms an average person would not be aware of, and to ensure that

the medication and dosage is appropriate. Considering there are not many cases dealing with the

overprescription of anxiety medications, this case provides a good example of how a lack of laws

in all aspects are severely affecting the lives of residents. If someone is actively seeking help and
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not able to receive adequate care, then how can it be expected that somebody with a mental

disorder such as anxiety, who may be reluctant to get help, is ensured proper treatment when

they would not be as persistent as Davids mother was.

Over prescription not only pertains to the prescription of drugs in general but also the

number of drugs which a person is prescribed. This can be described well in Heather Renae

McDonald told lawmakers that her husband, Scott Alan McDonald, was treated by the VA and

was on up to 15 pills a day within the first six months of back pain and mental health treatment.

In September of 2012, she said she found her husband dead on their couch after he had been

prescribed Percocet. McDonald maintained that her husband's liver was inflamed and that VA

clinicians would have known that if they had done liver function testing, in light of the large

number of medications he was taking. When I asked VA why more tests were not performed to

make sure he was healthy enough, they responded that it was not routine to evaluate our soldiers

pain medication distribution, she told lawmakers ("Legislators Call on VA to Stop

Over-Prescription of Powerful Painkillers," n.d.).

In this case the necessary care was not taken to ensure that Mr. McDonalds health was in

good terms. The description explains how an evaluation had not been performed because it was

not required by law, which directly correlates with the cause of death for Mr. McDonald. It is

very apparent that not all medical practitioners hold the motivation to be thorough, so it needs to

be required by law for these steps to be taken to ensure the publics safety.

One example that depicts greatly the benefits to taking the time to search out multiple

forms of treatment is in the situation of Justin Minyard. He is medically retired from the Army

and said that he had suffered from back pain. For this he was prescribed painkillers by both DoD
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and VA healthcare providers. At his worst point, he said he was taking enough opioid pain

medication to treat four terminally ill cancer patients. After looking for other options to control

his pain, he found a doctor at Fort Bragg who was conducting a clinical trial of spinal cord

stimulation. That treatment has been successful for him, and he said he is now off opioids. He

cautioned, however, that not all veterans and service members have the resources and awareness

to advocate for alternatives to opioids pain regimens. My wife had to advocate for me, not

taking no for an answer, he said in his written statement ("Legislators Call on VA to Stop

Over-Prescription of Powerful Painkillers," n.d.).

What stands out about Minyards case is not that he went searching for other treatments,

but that it was not him who did so. Many anxiety patients fall will to their psychiatrists, and it is

not for lack of caring yet too much trust in their medical providers. Due to this common theme

among the medical field, it should be required that doctors, such as psychiatrists, completely

inform their patients on all practices that may help whether they find them effective or not. They

should still be allowed to give their professional opinion to patients, but there needs to be a

system that combats against the greed of money that comes when prescribing medications as

well as the laziness that causes patients to get the short end of the stick.

Virginias Laws

Virginias laws do not mention on prescription medications except for on the

requirements a person must hold, the relationship between doctor and dispensary, and briefly the

requirements of observing previous medications. The law discussing the review of previous

medications are as follows as in the Virginia Code:

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any prescriber who is licensed in the Commonwealth to treat human patients and is

authorized to issue a prescription for a covered substance shall be registered with the

Prescription Monitoring Program by the Department of Health Professions. A

prescriber shall, at the time of initiating a new course of treatment to a human

patient to last more than 14 consecutive days, request information from the Director for

the purpose of determining what, if any, other covered substances are currently

prescribed to the patient. In addition, any prescriber who holds a special identification

number from the Drug Enforcement Administration authorizing the prescribing of

controlled substances approved for use in opioid addiction therapy shall... request

information from the Director for the purpose of determining what, if any, other covered

substances the patient is currently being prescribed. Nothing in this section shall prohibit

prescribers from making additional periodic requests for information from the Director as

may be required by routine prescribing practices. ("Virginia Law," n.d.)

Interpreted

Essentially, the Virginia Code lays out how before a patient is given any new form of

treatment the provider is supposed to review their file under the prescription monitoring program

to prevent any abuse in medications from being repeated or started. While this is a big step in the

right direction that Virginia needs to be taking in order to provide safe medical care, this code,

and other codes dealing with prescription medications, do not outline the care and the continued

steps that should be taken by these prescribers for prescriptions past the first fill.

California Law
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While many aspects of Californias laws concerning the prescription of medications

follow suit in terms of prescribing, labeling, and dispensing, there is one preventative measure to

ensure that there is no abuse in the form of tampering prescriptions. Prescribers must use tamper

resistant forms; Prescribers must order the new tamper-resistant forms from security

prescription printer companies that have been pre-approved by the Board of Pharmacy and the

Department of Justice to produce the forms ("Approved List of Security Prescription Printers,"

2016). This will ensure that patients cannot copy or produce forms dealing with medication that

would enable them to take prescriptions not according to how they were prescribed. Although

this is a minor step in working towards preventing abuse, it would help towards preventing this

type of abused here in Virginia such as those presented by Mrs. Simmons-Becil, ...or attempting

to duplicate scripts from multiple providers (B. Simmons-Becil, Personal communication,

November 25, 2016).

Solutions

Need for Stricter Laws

Half the battle of dealing with mental disorders, such as anxiety, is recognizing them. It

is even a bigger step for a person to admit that they need help dealing with this issue, and

actually taking the steps to get help versus suffering in silence. When a person goes to a doctor

or psychiatrist they should feel they are in the best hands possible, and with the lack of current

legislation, there is nothing to ensure this is the case.

Mrs. Bethanie Simmons-Becil has described her routine to ensure she only prescribes

necessary medications as the following:

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The Prescription Monitoring Program, is a multi-state monitoring program that records

every controlled substance prescription filled by a patient at all pharmacies. As a

conscientious provider, I will check the PMP prior to every visit, drug test clients at the

outset of a new prescription and then intermittently, and have every client sign a detailed

Controlled Substance Contract. Such a contract delineates where and when a client have

full prescriptions and provides consequences for violation of the contract, up to and

including discharge from the practice. (B. Simmons-Becil, Personal communication,

November 25, 2016)

The care that Mrs. Simmons-Becil provides for her clients is significantly different than

those required by law, and it should not be considering that even with these precautions she has

had patients abuse and become addicted to medication. Psychiatrists and doctors need to have

stricter requirements to ensure they do not become lazy with their practices that may cause

negligence, to require following up on patients before each visit in order to ensure that there are

no past addictions, that any new information regarding potential abuse has not been added by

other medical personnel, and that they are taking the care to ask questions that might reveal

abuse of medications.

One option some other states have approached is giving patients the ability to sue for the

negligent prescription of opioids. West Virginia has recently implemented this saying that it

opened the floodgates for doctor accountability ("Courts Say Patients Can Sue Doctors for

Overprescribing," 2016). An implemented law allowing this would ensure that prescribers take

more care to view all aspects of an individuals situation before writing a prescription, including

past histories that may demonstrate addiction. Another benefit is that it may encourage
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prescribers to start with less severe dosages or types of drugs versus jumping in to unnecessary

levels that may affect ability to perform daily tasks, or are more likely to spur an addiction.

Alternatives Doctors can Recommend or Prescribe

Some other options to deal with anxiety include aromatherapy, rescue remedy,

meditation, vitamins B, expressive outlets, and several lifestyle changes. Aromatherapy is the use

of plants and oils to alter mood. It works by stimulating the limbic system which releases

chemicals affecting the brain. Some of the benefits to aromatherapy include relaxation and

calmness ("19 Natural Remedies for Anxiety," 2013). Rescue remedy is, an apothecarys herbal

tincture for anxiety and panic attacks (B. Simmons-Becil, Personal communication, November

25, 2016). The remedy contains flower extracts which help a person relax during a stressful

situation that arises. Meditation allows a person to focus their attention on a particular moment

instead of allowing stressors to take over thoughts. This form of coping is useful because it can

be practiced anywhere without the need of anything other than ones self. Deficiency of B

vitamins can cause irritability and depression, so increasing them can lead to relaxation and

better sleep ("19 Natural Remedies for Anxiety," 2013). Creative outlets can be considered as a

range of things, including anything from writing feelings out on paper to practicing a hobby.

While many of these are used to get the mind of stressors some may actually help somebody

pinpoint their cause of stress. Lifestyle changes are harder and take longer to implement than

other alternatives. Exercise and a sleep schedule are just two of the possible changes that help

decrease stress and anxiety. These may take awhile to implement because exercise can be time

consuming and take a while to work up to, and in order to regulate a sleep schedule other factors

may be affected such as work, social time, and other daily activities or routines.
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Conclusion

Essentially, the difference between stress and anxiety is that stress is caused by

situational factors while anxiety is a result to stress. While they may have similar results, it is

important to understand this difference since it will determine the way in which it is dealt with to

resolve these effects. One way anxiety is dealt with is through medication, but it should only be

used for a short period time until reactions can be managed and not as a crutch. More hesitation

should be used when prescribing anxiety medications to assist in preventing the start or

continuation of an addiction. Unfortunately, through cases that have already occurred, it can be

seen that some prescribers are too loose in their checks; therefore, Virginia laws need to be

stricter to ensure the safety of patients. Anxiety medications should only be used in critical and

severe cases that debilitate a person from performing daily tasks. For other instances, other

alternative solutions, such as natural remedies, should be tested first.

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