Tuesday, February 7, 2012

Even more restrictions on Sudafed?

You can see this coming.  Even some idiots in Indiana want it: to effectively deny the mast majority of people access to an effective drug for combatting cold symptoms because a tiny minority of people misuse it.  Yes, we are talking about pseudoephedrine (PSE), the active ingredient in Sudafed, which is often used by meth heads to cook up meth.

We already have the incredibly stupid requirement that puts Sudafed behind the pharmacist's counter, and restricts how much you can buy.  Annoying and frankly insulting, but manageable.  To people such as Professor Keith Humphreys, however, that simply is not enough:
Methamphetamine cooks cannot operate their labs without easy access to the cold medicines that contain pseudoephedrine (PSE). This has resulted in a long-running political battle across the U.S. Many state legislators want to make PSE-containing medicines prescription-only, which as the Oregon and Mississippi experience shows, virtually eliminates a state’s meth labs. On the other side, the cold medicine industry, which makes hundreds of millions of dollars a year selling PSE to meth cooks, opposes such a restriction.
The industry’s response has been to propose an electronic cold medicine purchasing system called NPLEx. The idea is that if someone tries to buy too much PSE-containing cold medicine, the system would notice and block the sale.
From the point of view of stopping meth labs, the system is worthless. South Carolina put it in last year rather than create a prescription-only requirement, and saw meth lab incidents increase by 65%. Kentucky, where the NPLEx system was invented, has had it in place statewide since 2007 and seen meth lab incidents increase by 500%. Meth cooks easily thwart the system by using false ID or by hiring people to buy the cold medicine. The NPLEx system is thus worthless from the point of view of actual effectiveness.
Prof. Humphreys does not come out and say it, but you can see where he is going with this: he wants pseudoephedrine made prescription only.

I hate to oppose a mental health professional like Prof. Humphreys who has spent much of his career studying issues of addiction and has even contributed to rebuilding the mental health system in Iraq, but on this issue he is letting his occupation with addiction blind him to the overall benefit of pseudoephedrine.

Adam Ozimek did not when he discussed this issue a few years ago in response to the proposal by Oregon District Attorney Rob Bevett to make pseudoephedrine prescription-only:
The regulation he is proposing concerns pseudoephedrine, an ingredient in several allergy medicines and, unfortunately, methamphetamine. Where we are on the slope right now is that it can only be sold from behind the counter and buyers are required to present some for of photo identification. Purchases are recorded and buyers are prevented from going over a certain amount in a given time-period. Lost your allergy medicine? Too bad, we gave you 10 days worth, so you have to wait 10 days before you can get more.
This, however, has not stopped the determined meth makers who still manage to get enough pseudoephedrine to keep the streets supplied. Which brings us to the next step on the slippery slope. Bob Bovett wants us to follow Oregon and Mississippi’s leads and require a prescription for any drugs with pseudoephedrine.


So we tried putting it behind the counter. That was step one on the slope, and it didn’t work. Now he wants us to require a prescription, that’s the second step. When that doesn’t work, he’s shown all indication that he’d be willing to push for complete prohibition. I’m not sure what we’ll do when that won’t actually get rid of meth users but simply reduces the potency of their meth. I guess from then on it will just be asking for more funding for enforcement, and stricter penalties for violators.


The slogan for regulation like this  should be “Contrary our assurances that they would, the powers you’ve granted us to stop this problem have not worked. Therefore we need more powers, and we assure you they will work.”

Megan McArdle has kept her eye on the ball as well and rightly takes Prof. Humphreys to task for his post:
What really bothers me is the way that Humphreys--and others who show up in the comments--regard the rather extraordinary cost of making PSE prescription-only as too trivial to mention.

Let's return to those 15 million cold sufferers.  Assume that on average, they want one box a year.  That's going to require a visit to the doctor.  At an average copay of $20, their costs alone would be $300 million a year, but of course, the health care system is also paying a substantial amount for the doctor's visit.  The average reimbursement from private insurance is $130; for Medicare, it's about $60.  Medicaid pays less, but that's why people on Medicaid have such a hard time finding a doctor.  So average those two together, and add the copays, and you've got at least $1.5 billion in direct costs to obtain a simple decongestant.  But that doesn't include the hassle and possibly lost wages for the doctor's visits.  Nor the possible secondary effects of putting more demands on an already none-too-plentiful supply of primary care physicians.

Of course, those wouldn't be the real costs, because lots of people wouldn't be able to take the time for a doctor's visit.  So they'd just be more miserable while their colds last.  What's the cost of that--in suffering, in lost productivity?

Perhaps it would be simpler to just raise the price of a box of Sudafed to $100.  Surely that would make meth labs unprofitable--and save us the annoyance of a doctor's visit.

They can still buy cold medicine, protest the advocates for a prescription-only policy.  But as far as I can tell, there's really no evidence that the current substitute, phenylephrine, does a damn thing to ease congestion; apparently, a lot of it gets chewed up in your liver pretty quickly, and because the FDA only allows a low dose to start with, the resulting pills don't seem to be any better than placebo. For people who are prone to sinus or ear infections, that's no joke; one of the main ways you prevent them is by taking a decongestant as soon as you feel the first ticklings of a cold--not four days later, when your GP can finally see you.

Obviously, the suffering of someone caught in a meth lab is much, much higher--but how many of these people are there?  Should we deny millions of people a useful treatment in order to prevent a handful of fatalities?  Before you answer that, ask yourself whether you'd be willing to stop driving on the grounds that statistically, you're reducing the chances that someone will die.  Or to endorse a policy that involved punching 15,000 people in the head, hard, in order to prevent one death.

Perhaps it's unfair of me, but it seems to me that there's a lot of tunnel vision in these proposals.  People who present prescription programs as simple and obvious seem fixated on the horror of the stories they are confronted with . . . to the exclusion of the very large costs that they're proposing to impose on the rest of us.  All they're interested in is "how do we put an end to meth labs?", a question to which one can reasonably argue the answer is "better control of pseudoephedrine" [footnote omitted].

But no policy question is ever as simple as "How can we stop X", unless "X" is an imminent Nazi invasion.  We also have to ask "at what cost?" and "by what right?"  Humphreys sort of gestures at this in answer to critical commenters, but why isn't it in the original post?  The very large costs of these systems should be front and center in any post that seems to advocate for fairly sweeping controls.

Of course, Humphreys could fairly argue that the real point of his post is to critique the current, failed registration systems that have been implemented as an alternative to prescription-only.  But if that is indeed the central point, then I'd ask why his only complaint is the insinuation that industry is pushing these systems so that they can continue to sell to meth cooks?  The logical implication of his complaint doesn't seem to have occurred to him: if these systems don't work, then they should be repealed.  Full stop.  Regardless of what we do about making pseudoephedrine prescription-only, there's no point in spending time and money on a system that isn't doing anything.

But the meth warriors never seem to advocate repealing anything--not unless they can replace something even stricter.  This bias towards ever-tightening tends to make me somewhat skeptical when they come forward with yet another restriction that is urgently needed to make America safe.
As someone who suffers from colds, sinus infections and congestion fairly frequently, I can say with near-certainty that I would be very negatively impacted by making pseudoephedrine prescription-only.  In my experience, Sudafed and its generic equivalents have often been the only medication that works.  Without it, at times it's almost impossible to function.  I can say with definite certainty that millions of Americans agree with my position.
Yet that means nothing to the drug warriors. Everything has to be sacrificed in the Quixotic quest of the elimination of illegal drugs.  If it makes you completely miserable and unable to function, well, we must all make sacrifices.
Is this the step that will convince everyone the Drug Wars have gone too far? That the Drug Wars were always a losing proposition? (Remember that mind-altering drugs have been in use for the last 10,000 years.)
I can't think of a better way to convince people that the Drug Wars have become more harmful than the drugs they are trying to wipe out than to effectively deny the vast majority of Americans access to a safe and effective drug in pseudoephedrine simply because it is occasionally but rarely misused. 
When will this madness stop?


  1. Jeff,

    Since the state government is tracking Sudafed sales, are there any available figures on how much is sold in Indiana each year? Who would be the right state agency to ask?

    (and by the way, I buy about 10 boxes of sudafed each year for my family of five, it is the only thing that helps when congestion is bad).

  2. Off the top of my head, I do not know. At the state level, my guess is that the Indiana State Police or the Indiana Prosecuting attorneys Council might have some info.