Do We Need Even Tighter Controls on Sudafed?

Amateur meth labs are really, really terrible.  They explode.  They infuse the walls, and maybe the local water supply, with toxic chemicals.  They pose a serious threat to cops and firefighters, not to mention occupants of the houses they're in.   And decontamination seems to be rather daunting.

It's hard to tell exactly what the scope of the problem is; this DEA map unhelpfully lumps together labs, dumpsites, and the equipment used to make meth as "incidents".  And besides, lab busts are not exactly a random sample; they're going to vary by things like how much effort local law enforcement is putting into a meth crackdown. Nonetheless, I think it's fair to say that it's a large problem in the middle of the country, albeit one that has abated somewhat due to the influx of cheap meth being professionally produced by Mexican drug gangs.

The problem of meth labs has resulted in ever-increasing controls over the purchase of pseudoephedrine, aka the main ingredient in Sudafed.  That's why the stuff on the shelves is now called Sudafed PE, and to get the real stuff, you have to go to the counter and sign a book.

But it's not enough, says Keith Humphreys:

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.

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.

As several people pointed out in the comments, it's unlikely that the cold medicine industry "makes hundreds of millions of dollars a year selling PSE to meth cooks".  One prescription-only advocate puts the market for pseudoephedrine products at around $600 million a year; he contrasts this with pharmaceutical company estimates that "only 15 million Americans use the drug to treat their stuffed-up noses, and these people typically buy no more than a package or two ($10 to $20 worth) a year."

Now, personally, I sincerely doubt that the pharmaceutical industry has reliable estimates of how many of their purchasers actually have colds--or that they would share data indicating that half of their revenues came from meth cooks.  But let's say this is accurate: half of all pseudoephedrine is sold to meth labs.  That still wouldn't mean that manufacturers of cold medicines are making "hundreds of millions of dollars a year" off of the stuff--not in the sense that they end up hundreds of millions of dollars richer.  The margins on off-patent medicines are not high, and in retail, 50% or more of the cost of the product is retailer and distributor markup*.  Then there's the costs of manufacturing.

But this is sort of a side issue.  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"**.

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.

Update: Adam Ozimek gives us a glimpse of where this ends:

Uncharacteristically for regulation advocates, he provides a glimpse into the next and final step on the slippery slope: complete prohibition.
In 2009, Mexico, which had been the source of most of the methamphetamine on the streets of the United States, went further, banning pseudoephedrine entirely. The potency of meth from Mexico has since plummeted. This is great news. But now the ball is back in our court.
You will notice not an inkling that Mexico may have gone too far. Clearly he believes that if prohibition is what it takes to reduce the potency of meth (notice he's not even promising it would get rid of it) then it's worth it.

* Not profit--retail margins are pretty slim.  But the cost of shipping the stuff, putting it on shelves, and selling it.

** Though like many of the commenters on the original post, I'm skeptical that you can extrapolate from something that may have worked in one state, to something that would work nationwide.  It strikes me that there may be a reason that the majority of our meth labs seem to be in the middle of the country, which is to say, relatively isolated from easier sources of supply.