Deep-pocketed companies can get the poll results they want, which is a good reason not to believe industry-supported polls
A Vanderbilt University poll has shown that regardless of political affiliation, Tennesseeans strongly support returning Sudafed and other cold medications that contain pseudoephedrine (PSE) to prescription-only status. This policy has been proven in other states to virtually eliminate meth labs, so it’s unsurprising that Tennesseeans would endorse it after years of suffering from the fires, explosions, burns, poisonings, destroyed property and lost tax dollars that the labs cause. Yet State Senate Speaker Ron Ramsey was shocked by the poll’s result. To understand why, one has to appreciate how a deep-pocketed special interest group can finance polls that create a false impression about what voters really want.
The Consumer Healthcare Products Association (CHPA) represents the manufacturers of pseudoephedrine-containing cold medications that are easily converted to meth. Unlike the pharmaceutical companies that produce the same medications in extraction-resistant formulations, the manufacturers represented by CHPA take in hundreds of millions of dollars a year from meth cooks. As documented by journalist Jonah Engle, CHPA’s desire to protect this enormous revenue stream has led it to spend unprecedented amounts of money lobbying state legislatures to not return PSE-containing medications to prescription-only status.
But CHPA doesn’t just pursue its interests through lobbying. It also releases polls that overstate the public’s agreement with CHPA’s corporate clients. That’s why Speaker Ramsey was “amazed” to find that Democrats, Independents and Republicans (including 64% of Tea Party Republicans) in his state overwhelmingly support returning PSE-containing cold medications to prescription only status. Ramsey, like many other people, had been misled by a press release about a CHPA-sponsored poll claiming that 56% of Tennesseans were opposed to the policy.
CHPA released similar polls in Oregon and Mississippi prior to those states returning PSE-containing cold medications to prescription-only status. In both cases, the policy has been popular with voters and no legislator has been voted out of office for supporting it. The Tennessee poll and others like it are thus a continuation of a well-established corporate strategy of spreading misinformation about public preferences.
I have written before about new cold medications that are claimed by their manufacturers to be resistant to the extraction of pseudoephedrine (PSE), a key ingredient of domestic methamphetamine production. These medications hold out the tantalizing possibility of a “have your cake and eat it too” public policy in which PSE-containing cold medication is widely available but meth cooks are put out of business.
According to their manufacturers, these medications (e.g., Nexafed, Zeprhex) work by binding PSE in a lipid or polymer that leaves it with normal bioavailability for people with stuffy noses but limits extractability for meth production. However, the Drug Enforcement Administration is claiming that it is still possible to make meth from these “resistant” medications.
Who is correct depends on what it means to ask whether these medications “work”.
If “work” is defined as whether given infinite production resources, meth could be made from resistant medications, then the DEA is correct: The medications don’t work. A small amount of PSE per box of resistant cold medication can be extracted in a superlab, so if you had an unlimited number of boxes and lab technicians you could eventually make a significant amount of meth.
But if we ask whether these medications “work” in the public policy sense of whether they will curtail meth labs, the data show they will work quite well. It takes about about 10 times as much Zephrex as traditional cold medication (e.g., Sudafed) to make the same amount of meth, which translates economically into an unattractive proposition for a meth cook: The resistant cold medicine required to make meth would cost many times more than the highest price that the meth market will bear.
The DEA is thus correct only in the trivial respect of proving that these medications don’t work in a world in which the laws of economics are suspended. But in this world, they remain a valuable tool in the quest to reduce the destruction caused by meth labs.
This year’s political battles over making some cold medicines available only by prescription in order to reduce meth labs have a new wrinkle
The 2014 legislative cycle in a number of states will witness efforts to curtail the methamphetamine labs that cause so much death, destruction and environmental despoliation from West Virginia to Oklahoma. Oregon and Mississippi have proven that putting cold medicines that contain pseudoephedrine (e.g., Sudafed) on prescription-only status virtually eliminates meth labs. But other states that have tried to pass similar laws have been overwhelmed year after year by the might of the cold medicine industry, which spends more money on lobbying in meth belt state legislatures than any other (notably, in West Virginia, coal industry lobbyists express envy at the cold medicine industry’s influence).
One of the industry’s central arguments is that people with colds and allergies need PSE and will suffer from reduced access. However, new technologies in medication production render this argument moot. As I describe today at Stanford School of Medicine’s SCOPE Blog, it is entirely possible to write legislation in such a way that meth labs are choked off while access to PSE-containing medications is maintained.
There is thus a policy compromise on the table that could draw diverse support on a hard-fought, important policy issue. That will bring smiles to the faces of decent and intelligent people. But drug policy, like public policy in the U.S. generally, includes a faction of perennially angry people to whom compromise is a dirty word. Expect such ideologues to fight hard against the public interest on this one.
Purity and potency are not the same thing, and that matters for drug policy
How many times have you read scary stories in the press about addictive drugs of unprecedented purity? How often in movies has the villain been the one to cook up an incredibly pure drug? “Pure” in these cases is used as a shorthand for powerful and dangerous, but that isn’t what it means.
Purity is a measure of how much of some substance is “what it says on the tin”. Potency in contrast refers to the dose necessary for a substance to exert its effect on the body. Ivory Soap, famously, is 99.4% pure. But its potency when ingested is far less than that of 1% pure heroin.
This ends up mattering more than one might think in drug policy debates. Policymakers and parents get scared when they hear that an addictive drug is pure. But a pure drug can be safer than an impure drug if the potency of the latter exceeds the potency of the former. Even within the confines of the same potent drug, purity can increase safety if the impurities are nasty things such as levamisole or strychnine.
One concrete area where this misunderstanding is influential and sometimes exploited for effect concerns methamphetamine. A prescription requirement for the pseudoephedrine-containing cold medicines that are used to make meth would virtually wipe out domestic meth labs. Opponents of this policy sometimes try to scare people by saying that the result would be an influx of “much purer” methamphetamine made without pseudoephedrine (PSE) in Mexican superlabs (PSE imports are banned in Mexico). Yes, that form of methamphetamine is purer, but it’s less potent and hence less dangerous than methamphetamine made from PSE, even before you count up the burn injuries, explosions and fires that small-scale domestic meth labs cause.
Again this year, the cold medicine industry was the number one lobbyist in all the state legislatures that considered making pseudoephedrine-containing products available by prescription only. They won in every state, which is not surprising given that the Citizens United decision makes them even more powerful than they were in prior years. Legislators who wanted to set a prescription requirement to obtain the 15 cold medicines that can be used to make methamphetamine were simply outgunned by the financial might of the industry. Their states will again be ravaged by meth labs this year, and the industry will again pocket hundreds of millions of dollars by selling their products to meth cooks.
Dr. Walter Ling, one of the world’s most respected addiction treatment researchers, has completed the first long-term placebo-controlled trial of PROMETA. This alleged miracle cure for methamphetamine addiction proved completely ineffective. I have a short commentary in the journal Addiction (pdf here) describing the rise and fall of this heavily-promoted treatment protocol.
60 Minutes did some investigative reporting on PROMETA a few years back, noting that the treatment protocol was never FDA-approved and that a suspicious number of its advocates were discovered to have a financial stake in the product. The whole story is worth watching as a cautionary tale.
As someone who has worked with addicted patients, I am struck by the moment when journalist Scott Pelley asks the creator of PROMETA (a former junk bond salesman named Terren Peizer) about the need for evidence before an addiction treatment is marketed. Peizer responds as follows:
If you had a son. If you had a son or a daughter, and maybe you do. If he’s strung out on meth. And he’s going to kill himself. Would you, if you had the opportunity. And I said to you, will you treat your son with Prometa?…Would you take that option for your son?”
The answer to this question is yes for many people, but this undermines rather than supports Peizer’s contention that it’s wrong to wait for evidence. Rather, it is *because* people are so desperate for a cure to addiction that we have a responsibility to rigorously research putative cures before they are marketed to the public. Otherwise, vulnerable, frightened people may spend thousands of dollars on ineffective treatments instead of pursuing other options that have a greater chance of restoring them to health.
Most of the news in the new household survey on drug abuse is good: cocaine and meth use are down, meth initiations are way down. There’s an uptick in cannabis use, especially among young adults. So why is the official press release headlined “National Survey Shows a Rise in Illicit Drug Use”?
Oh, yes, and cannnabis use is up some (almost 20% from the 2007 trough, from ), especially among young adults (18-25). Cannabis use among those under 18 is flat. Mean age at first use is up from 17 to 18.4: that’s the direction you want to see it going.
So the on-one-foot summary of the results is “Nothing exciting, but basically good news.”
But if you were really, really, really stupid – or had a job that required you to pretend to be that way – you might just treat all use of illicit drugs as alike and simply count the number of users. In that case, the modest rise in cannabis use would swamp all the other results, because cannabis is by far the mostly widely used illicit drug, and a report mostly full of pretty good news would come out as “National Survey Shows a Rise in Illicit Drug Use,” complete with silly viewing-with-alarm quotes from officials.
(No, dammit, we are not “at a crossroads”! Next year is mostly going to look like this year.)
Even after 30 years in the business, it’s hard to get used to how plain damned dumb the official (and journalistic) discourse on this topic is. The household survey (aptly named NS-DUH, where DUH is pronouned “duhhhhhhhhh”) doesn’t get at what’s really interesting: the number of problem users, and especially criminally-active problem users. But it does contain some useful information. Too bad the people running the show mostly ignore that information and concentrate on fluff.