Two Quick Notes on Megan McArdle and Cold Medicines Used for Making Meth

I post a short item on cold medicines and methamphetamine, focus on my day job for a bit and wow, return to a sea of thoughtful comments and critique here at RBC and around the web. Well done everyone, and advance apologies that your comments warrant more thoughtful responses than I have time to give them.

I am going to though comment quickly about two things raised by Megan McArdle on her site.

(1) McArdle costs out the price of prescription-only PSE-containing cold medicines based on the incorrect assumption that cold/allergy sufferers would have to visit a health professional every single time they needed the medication. That would indeed be expensive, but that isn’t necessary for a low-scheduled drug. You would visit your doctor or nurse practitioner once and then when you had allergy flareups you would contact your health care provider, who would order a prescription refill for you by telephone or email. And note that because PSE-containing products can be dangerous you should at least once in your life consult a medical professional if you use them anyway.

(2) McArdle writes

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….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implication of his complaint doesn’t seem to have occurred to him: if these systems don’t work, then they should be repealed.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.

I don’t know why she felt the need to imply that I am too stupid to understand the intended implication of my own post. But putting aside the rudeness, yes, that is indeed the central point I was making. NPLEx doesn’t work at all and no one should waste time and money implementing it in their state. It adds inconvenience and cost and we would be better off if it didn’t exist, including but not limited to the fact that it’s a distraction in the obviously important debate about whether a prescription-only PSE law makes sense or not.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College Lonon. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over ten thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

38 thoughts on “Two Quick Notes on Megan McArdle and Cold Medicines Used for Making Meth”

  1. “You would visit your doctor or nurse practitioner once and then when you had allergy flareups you would contact your health care provider, who would order a prescription refill for you by telephone or email.”

    So this:
    (a) is different from existing registration schemes and is less amenable to smurfing, how exactly?
    (b) is an example of how we’re going to bring down health-care costs? Make every purchase of Sudafed require five minutes of the intervention of a medical professional?

  2. You would visit your doctor or nurse practitioner once and then when you had allergy flareups you would contact your health care provider, who would order a prescription refill for you by telephone or email

    Without clicking through to read McArdle, and commenting solely on your post, this is a brilliant solution for people who have a health care provider. And who have the money and the time off to visit the doctor that first time. And it elides the difference between people who have severe and frequently recurring allergy problems that are easily diagnosed and believed, and people who occasionally seek relief from a bad cold. I’m no medical professional, but I rather doubt that “I got a prescription because I had a really nasty cold two years ago, please can I have another prescription” will work over the phone.

    1. I have to go with Warren. The only way this kind of thing would work for ordinary people is by stockpiling, and that just moves the straw-buyer problem somewhere else. (I am thinking of the times I needed pseudoephedrine for a really bad cold, and the ones when we didn’t have any in the house either the local drugstores were all closed or I was feeling too rotten to go out. So I ended up huffing the offspring’s outdated albuterol. Getting a prescription, or even calling in for a refill, would have been way out of the question.)

  3. There’s soon going to be data on the impact of prescription-only pseudoephrine in New Zealand, where the border controls (for quarantine rather than drug reasons) are pretty good. The new law was introduced in September 2011. Even before the law change, the NZ Drug Intelligence Bureau was speculating that larger-scale methamphetamine producers would switch to phenyl-2-propanone as a starting compound, rather than trying to smuggle pseudoephedrine or the finished product.

  4. As the old saying goes, I think this is where I came in on this movie. My very first MM column was this one, http://www.janegalt.net/blog/archives/001572.html , where she finds herself turning blue because she’s all out of asthma inhaler — she’s out drinking in a smokey bar without her albuterol. Fortunately for her, a stranger who also has asthma, and who isn’t under the spell of Ayn Rand and therefore is silly enough to think people should take care of one another, loans her his inhaler, and her life is literally saved.

    Anyway, she’s out of her medicine because she never got around to contacting her doctor to get a refill and she’s really annoyed she can’t just walk into a drug store and buy albuterol over the counter. That’s the real reason she almost ended up in an ambulance, dumb laws and regulations.

    I’m beginning to think she’s against all doctor visits.

  5. For those of us with decent health care insurance, it’s probably even easier than that. Just ask your Doctor/PA to write you a script with a few refills on it when you get your yearly checkup. Then you can keep some in your medicine cabinet for when you need it and refill it when you run out.

    The downside being that they’d probably write you for some generic PSE, so you’d have to take several pills to treat all of your cold symptoms and be careful that whatever else you used didn’t contain another decongestant.

    Of course, for people with poor or no health insurance or for those with less accommodating health care professionals, this becomes yet another annoyance for those trying to navigate our nation’s broken health care system.

    1. In some (most?) states prescriptions have a limited life. In MA, where I live, I think it’s six months, so I wouldn’t be able to get a refill a year after the original script was written.

    2. Honestly, you ought to be using several pills anyway rather than a pre-mixed mess that either has stuff you don’t need and/or stuff you do need in the wrong dosage for you.

  6. It is silly that one has to jump through more hoops to get a vanity drug like Propecia than a drug that can be utilized to make hard-core drugs…

    I think this all comes down to if one thinks ending the Meth problem is worth the cost of causing an inconvience for allergy and cold sufferers. My thinking would be that the cost benefit analysis would weigh in favor of Keith’s preferred policy option…

    Frank

    1. Propecia is actually a low dose of the prostate drug Proscar and can have fairly serious side effects. The drug’s effect may be for vanity, but it’s a serious bit of medicine that requires a doctor’s supervision.

  7. I think this all comes down to if one thinks ending the Meth problem is worth the cost of causing an inconvience for allergy and cold sufferers. My thinking would be that the cost benefit analysis would weigh in favor of Keith’s preferred policy option…

    Theoretically, one should be able to cost out the inconvenience to allergy and cold sufferers, the time spent dealing with this that would otherwise be leisure, perhaps the aggravation, and so forth. But how can anyone put a dollar value on liberty?

    To update Edmund Burke to modern day America, “But the age of [freedom and liberty] is gone. That of sophisters, economists, and calculators has succeeded; and the glory of [America] is extinguished forever.”

    Better yet, to update Patrick Henry (both more pithy and apropos), “Give my librium, or give me meth!”

    (This being the internet, I feel that I must make clear that this is snark. Don’t mistake this comment as support of McArdle, whose writings are apparently not snark.)

  8. Your ellipses, I think, give a somewhat misleading picture of what I said.

    “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.”

    I don’t know whether it occurred to you, or whether you didn’t think it was worth bothering the reader about. But the omission of it from your post seemed rather glaring.

    As for the rest, I’d only echo Warren Terra: not everyone has a primary care physician who will prescribe these sort of things over the phone. My doctor won’t prescribe a damn thing over the phone for me, and it’s extremely difficult to find a new primary care physicians in DC–a problem that, if Massachusetts is any guide, everyone will start having in 2014.

    1. Experience in DC demonstrates that regulation of the sort seen in Massachusetts makes life difficult? Is this meant to make sense?

      1. In DC, most of the health insurance is extremely generous, so people see doctors a lot. In Massachusetts, the experience post-RomneyCare was that it was harder to get in to see a doctor, because of course, they hadn’t actually increased the supply of doctors, only the demand for same. I think most healthcare analysts on any side of the political spectrum think that 2014 is going to see much longer queues and difficulties with physician access, particularly in states that have a relatively high proportion of uninsured.

        1. This is of course a very specific definition of “demand” – these people now crowding in to get medical attention had the need all along, but with no way to access medical resources they didn’t constitute a “demand” for medical attention in the economic sense you mean.

          I’m not going to pretend to know all the answers about how medical resources should best be utilized; maybe there should be more primary-care doctors, and maybe more of the people seeking medical attention should be turned away as not truly needing it. But the fact that for the first time previously deprived people are able to seek out the help they think they need doesn’t strike me as being an obviously bad thing, and I don’t think poverty and class bias are particularly good criteria by which to turn people away from the medical system.

          1. Look, I really wasn’t trying to restart the health care wars. I was just making a fairly narrow empirical observation, which is that Obamacare is almost certainly going to increase wait times for PCPs, because the PCPs are limited, and more patients will be demanding slots. Obviously, there are good aspects of this (people who couldn’t get to see a doctor before) and bad (people simply becoming less price sensitive and going to the doctor more, something we observe a fair amount of in Medicare).

            In this environment, however, I think it’s worth adding that to the price of making pseudoephedrine scrip-only.

          2. I disagree with Megan as much as anyone, but she has a perfectly valid point here.
            Have you ever LOOKED at the graph of number of doctors being trained in the US over the past forty years? It is more than a little eye-opening. Even as the population rises, the number of doctors trained is flat, with a slight downward trend. Many more of those doctors are now women — meaning they’ll probably have a shorter professional life, at least taking time out for kids. And both male and female doctors are taking ever more time out to lear new things.

            The point is — more money targeted at a fixed supply simply makes prices rise, it doesn’t increase the supply. What America needs is to train more — substantially more — doctors. But of course, that does not appear to be on the radar of either the president or congress, neither of who have the guts to stand up to the doctors union.

          3. Maynard,
            I don’t disagree with you, but as I’m sure you’d agree this is a problem that could and should be solved by methods other than denying care to the less fortunate. As you say, we could train more doctors. We could also radically reconsider the way we train doctors: at present, newly qualified doctors are massively indebted – in addition to tuition and living expenses they are paid first not at all and then laughably as they begin to undertake patient care. The fact that a newly qualified doctor, having been an adult for about a decade, must now repay those huge debts affects their earnings structure and their career path for the rest of their life. If doctors were able to leave medical school with minimal debt they might be more free to practice primary care and to serve less-wealthy patient populations better.

          4. No maybe about. We need more primary-care practitioners, and our medical education system is increasingly geared towards turning out fewer.

            We are going to end up with nurse-practitioners and physician’s assistants filling the void. Some nursing programs are starting to try to fill the gap with doctorally-qualified nurses (I think some programs are calling the degree DNP, Doctor of Nursing Practice). As you might predict, the Medical Deities are having conniptions about someone doing clinical work with the title “Doctor” who didn’t attend medical school.

    2. Megan,

      I don’t think anyone can read Keith’s first post and not understand that he thinks NPLEx should be scrapped. I mean, if you call a system “worthless,” it seems pretty clear that you think it should be dumped.

      1. But he doesn’t say that. Instead he complains that manufacturers are supporting it to save their “hundreds of millions” in profits from selling to meth cooks, and contrasts it with the prescription-only system that he says is clearly effective. Given that he mentions scrip-only, and not repeal, I think the logical inference is that he supports moving to scrip-only. Other commenters do seem to agree with my read, in this post and that one.

        1. Megan — If calling something worthless doesn’t indicate a writer’s negative attitude towards it, what on earth would? “Worthless, and I really mean that”, “So so totally worthless”? “Super-duper worthless”?

          1. When you complain that this “worthless” system is only being proposed as a no-teeth alternative to a much tougher system that actually works, the logical inference is that you are calling for the tougher system, not calling for a simple repeal of NPLex. Most people urging the repeal of such a system would have mentioned that somewhere.

            So just to be clear: you are calling upon all 50 states to do away with all the ID/signing requirements, if not put the stuff back on the shelves? That was one of the main points you were trying to make in the prior post?

        2. True. He doesn’t say, “Let’s dump NPLEx and figure out what a sensible thing to do is.” That’s because he’s advocating for what he thinks is a sensible alternative, which implies dumping NPLEx.

          But I think you’re picking nits. If a medical researcher wrote an article that called some current treatment worthless and advocated for a specific different approach, it would be fair to say that researcher thought the current treatment should be abandoned, even if the article emphasized the benefits of the alternative.

          Your complaint seems to be that dropping NPLEx was not the main thrust of the post, even though it’s clearly an implied objective. You would write a different post, but that doesn’t make Keith’s wrong.

          As for criticizing drug companies, well the meth lab profit numbers may have been overstated, but it’s surely fair to criticize them for pushing a worthless system to alleviate concerns. If a state legislature is considering going to a prescription system then the drug companies can certainly make legitimate arguments about access and so on, as many here have done. But selling NPLEx as an alternative is not an honest approach. I understand that it may have seemed reasonable when introduced, but now the data is in.

          1. My complaint is that if you only offer one alternative–even stricter controls–then you’re not really fully grappling with the implications of the complaint that the system doesn’t work. It could imply tighter controls; it could also imply dropping the system entirely and just going back to the old, easier regime. You should probably go on to note these two possibilities, and explain why you think that one is better.

            But the post is written to assume the conclusion that we need to tighten, without supporting it by, say, comparing the costs to the benefits. Instead, he argues from the allegedly vast profits that cold medicine companies are reaping from meth cookers, an assertion that he also doesn’t support.

  9. Keith: “I don’t know why she felt the need to imply that I am too stupid to understand the intended implication of my own post. ”

    Because she’s a hack, and when caught out she resorts to snark, insult, and extremely contorted interpretation of her and others’ writing.

  10. It would be grossly inefficient and expensive to require a physician’s prescription for decongestants simply to inhibit access to meth makers. That’s not a proper use of the medical system. Perhaps the answer to the meth problem is that we won’t be able to attack the problem by limited access to raw materials and, therefore, we have to focus on other strategies.

  11. I have to push back on the “it’s so dangerous you should see a doctor at least once”. How dangerous is it coared to other OTC drugs?

    Well, it’s really bad if you have high blood pressure. If you do, it can spike your BP into stroke territory. There are other OTC drugs that have dangers: Tylenol has a very narrow theraputic range and an overdose can lead to liver failure, aspirin can cause gastric bleeding, etc.

    You would visit your doctor or nurse practitioner once and then when you had allergy flareups you would contact your health care provider, who would order a prescription refill for you by telephone or email.

    Um, no. You might be able to get refills for a year based on an allergy exam, but not any longer. For a cold, you would need to visit the PCP. State medical boards are clamping down on any sort of over the phone “exam” that leads to a prescription being written except for emergency refills for chronic conditions. At least that is the guidance my wife has gotten.

    1. Oh, and I don’t have a dog in this hunt. I have well-controlled high blood pressure and can’t take PSE. I have to reach for the Benadryl if it gets too bad and not drive.

  12. “You would visit your doctor or nurse practitioner once and then when you had allergy flareups you would contact your health care provider, who would order a prescription refill for you by telephone or email.”

    Prof. Humphreys obviously lives in a different world than I do. I’ve never had a doctor who would provide a refill request based on an email. Or that even had an email address that she would share with patients!

    And what about people who don’t have allergies? You might have heard of these things called “colds”, right? There are a lot of them going around this time of year – I’ve had four since December – and pseudoephedrine is the only thing that can provide symptom relief that doesn’t make you drowsy. (The new-generation antihistamines do nothing for colds.)

    1. JFTR, my doctor responds to email and will order a refill based on a phone call or email. OTOH, I’ve been his patient for about fifteen years. But still, his email address at least is generally available to his patients for questions, etc. as is the number of his PA to call for prescription refills.

      1. Obviously this is because you’re in Massachusetts where, as McArdle will inform you, it’s impossible to see a doctor.

        1. C’mon, I didn’t say it was impossible, I said that it was very hard to find a primary care physician who was accepting new patients. This has been widely reported in the press there. It’s obviously not a difficulty for people who already have a long-term relationship with a PCP, though it is apparently harder to get a timely appointment.

      2. Wow. In my experience, physicians’ offices treat phone requests for prescription refills like something they’re not being paid to do – because they’re not. I’m lucky to get one called in without having to badger the office multiple times.

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