Understanding How Meth-Resistant Cold Medications Really Work

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.

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 London. 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 thirteen 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.

42 thoughts on “Understanding How Meth-Resistant Cold Medications Really Work”

  1. In the immortal words of Sir Robert Watson-Watt, the driving scientific brain behind the critical development of radar in the 1930s for the air defence of Britain:

    Second best tomorrow.

  2. As a cold sufferer, this is wonderful news. My strategem so far has been to stockpile, make sure I have a couple boxes of Sudafed in the house for when the inevitable cold strikes. This means I have to remember, in advance of the cold, and at a time when the pharmacist is at the back of the grocery store to check my driver license and sign me in the book.

    1. Do you gargle daily with warm saltwater? There’s quite a bit of support for that cutting down colds (a Johns Hopkins study said it halved them), and I’ve noticed a sharp dropoff in the few years I’ve been doing it personally.

    2. ” ‘Tis not contrary to reason to prefer the destruction of the whole world to the scratching of my finger. “…

      In some theoretical sense, you are correct. In reality, we human beings are all bound to each other by myriad ties, and it is churlish to insist that our own comfort be the ONLY thing that matters when weighing issues that may affect the health and happiness of some of our weaker fellow human beings.

    3. Sorry, that’s just not true. People who use meth are not the primary victims in this case. Meth labs are a scourge on poorer neighborhoods, rendering homes unlivable without extensive and expensive cleanup.

    4. I would question your use of the word “voluntary”. Surely the addicted are operating under a different sort of freedom. And even those who are not yet addicted are operating from profound ignorance. We could make it legal for people to do all manner of dumb things but we don’t, out of a combination of liability and sense of protecting themselves from themselves by protecting themselves from themselves.

      One might ask what type of person decides to take their first hit of meth? What about their personal history has made them so vulnerable to such a bad choice? Should there not be, if given the chance, someone there to step in and guide them from self-destruction?

  3. Keith,
    You’re correct in that this will likely reduce the amount of meth cooked casually by users and smalltime producers.

    The DEA is correct in that it will do little to stem meth.

    Both are correct only to the extent that they depend on “a world in which the laws of economics are suspended.”

    Because the Mexican drug cartels, themselves a product of the DEA’s earlier failures to stem the cocaine trade, will simply step into any gap in supply requiring bound PSE in OTC drug products.

    The DEA would obviously prefer to keep the topic fixed on the fact that bound PSE will fail as a policy, without admitting their own role in the reason why that will happen, as well as any questions about their obviously failed law enforcement strategy.

  4. @Mike: You wrote “The DEA is correct in that it will do little to stem meth.”

    You misunderstand both the policy and the claims of DEA. This is harm reduction, it is not intended or expected to affect use. No one claims it will stem meth use per se; that’s not the point, any more than the point of needle exchange is reduce heroin use. Use reduction is not the only legitimate goal of drug policy, and you might consider widening your perspective to accommodate that possibility.

    1. Keith, if you assume anyone who favors legalization or opposes the DEA is unserious, you will close off your mind to the real solutions.

      You have to start by throwing out your ideology and accepting that people will do things you don’t want them to. Then go from there with harm reduction.

      1. In other words, Keith has to abandon what he believes and believe what you believe. No he doesn’t.

    2. Keith,
      I’m sorry you feel that way. I think the main difference between us on this is your position that any retail gain in harm reduction is worth the cost, while I simply want to caution that it’s the net overall effect we need to focus on in drug policy if we ever want a game that starts to look like an end game, rather than an endless series of overtimes.

      I don’t think it’s anything but an observation that the government buys a lot of opinions it like and very few it doesn’t like. Please don’t take this personally, I think you’re rocking the boat just by bringing this up in the face of what is really contemptible opposition by the DEA.

      There was little serious consideration given to a whole range of policy options that involve regulation and legalization by policy analysts UNTIL the voters finally put their foot down and informed the political class they’re tired of pussyfooting around with the deck chairs on the SS Titanic Drug War and veered off the captain’s desired course to legalization of marijuana. Unless the government starts wising up, that will only accelerate as a trend. As a taxpayer, I would think that we need a little less of what the DEA wants to hear and a little more of what it needs to hear — just for starts.

      I would be enthusiastic about this idea, if there was a different end game associated with it. But there won’t be. The DEA has already indicated where it wants to be, which is exactly where it does more harm than good in its enforcement priorities, mostly because it’s eager to produce the kind of statistics that look like “results” when it comes budget time. After 40 years, you’d think Congress would wise up, but no, they just want more flim-flam.

      I’d be interested in knowing why you believe the Mexican cartels will pass up the opportunity the combination of this and the DEA’s continued efforts will hand to them. Is this the one drug the DEA will be able to stop at the border? Maybe international controls of meth precursors are more effective than previously? Maybe the fight for who’s the next capo will take precedence over expanding a product line they’re already into north of the border?

      I may be rough around the edges, but after 40 years of watching the wheels spin on drug policy with little to show for it except the retirement payments of several generations of DEA agents and the ruined lives of hundreds of thousands of Americans, I simply no longer will accept they represent the solution to anything to do with drugs in this country. I’m really not even a fan of legalization of meth. It’s bad stuff. But 40 years of failed policy is even more toxic to our society. We may actually be better off with closely controlled distribution than with anything that resembles the current situation.

  5. This revives a question from last month’s thread: if the FDA wants to keep it behind the counter, does not this defeat much of the purpose of the new formulation? Cold sufferers like Dave Schutz would benefit if they could just go to the drug store and get Zephrex off the shelf. If he has to go through the same rigamarole with Zephrex as with Sudafed, will he not just end up having to pay more and jump through the same hoops that he has had to jump through before the new product was introduced? He may as well stick to Sudafed if that is the case.

    BTW, what is known about “the highest price that the meth market will bear”? There must be some good estimates about the elasticity of demand for meth, and some helpful data about what meth users are likely to substitute if the price rises too high. I would guess that cocaine markets would grow, but have no idea by how much.

    The potential for harm reduction is clear, but unless the eradication of one market is accompanied by an expansion of effective treatment opportunities and attention to the growth of other black markets, the purpose of Zephrex will suffer the fate of all the other latest and greatest innovations in drug policy.

    1. Ed,
      I won’t speak for Keith here, but I think he’s right on this point. Reducing the yield 10-fold will make the cost of the end product so high that making a “profit” is a very marginal enterprise for a cook doing it for anyone but themselves. Remember here that profit isn’t simply cash, but the end product itself in most cases of guerrilla cooking, which dominates the scene in many parts of the country now. To take the risks in obtaining the raw materials, especially if the intent is to keep them behind the counter anyway along with a signature register, and make the effort for so little output makes the microeconomics of cooking go well into the red. Yes, this will discourage most cooking except for personal use — and it will likely even impact that for all but the most desperate users.

      It’s what happens next that there’s real disagreement on. Here’s my take. Yes, there will still be a few cooks scattered across the countryside, but it will be primarily for personal use and a very marginal enterprise. That’s been the trend in the trade wherever the cartels aren’t already supplying imported meth. But nature abhors a vacuum and the demand will be large enough and the existing routes for marijuana and cocaine robust enough that adding meth to the wholesale menu will be an easy thing for suppliers.

      The question will be connecting the supply with the demand. I’m sure that will take some time, but not more than a year or two if everything in the US was suddenly switched to bound PSE formulation. Just as the refusal to consider taking marijuana legal provided the necessary logistical infrastructure for the rise of the cocaine trade in the late 70s when enforcement heat was turned up on marijuana, we’ll see a similar situation develop with meth. All the needed clandestine infrastructure is already in place, from the availability of precursors to factories in Mexico to the reach of marijuana across the country in every neighborhood, to supply a ready-made marketing team for meth to spread, perhaps even more effectively than it already has in many areas.

      Given the efforts already made to reduce the availability of precursors OTC, it’s probably time for a serious study of what relationship this might have to seizures of Mexican-origin meth up to this point. There may already be signs of a trend that might be informative here. I suspect if such a study exists, it’s likely classified, because it is unlikely to reflect well on the efforts already made – or others that may be tried under the big stick, little carrot policy approach to drug abuse we engage in now. Such results chip away at the illusion of control that law enforcement tries to conjure up against a problem they milk for bugger budgets every year with fewer and fewer evident results — and no sign of an end game. You’re either part of the problem or part of the solution. I don’t see anything being “solved” by how drug policy has operated for some 4 decades, despite periodic attempts to reinvent the meaning of “success.”

      1. Obviously, I meant “bigger budgets” in the last paragraph, but somehow hit pretty accurately on another viable description of cost-effectiveness of spending more money on the DEA and getting less and less in terms of effective “results.”

      2. My points were a bit simpler. First, I think it is a mistake o the part of the DEA to put the bound PSE behind the counter if it is in fact prohibitively expensive (though technically possible) to manufacture meth with it; this impedes access of Dave and others to symptom relief when they have a bad cold.

        Second, bound PSE is a clear supply-side strategy; it is different from interdiction in not requiring armed battles with drug lords but is similar in curtailing the amount of the drug on the illegal market. Supply side approaches unaccompanied by demand side approaches such as effective treatment programs are short-sighted and are likely to lead to growth of other illegal markets as demand elasticity leads to substitution of other stimulants for the now-unavailable meth. Price increases within what the market will bear can also have the unintended consequence of driving addicts to crime in order to obtain their desired drug.

    2. > will he not just end up having to pay more and jump through the same hoops

      This is a feature, not a bug.

      1. The higher price is a feature not a bug for the maker of Zephrex. Impeding access sounds like something against their interests and like a bug not a feature. I am assuming that your placing “having to pay more” in boldface reflects your opinion that it is the price and not the hoops that constitute the feature; presumably impeded access, a disincentive to purchase the product, remains a bug.

  6. One way or another, it sounds as if bound PSE would shift production to larger operators. What does this mean in terms of environmental damage? Do/will the larger operators run more efficient, cleaner labs, or just operate in places that care even less about the byproducts?

    1. @paul: That is entirely possible. Yes, they do seem to run cleaner and more efficient labs. Fires/burns/discarded acid etc. seem to be almost entirely a consequence of low-end operations, so the harm is reduced when here are a smaller number of large labs than a huge number of small ones.

      Note that in terms of location, PSE-processing meth superlabs are not in Mexico; California is probably the biggest concentration.

  7. I’ve never had any difficulty in buying Sudafed or generics in Europe. Is the meth lab a peculiarly American institution?

    1. Americans use more meth per capita than Europeans, and I am not sure of the supply chain for what is used in Europe. As for it being American, like most things you could point at some states and say no and others and say yes, they are heavily concentrated in about one quarter of US states, others seem to have few or none.

      1. Keith,

        The last few times I’ve visited the auld sod (Hawaii), I’ve noticed PSA campaigns targeting meth abuse. It’s apparently known as “ice” over there. Do you know if the islanders are cooking their own, or (like so much else there) are they importing from the mainland? Local cooking seems problematic to me: anhydrous ammonia isn’t nearly as available there as it is in Kansas (to name another place I’ve lived for more than a few years where meth is a perceived problem).

        1. Dennis,
          To my knowledge, “ice” was originally a form of meth peculiar to distribution networks originating in Asia. Whether or not the actual product in Hawaii travels those routes or is simply someone with a local or mainland product trying to cash in on a known “brand” I don’t know. It may be a little like that bean paste shaved ice, a specifically Hawaiian cultural twist mashing up elements of several cultures.

  8. Keith, to what extent does the low “extractability” really mean “extractability with current recipes”? Is there a reason to expect that, a year or two after its release, someone won’t find a new recipe—“add powdered lead, meat tenderizer, and Red Bull”—that defeats the lipid or polymer binding?

  9. I agree with Keith that there is a “tantalizing possibility of a “have your cake and eat it too” public policy.” You’ll recall that Tantalus was completely unable to achieve his goals.

    From my own humble perspective as a sometime cold suffered I suspect that, big pharma claims to the contrary, the “bound” stuff will not work as well as the stuff now hidden behind the counter.

    But getting it out on the shelves will certainly help sales, especially if it doesn’t really work and folks buy more and more.

    As has been noted by many (see, e.g., http://www.amazon.com/Methland-Death-Life-American-Small/dp/B00BV2N28S/ref=sr_1_1?s=books&ie=UTF8&qid=1386017009&sr=1-1&keywords=methland) the meth thing a result of social forces and is not likely to be law enforced or technocrated away.

    1. I am often a skeptic of the drug war too, but let’s not get too excited here. Being addicted can’t really be considered any real kind of freedom, even if you got to “choose” whether to try the drug that first time. Whoopdedoo. I think we can do better than that.

      1. Anon, would you consider picking a name so we can distinguish you from the other nyms here? Does not have to be your real one, obviously.

  10. Children, please!
    Do these new medications work? Can I use them when I have a gold in by doze?

    1. Yes, there’s no doubt they work as medications.
      The question – which Keith answers in the affirmative – is whether the new formulation “works” to prevent kitchen-level meth production.

  11. OK. Time for some moderation, starting with a review of the bidding.

    Keith Humphreys, who actually knows something about the problem illicit meth manufacturing, has been working to make it harder for meth cooks to get pseudoephedrine to use as a precursor, because small-scale meth production is a health, safety, and environmental nightmare Various commenters have objected that his proposed policies would cause inconvenience or worse for patients.

    Now a company has come forward with a formulation that would solve the problem on a technical level, allowing PSE to go back to open-shelf availability.

    The DEA, which has been on Keith’s side on the question of putting PSE behind the counter or making it prescription only, is resisting the new solution. Keith points out that DEA’s objections are nonsensical.

    So, logically, the people who had been objecting to PSE controls ought to be happy to have Keith on their side. But instead Mike tries to change the subject by claiming that the new approach won’t solve a completely different problem and is therefore a mere bureaucratic flim-flam, even though the bureaucracy he so hates is opposing it.

    Keith is clearly the grown-up here; it’s Mike and his supporters who are acting childishly. Yes, I know there are people who dismiss any concern about drug abuse as getting one’s knickers in a pointless twist, and are incapable of thinking at all about drug policy without going into an anti-drug-war rant.

    For them, I have a polite request. Please, pretty please, pretty please with a cherry on it, either just go away or STFU. You’ve made your point. Anyone who reads this blog knows what it is. Some of us would like to conduct a serious discussion of drug policy, and you’re making that impossible.

    I will leave the offending posts up in this case. But from now on, everything along those lines will be relentlessly zapped. No doubt your comments will be welcome on DrugWarRant. They are no longer welcome here.

    1. You do not need to be on a drug war rant to recognize that the DEA is a law enforcement agency, not a public health agency. A new supply side intervention has some effects which call for comment from the public health community, namely, the need for better access to services which can curtail demand rather than displace it to other markets. This is not even a divisive point, but it deserves more emphasis than it is getting.

      1. But there’s a way to make that point without implying that the post’s author is a DEA shill or drug warrior, or going off on a libertarian screed, both of which have happened repeatedly in this comment thread and others.

        1. Just for the record, I do want to apologize for any mischaracterization that may have been read into some of my admittedly poorly worded and hastily composed comments. It was not my intention to stir the libertarians into a frenzy. I’m decidedly not a libertarian, but the drug war makes for very strange bedfellows, as any user of this site knows.

          It was not my intent to attack Keith. I did not intend to imply he was with a “DEA shill or drug warrior” — simply that unintended consequences is how we’ve arrived at today in the drug war and we should be very cautious about adding to that policy graveyard.

          Just to reiterate, my comment was an observation in general and specifically not about Keith, at the same time recognizing the distance between the DEA and the work he and others are doing. For example:
          “I don’t think it’s anything but an observation that the government buys a lot of opinions it like and very few it doesn’t like. Please don’t take this personally, I think you’re rocking the boat just by bringing this up in the face of what is really contemptible opposition by the DEA. ”

          I noted my own objections to meth here and previously. I also agreed that bound PSE will have a significant part of the intended effect, I just don’t like the net accounting. If that was seriously off-topic, I apologize again. And will try to do better in staying on topic.

        2. Having been accused of being a drug warrior on other threads, I am well aware of how that can happen. On this website, much depends on the ability of supposedly educated people to read.

          The DEA’s mission is to enforce the federal controlled substance laws. Its mission is not to consider the ramifications of what it is doing. Our mission on these threads is to consider those ramifications.

          Putting meth labs out of business is a worthy thing to do, but some unintended consequences can be anticipated. Considering these consequences and how to make policy about them can be the topic of a different thread. Keith is an authority on what kinds of intervention effectively decrease the demand for addicting drugs. Access to these services is also within his field of expertise.

          So Keith: what are the prevention/treatment measures which need to be taken after bound PSE replaces Sudafed? Much meth is produced and consumed in rural areas, and access to treatment may be more problematic than in urban areas.

          I am not asking for a response today, but on a different day and a different thread, this would be of great interest to me and many others who read this website.

          1. Keith publicly disagreed with the DEA and got accused by Mike and his minions of being a DEA shill. Why would any sensible person persist in this discussion with people who are that dishonest and that hateful?

    2. Anon, you’re the one likening caffeine dependency with meth addiction.
      I don’t consider that being part of a ‘serious’ discussion. It’s hyperbole, straight up.

    3. The problem is that Mark and Keith are generally looking at a very specific question that is much narrower than legalization or not. So someone popping in and saying we should just legalize drugs is completely irrelevant to the actual post. It may be true but bringing it up isn’t useful in the specific context. It isn’t that they want a discussion in which the only real solution is taken off the table; it’s that your idea of the solution has nothing to do with the specific topic addressed.

      This is generally followed by accusations that wanting to look at a specific element of the question rather than the big picture means that you are, to quote one particularly noxious commenter, “. . . a horrible human being.”

      If you are not interested in specific policy questions and only want to talk about drug policy in the biggest picture possible, you’re reading the wrong blog and your comments aren’t useful here.

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