Pseudoephedrine and Meth: No Easy Solution

This week, Union, a town of about 8,000 people in Franklin County, became the second city in the nation to pass an ordinance requiring prescriptions for medications containing pseudoephedrine. Pseudoephedrine is the active ingredient in nasal decongestants such as Sudafed, but can also be used in the production of methamphetamine. Union’s new ordinance has renewed calls by sources such as the Riverfront Times to expand this regulation to the rest of Missouri. The Riverfront Times argues that the benefits of preventing meth production and use (assuming that the sort of regulation in question would actually accomplish that goal, which is a big assumption) far exceeds the costs of “inconveniencing consumers,” but the evidence points to costs far more complex than mere inconvenience.

No one can deny that meth production and use has a serious economic, legal, and social impact on communities. But the nasal congestion that drugs like Sudafed treat has an impact as well. Acute rhinosinusitis (or ARS, the technical term for nasal congestion lasting less than four weeks) affects approximately 32 million adults annually in the United States, or about 16 percent of the population older than 18. The effect on work and school absenteeism is predictably large, with 98 percent of workers citing minor illness such as colds and allergies (the primary causes of ARS) as a major cause of short-term absence.

ARS results in approximately $6 billion in annual costs, nearly 90 percent of which are associated with doctor or emergency room visits. In fact, ARS and other upper-respiratory illnesses are the leading cause of primary care visits after hypertension and routine checkups. Unfortunately, there is little that primary care providers can do for ARS, with treatment generally combining symptom control through over-the-counter decongestants with prescription antibiotics. Yet a recent study found that antibiotics provided little benefits for ARS, because bacterial infection complicates only 13–38% of ARS cases (compared to the 85–98 percent of cases in which antibiotics are prescribed; why doctors continue to prescribe a clearly ineffectual course of treatment is a topic for a separate post altogether).

Indeed, it appears that the only effective treatment is symptom management with decongestants, and currently decongestants containing pseudoephedrine remain the clear winner in terms of efficacy. Studies have failed to prove the efficacy of phenylephrin, the main alternative to pseudoephedrine that is used in formulations such as Sudafed PE.

So, with no effective alternative to treat nasal congestion, mandating a prescription for pseudoephedrine-based decongestants would leave ARS sufferers in a tight spot. Sufferers must opt to call out sick and stay home, find time to go to the doctor’s office (if you can get an appointment) or the emergency room, or just push through it and go to work unmedicated — and I hardly need to tell an allergy sufferer how little work generally gets done in that state.

The end results of this regulation are all unappealing: increased absenteeism, reduced productivity, or increased primary or emergency care visits. The last may not seem like such a bad thing, but hospitals and doctors, who are currently slammed by increased volume because of influenza, might have a different opinion. Increased volume leads to increased wait times for patients, keeping those with minor illnesses away from their jobs and lives (and in close proximity to contagious patients) and keeping those with serious illness from getting the treatment they need, especially since emergency rooms may be tied up by people with minor illnesses when primary care providers are booked up. And, as mentioned above, these visits already account for $5.4 billion of the $6 billion in annual costs associated with ARS; increasing the number of visits would cause those costs to balloon.

With the contagious illness season coinciding with the ARS season, we need to be empowering patients to manage their own symptoms whenever possible, rather than restricting that capability. Meth production and use certainly has its costs, but so does an overly restrictive regulation, such as Union’s. Balancing the benefits and the dangers of drugs such as pseudoephedrine is not an easy task, but an “easy,” all-or-nothing solution such as this one amounts to taking the easy way out.