The Journal Gazette
Sunday, January 10, 2016 5:35 am

A congested issue

Tim Harmon

Why is pseudoephedrine back in the news these days?

A proposal that has been rejected by the legislature before will get serious attention this session.

Rep. Ben Smaltz, R-Auburn, is introducing a bill that would allow Hoosiers to buy Sudafed and other pseudoephedrine products only with a doctor’s prescription, and House Speaker Brian Bosma has indicated the proposal will be a priority.

Pseudoephedrine, a generally safe and effective decongestant, is also a key ingredient in the making of methamphetamine, a powerful and dangerous stimulant.

Smaltz said Thursday his bill won’t solve the whole meth problem. Rather, it is aimed at preventing a particular kind of collateral damage from meth labs.

"There were 282 kids found in meth labs last year ... 2,500 since 2003. When a meth lab is busted, and the kids are in the house, they lose their parents, they lose their pets, they lose their stuff." Then, Smaltz said, they’re taken for decontamination and blood tests. He quotes a chilling U.S. Drug Enforcement statistic: 35 percent of the children found in meth-lab situations test positive for meth.

The children ultimately end up on the doorstep of a foster home, sometimes wrapped only in a blanket because all of their clothes have been contaminated.

Though the Indiana Department of Child Services doesn’t break out cases by individual types of drugs, Jeanette Keating, assistant director of communications, confirmed this week that the problem of children in drug situations is growing rapidly.

"Between March 2013 and March 2015," Keating wrote in an email, "there was a 71 percent increase in the number of children that were removed from their home because of parental drug use ... In March 2013 there were 1,520 children removed with drug use being identified, and in March 2015 there were 2,600 children removed due to parental drug use."

But there are other ideas for reducing meth production, too, and some question whether the cost and inconvenience for cold and allergy sufferers really outweighs the potential benefits of requiring a prescription.

Isn’t pseudoephedrine already restricted?

Yes. In 2005, Gov. Mitch Daniels signed a law limiting the amount of pseudoephedrine Indiana customers could buy. Now there’s a national law requiring pharmacies to check customers’ IDs and make them sign in to buy the drug. In 2013, the state began using a real-time tracking system called NPLEx that prevents individuals from going store-to-store to buy more than the legal limit of pseudophedrine products.

Despite that, Indiana has led the nation in meth-lab incidents since 2013 – and it’s becoming a big lead. According to the U.S. Drug Enforcement Administration, there were 9,338 such incidents nationwide in 2014, and 1,471 of them were in Indiana.

What about our area?

Noble, Allen and DeKalb all ranked among the top seven Indiana counties in meth-lab seizures, according to Indiana State Police statistics.

Allen County, in fact, may have set a record for meth-lab shutdowns in 2015, according to Capt. Kevin Hunter, who heads the Fort Wayne Police Department’s Vice and Narcotics Division. All the busts here involved "one-pot" labs, Hunter said.

Hunter supports the push nationwide to make pseudoephedrine prescription-only. "States that have done it have seen a dramatic decrease in such labs," Hunter said.

So does Allen County Prosecutor Karen Richards.

"We’ve got to do something about the meth lab problem," she said.

Why do these one-pot labs do so much damage?

The one-pot method of making meth simply involves putting pseudoephedrine and some other potent ingredients such as lithium in a bag or bottle and shaking it around.

"I don’t need much space to make it," Hunter said. "I can make it at home. I can make it walking down the street."

The process may be even more volatile than larger, more traditional labs, leading to explosions and fires. And the materials that get left behind can dangerously contaminate a home or car – or make a discarded plastic pop bottle lying on the street a potential bomb.

"There are 4,900 homes in Indiana listed on the meth registry," Smaltz said. "There are almost 700 in Fort Wayne."

Does requiring prescriptions to buy pseudoephedrine really make a difference?

Yes – at least in terms of reducing the one-pot meth labs. Oregon began requiring prescriptions for pseudoephedrine a decade ago, and the state has seen dramatic drops in home- or car-based labs.

But critics of the law say meth is still a problem in Oregon, much of it smuggled in from Mexico. Washington Post blogger Radley Balko argues that, by some measures, meth consumption has gone up in Oregon since the prescription rule went into effect in 2006.

Even if requiring a prescription doesn’t stop people from accessing meth by other means, Richards said, reducing access to pseudoephedrine means that "at least they’re not going to be manufacturing it in the house next to you."

Meth is a global problem, Smaltz said, one that’s far to big to be wholly solved by one new law. "This bill is 100 percent designed to eliminate meth labs."

What’s the downside of requiring a prescription?

Rep. Ed Clere, R-New Albany, declined to hear an earlier prescription bill when he was chairman of the House Public Health Committee last session.

"I’ve been consistently opposed to it," he said Tuesday.

"First, pseudoephedrine is a proven, safe, effective, inexpensive remedy," Clere said, "and I would hate to see Hoosiers have to go to the doctor to get something they can get over the counter.

"Another very real issue is our already overburdened primary health care system." Requiring a prescription for a cold remedy would mean "forcing people into the primary care system when we have a shortage of primary-care physicians and a lack of providers in many communities."

"Beyond that," Clere said, "I’m not convinced that it would actually reduce the presence of drugs in our local communities."

Abraham Schwab, a medical ethicist at IPFW, said he wouldn’t rule out a prescription system. But he shares Clere’s concerns about the burden on doctors and their patients.

"We all know that physicians don’t have enough time already," Schwab said Tuesday.

Requiring prescriptions may not require much public money, Schwab said. But those who need relief from allergies or colds may be forced to make time for and pay for doctor’s office visits or stay home with their congestion. As is usually the case, the burden might be borne disproportionately by the poor.

"In general," Schwab said, lower-paying jobs mean "I’m going to have very defined times that I have to be at certain places." So, costs aside, it’s not as easy to take time off to go to the doctor. "And (the poor) can afford the least to miss work" for illness, he said.

Can’t the doctor just write a standing prescription?

Indiana law doesn’t allow that, according to Tracy Brooks, assistant professor of pharmacy practice at Manchester University.

But Smaltz said his bill would allow doctors to write prescriptions that can be filled up to five times within six months. In addition, he said, doctors would be allowed to prescribe Sudafed over the phone for patients he or she has seen before – even if the previous visit was for a different reason.

Indeed, Smaltz said, patients of all income levels who use pseudoephedrine regularly may see their costs go down because the medicine would be covered under their public or private health plans.

What about Sudafed PE, which is still available in the customer aisles? Isn’t that an answer?

Probably not. Instead of pseudoephrine, Sudafed PE contains phenylephrine, also considered a decongestant – but a poor one.

"Most clinicians will say PSE (pseudoephedrine) is much more effective against congestion compared to phenylephrine," Brooks wrote in an email Wednesday. "The data is rather weak that PE is effective."

However, a new type of pseudoephedrine may offer hope. Two new "tamper-resistant" pseudoephedrine drugs called Nexafed and Zephrex-D are now on the market. It’s possible they will be more expensive than ordinary pseudoephedrine products, Brooks wrote. But "the data submitted to the FDA for approval showed it was as effective as PSE."

The website for Zephrex-D says the pill "contains the pharmacist-trusted pseudoephedrine you’ve come to rely on," but also has a "unique meth-blocking technology."

Smaltz said the new products look promising, and his bill will include a "carve-out" that will allow truly tamper-proof pseudeophedrine to be sold over the counter.

Are there other ideas?

Yes. Indianapolis Republican Sens. Randy Head and Jim Merritt will be offering a bill that would require a pharmacist to talk with and approve anyone who wants to buy pseudoephedrine and reject anybody who didn’t seem to have a need for the drug.

Pharmacists and community leaders began such an approach in Rochester, Indiana, and its proponents say it’s worked well.

Harry Webb, who owns pharmacies in Rochester and Akron, said his community’s plan was modeled on a law that has helped reduced meth labs in Arkansas.

"Pharmacists," Webb wrote in a piece that appeared in The Journal Gazette on Dec. 23, "can often deter illegitimate requests to purchase products containing pseudoephedrine by having a brief conversation with patients, and asking a simple series of questions."

Clere said he thinks that proposal deserves discussion, though he would not want to see pharmacists overburdened with extra work, either.

We’ve heard so much about problems with heroin and prescription drugs in Indiana. How does meth rank in comparison?

"The three worst drugs are heroin, spice and meth," Hunter said. "Each causes destruction in different ways.

"There are some deaths due to spice (synthetic marijuana) and meth, and lots of deaths due to heroin.

But the users of opioids and meth aren’t usually the same people.

"Meth is a central nervous stimulant. Heroin and fentanyl are supposed to be calming," Hunter said. Meth users don’t tend to interact with gangs and dealers the way other drug users do. "Meth typically leaves a person very paranoid."

Meth offers its own set of challenges.

"The problem with meth," said Allen County Prosecutor Karen Richards, "is that it is so highly addictive."

"Users deteriorate very quickly," Hunter said. "They lose hair, teeth, their face will be sunken in. There are ‘meth-bugs.’ " Users think there are bugs all over them, and they pick at or scratch their skin into sores and scars.

"It’s a dramatic decline," Hunter said, "and it doesn’t take very long."

Meth can also lead to mood disorders and psychosis, as well as brain, cardiovascular, liver or kidney damage. Because users tend to practice unsafe sex, they also get and spread a variety of infections, including HIV.

Though it’s possible to kick the meth habit, users usually don’t stop until they’re in prison – or dead.

If the legislature can’t agree on a new way to control pseudoephedrine, is there anything to be done?

Clere suggests that the state needs to focus on "more addiction treatment. We can’t view the drug problem in isolation," he said.

"Focus on the demand side, not the supply side. Reduce demand."

Tim Harmon is an editorial writer at the Journal Gazette.


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