Meth-makers, Cold Sufferers Could Face Tighter Limits on Pseudoephedrine Purchases

The Tennessee General Assembly returned to Nashville last month, armed with legislation they've been working on since last spring. Chief among the Legislature's first targets this year is meth labs, thanks to a new bill introduced by Gov. Bill Haslam as part of his public-safety legislative package.

The Tennessee Anti-Meth Production (TAMP) Act seeks to stymie would-be meth-makers by further limiting access to pseudoephedrine and ephedrine products, which are frequently used as decongestants in products like Sudafed, without a prescription. Since 2005, when the federal government passed the Combat Methamphetamine Epidemic Act (CMEA), pseudoephedrine purchases have been limited to 9 grams within 30 days (and 3.6 grams per day). Tennessee passed its own state law with the same rules in 2005 called the Meth-Free Tennessee Act. The limits amount to about 183 tablets containing 60 milligrams of pseudoephedrine per month, and products like Sudafed are usually purchased in boxes of about 20 or 40 tablets. Since 2012, sales of pseudoephedrine and ephedrine products in Tennessee have been tracked and logged by the National Precursor Log Exchange (NPLEx), a database that can be accessed by pharmacists and law enforcement to keep an eye on how much pseudoephedrine products are being purchased by people. It makes it easier for pharmacists to know when to block sales of the products to people who have purchased suspicious amounts of it and alert law enforcement.

The federal limits also apply to online sales of pseudoephedrine and ephedrine products. In fact, online purchases are capped at 7.5 grams per month, which would be about 73 60-milligram tablets. If the governor's bill is passed, it's unclear whether people buying and selling within Tennessee would be subject to federal or state laws, says Michael Rabkin, the director of communications for the Tennessee Department of Mental Health and Substance Abuse Services.

This year, Haslam hopes to speed up the decline in meth labs across the state with what would be the most stringent monthly limits on pseudoephedrine and ephedrine product purchases in the country. The TAMP Act further limits the amount of pseudoephedrine products to 2.4 grams per 30 days without a prescription, though a pharmacist would be able to override that limit up to 4.8 grams at his or her discretion. Currently, only Alaska and Minnesota have tighter monthly limits. Both states capped over-the-counter sales at 6 grams per month. Rabkin says the bill was created with input from experts in the Department of Mental Health and Substance Abuse Services, the federal Department of Safety and Homeland Security, and the Tennessee Bureau of Investigation.

The hope with these federal and state laws was to reduce the number of meth labs across the country, since one of meth's key ingredients is pseudoephedrine. The number of meth labs in Tennessee has fluctuated since 2005. The number of meth labs in the state decreased from about 1,200 that year to about 600 labs in 2007. However, the number of meth labs increased to their all-time high of 2,157 in 2010. After decreasing once again in 2011, there was a slight uptick in the number of labs in 2012. Numbers of labs counted in 2013 aren't available yet, but Tennessee is still considered to have the second-highest number of meth labs in the country behind Missouri.

The Offices of Research and Education Accountability in the Tennessee Comptroller's office released a 2014 update report on the production of meth in the state, and found that the number of meth labs in Tennessee hasn't changed much since the state began using the NPLEx database in January 2012. "Incidents are down from the highest level in 2010 of 2,082, but remain at high levels compared to other states," the report says.

Knoxville is routinely called one of the worst places to be for allergy sufferers. In both 2012 and 2013, Knoxville was ranked as the third-worst place for fall allergies in the Asthma and Allergy Foundation of America's "allergy capitals" survey, and Chattanooga, Memphis, and Nashville were all ranked in the top 25 worst places for allergy sufferers. But Michael Blaiss, a former president of the American College of Asthma, Allergy, and Immunology and current clinical professor of pediatrics and medicine at the University of Tennessee Health Science Center in Memphis, says those surveys are unscientific and simply based on the number of allergy treatment centers.

"The survey's not a scientific survey. I think when you look at asthma data from the CDC, we're average. We're not worse or better. We know from a survey I did called Allergies in America that we did back in 2006 and 2007, about 14.5 percent of the population has allergic rhinitis documented by a healthcare professional," he says. "Lots of people have allergies, but this data of Knoxville or Chattanooga always being the worst—I don't think this survey is a pure scientific survey documenting the number of patients who have allergic rhinitis that live in the area. I've told the AAFA that in the past."

Blaiss also says he personally sees no problem with Haslam's proposed limit on over-the-counter pseudoephedrine purchases since those drugs are used more for colds than allergies. In fact, prolonged use of pseudoephedrine products are not a good idea, Blaiss says, because of the side effects those drugs can cause, which include insomnia, increased blood pressure, and difficulty urinating.

"Pseudoephedrine has never been designed for chronic use. It's more for upper respiratory than for allergies," he says.

In fact, Blaiss says, people who have allergy-induced congestion all the time have much better options for relief, including intranasal corticosteroids like Nasacort, which will be available over the counter starting this spring.

"[Intranasal corticosteroids] treat all the symptoms of allergic rhinitis. Not only do they relieve congestion better, but they control sneezing, nasal itching, and runny nose. Pseudoephedrine only controls congestion. Pseudoephedrine is fine as an acute treatment for, say, an upper respiratory infection or a cold. As far as chronic treatment for allergic rhinitis, it's not an appropriate treatment. Intranasal steroids are more appropriate, oral antihistamines are more appropriate, and they don't have the side effects."

Blaiss also echoed the administration's assertion that people who feel like they need to use products like Sudafed for longer than 10 days should go see the doctor anyway, since that could be a sign of something beyond a cold.

"Most of us don't feel that patients should stay on decongestants that have allergic rhinitis," he says. "If [symptoms] last longer than [a regular cold], then maybe there is a bacterial infection or something like that, so you need to see a healthcare professional."

Winchester, Tenn., Police Chief Dennis Young led the charge last year for an ordinance in his city that requires a prescription for pseudoephedrine products. Young says that despite the state Attorney General's ruling that the field of regulating the drug is a state job and shouldn't be done by cities, Winchester pharmacists and physicians have worked together to continue selling products like Sudafed with a prescription only. (Young notes that 529 pharmacies in the state have pulled pseudoephedrine products out of their stores.)

Typically, to get a prescription, people have to see a doctor or a medical professional in person. That could pose barriers for people who can't afford a visit to the doctor or can't take time off work to go to the doctor during normal business hours. But Young says he worked with pharmacists and doctors on the "front end" of creating the ordinance.

"In our community, we met with all our medical professionals on the front end and asked for their assistance in this battle against meth, and they all agreed to call prescriptions in to their patient's pharmacy free of charge, and during normal doctor visits offer a prescription to be put on file," Young says.

Young adds that, since the ordinance went into effect, he's seen a 68 percent decrease in meth labs in his city, a 100 percent decline in "smurfing" (where someone purchases pseudoephedrine drugs for a meth cooker), and a 14 percent decrease in crime overall in Winchester, and credits the prescription-only ordinance. Young pointed out that both West Virginia and Kentucky have strict annual limits on how much pseudoephedrine people can purchase (48 grams and 24 grams respectively), and the governor's bill does not pose any annual limit (though if a customer got a pharmacist override for the 4.8 gram-limit every month, that adds up to 57.6 grams in a year). Federal law places a limit of 54 grams of pseudoephedrine sold to an individual within six months.

Young says Mississippi is a prime example of what's possible if the state were to opt for the prescription-only route.

"The state of Mississippi eradicated over 90 percent of meth production in their state by passing a prescription requirement for pseudoephedrine," he says. The state comptroller's report shows a 73 percent decline in meth labs in Mississippi between 2010, when the state's prescription-only law went into effect, and 2012.

But Rabkin says 97 percent of Tennesseans purchase less than 4.8 grams of pseudoephedrine products every month, according to NPLEx records.

"We also know that in 2012, the average purchaser bought just 4.8 grams for the entire year, and that 79 percent of people who bought the products bought less than 4.8 grams during only one or two months [of the year]," he says.

And the research in the comptroller's report supports Rabkin's information: "As in 2012, 80 percent of purchasers bought less than five grams in the six-month period. The six-month purchase limit is 54 grams," the report says.

Rabkin also says that the 2.4 grams that the legislation would allow people to purchase without a prescription or a pharmacist override was determined because it's "based on the most common box size, which equals a 10-day supply of the maximum daily recommended dose of 240 milligrams. The box also says that if symptoms persist after seven days, a doctor should be consulted."

A 10-day supply of 60-milligram tablets would be about 40 tablets.

There are products on the market that contain meth-resistant pseudoephedrine products (such as Nexafed), but Susan Mattson, the principal legislative research analyst for the Tennessee Comptroller of the Treasury, says it's really too soon to tell whether these alternatives are an effective option for reducing meth labs.

Severe allergy and cold sufferers might just have to jump through a few more hoops to get enough Sudafed if this bill is passed. But ultimately, Rabkin says it's the state's best option to reduce the number of meth labs.

"Meth lab seizures and meth use have affected many aspects of Tennesseans' lives. It is our belief that the governor's bill is the best option to limit access to the products that are used to make meth without causing [most] law-abiding citizens additional inconvenience," Rabkin says.