Standing in line for my pseudoephedrine

Interesting essay from the Atlantic about the societal costs of curbing access to the cold medicine pseudoephedrine.  It's the latest bouncing around the blogosphere following the introduction of legislation to make an effective cold medicine prescription-only. 
In Do We Need Even Tighter Controls On Sudafed?  Megan McArdle argues that requiring cold suffers to go to their doctor to get a prescription for pseudoephedrine (PSE) creates an unnecessary burden on the health care system when compared with its impact on cleaning up amateur meth labs. 
The author seems to have done some math, but her research into the history and scope of meth appears limited to a few episodes of Breaking Bad. (For an excellent investigation into the history of the current epidemic, I suggest this Oregonian investigation. She states that controls on pseudoephedrine are aimed at controlling meth lab explosions from "amateur" cooks (who cooks meth as a hobby?) in the midwest.
Actually, meth was a long time Northwest phenomenon. For two decades law enforcement officials had trouble getting anyone back East to take it seriously.  I know, because I was a cops and courts newspaper reporter in the days when meth was exploding in the 1990s. These days, I'm on the other front line -- treating meth addicts daily for the toxic effects of abuse.
This is not a case of toxic labs and benign recreational drug -- the drug itself is toxic too. Making tighter controls on the ingredients was originally an effort to make it harder to get the drug, not just more difficult to make. 
Rural communities -- ill funded an ill equipped to do toxic clean up work -- were overwhelmed when meth was home grown. Fragile ecosystems, national parks, wildlife refuges and rural water supplies were contaminated and endangered by meth labs. Oregon's requirement for prescription-only pseudoephedrine helped cut these meth lab incidents down to zero. 
Indeed, controls like those imposed in Oregon and Washington helped create the large scale meth factories in Mexico. This is not a product we want Made in the USA if we can help it. When Mexico banned the main component of meth cooking outright in 2009, production started shifting back to the United States -- this time to places in the country with larger potential markets and less restrictive purchasing of the main ingredient.  
Outside of Oregon, meth cooks have found ways around the registration laws by using proxies and false ID to get PSE in states that don't require a prescription. 
As Oregon lawmaker Rob Bovett recently wrote for the New York Times in an Op-Ed that kicked off the debate:

The only effective solution is to put the genie back in the bottle by returning pseudoephedrine to prescription-drug status. That’s what Oregon did more than four years ago, enabling the state to eliminate smurfing and nearly eradicate meth labs. This is part of the reason that Oregon recently experienced the steepest decline in crime rates in the 50 states.

The problem is that pseudoephedrine is an effective cold medicine where as the replacement ingredient in Sudafed  Phenylephrine (hydrochloride)  is not. That means that some people will go the extra mile to "get the good stuff."  Here is Washington, you have to sign a registry and show ID at the pharmacy counter -- it is embarrassing, but not much of a hassle. I've done it. 
In Oregon, you need a script. Oregon Sen. Ron Wyden is now proposing that the drug be prescription-only nationwide. 
Sure, if you imagine all those cold suffers that currently buy Sudafed over the counter going to their primary care doc to get scripts, that's going to add up. Most folks will just suffer through the cold or buy something else. The companies that make PSE will see profits dry up.
Thus far, however, the authors of this debate fail to mention the societal costs of Meth in realistic terms. Meth addicts make up a substantial population of those treated in the Emergency Room for everything from abscesses, life-threatening infections, meth-induced psychosis and dental pain. 
Making PSE prescription only is an escalation in an arms race over a dangerous and toxic drug with massive societal impacts -- much greater in scale that the profits of a drug company or the comfort of those suffering through a runny nose. 


Required Reading: Unnecessary Epidemic

Guess What? Smoking Pot, Meth Bad for your Asthma

So the last case of the morning yesterday was a 24 year old male in respiratory distress. He got duoneb breathing treatments and a magnesium drip in route and the paramedic was still coming code 3 so we knew he was struggling. The patient arrived drenched in sweat and pale with resps about 40 a minute. 
He looked sick and was wearing out.  The MD ordered BiPap for him, but he was barely tolerating the nebulizer mask. He had that hypoxic anxiety that is common in older COPD patients who feel like they are drowning and you just can't convince them that they are getting enough air even after you fix them. 
Yet this kid seemed to have something else going on too. We asked him if he had smoked. He nodded his head "yes" to smoking meth and pot over the past two days. 
He was too wound up to tolerate the BiPap mask and was getting increasingly agitated. His ABGs were horrible. We intubated him. 
The social worker came back from the family waiting room and said his girlfriend was out there and appeared to be tweaking on meth too. The social worker asked us about the effect of meth on the lungs - on top of asthma.  
"Well, they clean up meth labs in hazmat suits if that tells you anything," I said. "Smoking pot isn't good for your lungs either."
One of the ED techs was standing next to me and protested.
 "There's never been any study that has proven pot is bad for your lungs," she said.
 I get a lot of pot-apologists in the 20-30 year age range - after all their parents and grandparents often smoked in their presence and so I'm sure they've all been indoctrinated about the overkill warnings in Reefer Madness. In isolation, I agree that it is a much more benign drug than meth - or even alcohol for that matter. 
Yet her assertion that smoking pot was not harmful to the lungs of an asthmatic seemed pretty counterintuitive to me. Taking smoke into your lungs and holding it in as long as possible just seems like something an asthmatic wouldn't want to do. 
Moreover, I used to tell my oncology patients that if they needed marijuana to help their appetite, they should bake it rather than smoke it. I'd seen many cases where COPD exacerbations were set off by smoking pot.
Indeed, smoking pot rapidly accelerates the progression and development of some lung diseases. A 2008 study found that "the development of bullous lung disease occurs in marijuana smokers approximately 20 years earlier than tobacco smokers." Published in the journal Respirology, the authors found that CT scans revealed the progression of bullous lung disease in pot smokers. 

Patients who smoke marijuana inhale more and hold their breath four times longer than cigarette smokers. It is the breathing manoeuvres of marijuana smokers that serve to increase the concentration and pulmonary deposition of inhaled particulate matter – resulting in greater and more rapid lung destruction. Science Daily reported.

Moreover, other research has supported a significant increase in COPD development if a patient smokes pot and cigarettes -- a synergistic effect greater than either alone. Some studies indicate that exposure to pot smoke at a young age helps predispose patients to COPD development later in life. It certainly kills cilia and damages airways - which of course predispose repeated upper respiratory infections and chronic bronchitis.
Of course, it is hard to due randomized controlled trials on an illegal substance, even if that substance is the second most smoked product on the planet. As a 2009 review of the links between Pot and COPD concluded:

"Firm conclusions cannot be drawn about the association between use of marijuana and COPD based on the limited and inconsistent data available. The studies that address this topic are limited by their small numbers of participants and by the uncertain accuracy of self-reported use of marijuana, particularly in view of its illegality and the difficulty of accurately recalling amounts previously used. Nevertheless, the consistency of some aspects of the available data allows us to more firmly conclude that smoking marijuana by itself can lead to respiratory symptoms because of injurious effects of the smoke on larger airways."

Note the part there about the trouble with pot smokers having trouble remembering...
Marijuana has become more and more accepted in society and these days medical pot dispensaries are opening up faster than Starbucks stores. A few years ago it was estimated that  11 million people smoked marijuana during the last month, and approximately 20% of these smoke almost daily. These smokers -- even if they don't smoke tobacco -- report chronic bronchitis, frequent phlegm, shortness of breath, frequent wheezing, chest sounds without a cold, and pneumonia, according to a 2004 study. 
Moreover, other studies have found significant damage at the cellular level and may predispose patients for lung cancers. It disrupts the immune response in the lungs as well, predisposing patients to respiratory infections. 

"Regular marijuana smoking produces a number of long-term pulmonary consequences, including chronic cough and sputum, histopathologic evidence of widespread airway inflammation and injury and immunohistochemical evidence of dysregulated growth of respiratory epithelial cells, that may be precursors to lung cancer. The THC in marijuana could contribute to some of these injurious changes through its ability to augment oxidative stress, cause mitochondrial dysfunction, and inhibit apoptosis."

Another study found that pot delivers different doses and chemical changes compared to tobacco: Each joint delivered five times the increase in carboxyhemoglobin levels compared to tobacco. Toking delivers three times as much tar to the lungs versus smoking.
What about meth? Well there's pulmonary hypertension, but so far I didn't find a lot of controlled studies on it. It's a drug that has been around since 1919,  but has become wildly popular only in the last 20 years or so and so the research is more focused on the more obvious health effects.


So, if you have asthma don't smoke meth and don't think that pot is healthy just because you got a script for it.