Pseudoephedrine Abuse in Alabama
Gregory Guin, Pharm.D., Sean Heironimus, Pharm.D., and Allen Long, Pharm.D.
Harrison School of Pharmacy, Auburn University
corresponding author:
Wesley T. Lindsey, Pharm.D., Assistant Professor of Pharmacy Practice
Drug Information and Learning Resource Center, Harrison School of Pharmacy, Auburn University
Universal Activity #: 0178-0000-12-103-H04-P | 1.0 credit hours (0.1 CEUs) | Expires June 18, 2015
PROGRAM OBJECTIVES
After completing this program, the participant will be able to:
• Discuss the abuse rate of methamphetamine in Alabama.
• Discuss the different production methods of methamphetamine.
• Review the current pseudoephedrine laws that are in place in Alabama.
INTRODUCTION
Methamphetamine production and abuse has become a
worsening public health problem over the past five years in Alabama.
Readily available precursors, new production techniques, and high
market price have increased demand for the drug over the past few
years. Alabama, in cooperation with federal agencies, has taken
action to try and curb the production of methamphetamine. This
paper is designed to discuss the severity of the problem currently in
Alabama, the new methods of hindering methamphetamine addicts
and producers from obtaining precursors, and to inform pharmacists
of their role in halting illegal methamphetamine production.
METHAMPHETAMINE HISTORY AND ABUSE RATES
Methamphetamine HCl, also known as desoxyephedrine, was
approved by the FDA on December 31,1943 and is still available
under the brand name Desoxyn® and is indicated to treat ADHD
in children and refractory obesity.1,2 Over the years it has been
used to keep fighter pilots awake in World War II, as a nasal
decongestant in the 1930s, and also as a drug to treat depression.3
In the United States it has been associated with outlaw motorcycle
gangs, which is where the street name “crank” originated. The
motorcycle gangs would keep the methamphetamine in the
crank cases of their motorcycles to hide it from law enforcement.
Although methamphetamine has legitimate uses in the medical
world, it is one of the most abused controlled substances in
the United States.4 Methamphetamine causes an intense short
rush after smoking or injection similar to cocaine, however
when taken orally it can produce a long-lasting high for up to
12 hours.5 Methamphetamine produces this high by releasing
large amounts of dopamine into areas of the brain that regulate
quiz on p
age 60-6
1
pleasure. Long term use can lead to hallucinations, delusions,
paranoia, and aggression.
According to the 2008 National Survey on Drug Use and
Health five percent (12.6 million people) of the U.S. population
12 years and older reported using methamphetamine at least
once. The methamphetamine abuse problem in Alabama has
steadily been getting worse.4 The National Meth Center reports
that nationally, around 6.1% of drug treatment admissions list
methamphetamine as their primary drug of choice.5 Alabama
averaged above this number in 2009 and 2010, with rates
being 7.7% and 8.9%, respectively.5 The DEA has provided
the approximate number of methamphetamine producing
laboratories busted, and the numbers indicate that the amount of
methamphetamine being produced has been on the rise over the
past five years. There has been a dramatic increase in the number
of labs discovered, which can be seen in Table 1.
TABLE 1
NUMBER OF LABS BETWEEN 2006-2007
Year
2006
2007
2008
2009
2010
# of labs
discovered in AL
205
216
605
614
666
Table 1: Pharmacotherapy
of Gout
PRODUCTION
OF METHAMPHETAMINE
Pseudoephedrine can be used to make the powder, crystalline,
Acute Gout Therapy
or liquid forms
Pseudoephedrine
fromDrug Reactions
Drug of methamphetamine.
Dose Regimen(s)
Adverse
common cold products is the[PO
primary
source
used to produce
unless
noted]
NONSTEROIDAL ANTIINFLAMMATORY
(NSAIDs)
methamphetamine
domestically. The singleDRUGS
ingredient
tablets
Ibuprofen (eg, Advil,
800 mg QID
GI bleeding/irritation, renal Ca
are
the
preferred
dosage
form
to
make
methamphetamine,
but
Motrin)
dysfunction
ble
Indomethacin* (eg,
Indocin)
Naproxen* (eg,
Naprosyn)
25-50 mg QID for 3
days; then BID for 4-7
W W W. A PA R X . O RG
days.
500 mg BID for 3
days; then 250-500
mg QD for 4-7 days.
53
ble
dys
ret
CH
Th
com
it can also be made from combination products, liquids, or gel
caps. Liquids and gel caps are typically not used due to requiring
a more difficult process and a low yield with low purity.7 The
crystalline form, also known as “ice” or “crystal meth”, is a more
potent smokable form of methamphetamine, and can be produced
in the same way as the powder with an added step. Liquid
methamphetamine is the newest form of methamphetamine and
has been discovered in tequila bottles and windshield washer
reservoirs being brought across the border with Mexico.8 It is a
clear yellowish liquid, which can be boiled down to the powder or
crystalline form, once it is smuggled into the U.S.
According to the U.S. Department of Justice, methamphetamine
availability in the U.S. increased from 2008-2009, while cost
decreased and purity increased.9 Production by drug cartels in
Mexican super labs which can produce at least 10 pounds of
methamphetamine per cook, currently dominates the market and
continues to grow due to restrictions on the sale of pseudoephedrine
in the United States.9 According to the Drug Enforcement
Administration, most of the methamphetamine produced in Mexico
is performed using the phenyl-2-propanone (P2P) method, which
uses P2P as the precursor, due to restrictions on pseudoephedrine in
Mexico.9 Clandestine labs have traditionally been the main way that
methamphetamine is produced in the Southeast and poses a great
threat due to the hazardous chemicals used in production. Small labs
use pseudoephedrine as the precursor to make methamphetamine
using one of three methods: the red, white, and blue method; the
Nazi method or Birch reduction; or the “shake and bake” or one
pot method. All of these recipes are widely available on the internet
and can be performed with minimal knowledge of chemistry. The
red, white, and blue method gets its name from the red phosphorus,
white pseudoephedrine, and blue iodine used in the reaction. The
Nazi method requires sodium or lithium and anhydrous ammonia
which react violently with each other and produce an extreme amount
of heat. Each method requires different chemicals to complete the
reaction of pseudoephedrine to methamphetamine with the “shake
and bake” method being the most simple and popular due to the
ability to conceal the lab. This method can be easily performed in a
small soda bottle while driving down the road or out in the woods. A
small soda bottle is much easier to conceal than a small laboratory and
if the person is discovered by law enforcement, it does not give away
the entire lab.
The reaction to convert pseudoephedrine to methamphetamine
is relatively simple due to the similar structure of the two compounds.
Common chemicals required in the conversion process are
Methamphetamine
Pseudoephedrine
*taken from http://www.pharmgkb.org/index.jsp
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A L A B A M A P H A R M A C Y A S S O C I AT I O N
S U M M E R 2012
methanol, acetone, ether, hydriodic acid, lithium, muriatic acid,
red phosphorus, sodium hydroxide, sulfuric acid, and toluene.10
Watching for individuals who purchase common chemicals used in
the manufacturing process along with pseudoephedrine may be a
way to detect illegitimate purchasers of pseudoephedrine. Everyday
products containing these chemicals can be seen in Table 2 and
can be purchased at most variety stores. The potential hazard of
clandestine labs is that the waste from the labs is very toxic to
humans and the environment and the gases produced are highly
flammable and explosive. Some signs that a methamphetamine
lab may be present in a residence are unusual odors, lots of trash
(chemical containers, coffee filters, match boxes), windows covered
with aluminum foil or black cloth, frequent visitors, and excessive
security.12 Toxic waste is a large part of the manufacturing
process: with each pound of methamphetamine made using
pseudoephedrine, six pounds of waste are generated.10 For an
updated list on property where clandestine labs have been found
by state and county authorities go to www.dea.gov and search for
National Clandestine Laboratory Register.
CURRENT PSEUDOEPHEDRINE LAWS
Pseudoephedrine is currently a listed precursor chemical
per section 20-2-181 of the Code of Alabama.13 The Code of
Alabama defines a listed precursor chemical as “any chemical
substance that in addition to legitimate uses is used in the unlawful
manufacture of a controlled substance”. Examples of other
listed precursor chemicals are ephedrine, ergotamine, hydriodic
acid, methylamine, phenylpropanolamine, and piperidine. This
designation requires special monitoring and sales procedures for
pseudoephedrine. Current laws apply to any product that contains
30 mg or more of pseudoephedrine and is not being sold due to a
legitimate prescription. Any product that contain 30 mg or more
of pseudoephedrine must be sold in blister packages and must be
stored behind the counter where the public is not permitted, or
in a locked display case where a customer must ask for employee
assistance. No more than 3.6 grams of pseudoephedrine can be sold
to a single customer per calendar day or more than 9 grams per 30
days. Any person buying pseudoephedrine must be at least 18 years
of age, provide a government issued photographic identification,
and sign a record of the transaction.
According to Act 2010-215 amending section 20-2-190 of
the Code of Alabama, as of January 1, 2011 any retailer wishing
to sell pseudoephedrine, whether a pharmacy or a non-pharmacy
business registered with the Alabama Alcoholic Beverage Control
Board, must use the National Precursor Log Exchange (NPLEx)
system. The NPLEx is provided to retailers and law enforcement
agencies for free through the National Association of Drug
Diversion Investigators (NADDI). The system creates an electronic
record for each attempted purchase of OTC cold and allergy
medications containing pseudoephedrine in Alabama through the
National Precursor Log Exchange system. This information then
is transferred to the NPLEx database, where it can then only be
reviewed by law enforcement agencies. Pharmacies may only access
the information that their specific store has entered, so they do not
have access to the entire database.
This new system still requires the purchaser to be at least 18
years of age, present a government issued photographic identification,
and sign a record of the transaction; however, it logs sales throughout
Alabama in real time.14 The NPLEx hopes to cut down on “smurfing”,
which is when a group of people go from one store to another
buying the maximum legal amount of pseudoephedrine at each
store in order to obtain enough to cook methamphetamine. The
NPLEx logs the name and address of the patient, the time and date
of the sale, the name of the product, the total quantity (in grams) of
pseudoephedrine contained in the transaction, and the total amount
purchased by the individual in 30 days. If the patient exceeds the limit
of 3.6 grams/day, or 9 grams/30 days, the system will issue a “stop-sale”
alert. If a “stop-sale” alert is generated, the seller should not complete
the sale unless they fear of bodily harm if they do not complete the
sale. Any person who overrides the “stop-sale” alert without fear of
bodily harm is guilty of a Class C misdemeanor for the first offense,
which can include up to three months in jail and up to a $500 fine, a
Class A misdemeanor for the second offense, which can include up
to one year in jail and up to a $6,000 fine, and a Class C felony for
each subsequent offense, which includes up to 10 years in prison and
a maximum of a $15,000 fine.15 The owner or operator of a store
cannot be penalized for conduct of an employee as long as he or she
documents employee training either conducted or approved by the
Alabama Drug Abuse Task Force. If a store selling pseudoephedrine
in compliance with the previous laws experiences a mechanical or
electronic malfunction, the store can continue to sell pseudoephedrine
by maintaining a written log or an electronic record until they are
able to comply with the previous laws. Any store in compliance with
the previous laws may submit an exemption from submitting to the
NPLEx to the Alabama Alcoholic Beverage Control Board stating
the reason why they are seeking exemption. The Board may grant
an exemption for a maximum of 180 days. The retailer must still
maintain a log of transactions and each purchaser must meet the sales
requirements as mandated by law.
Currently 1,042 pharmacies in Alabama (approximately
97%) have registered with the NPLEx. As of March 31, 2011,
only 41 of the 4,351 non-pharmacy businesses that sell products
with pseudoephedrine were registered with the NPLEx system.14
Many of these that have not registered with the new system have
notified the task force that they no longer intend to sell OTC
medications containing pseudoephedrine.
CURRENT STATE OF PSEUDOEPHEDRINE SALES
In a statement released by the Alabama Drug Abuse Task
Force, as of April 12, 2011, the new electronic system used to
track OTC sale of products containing pseudoephedrine, issued
a “stop-sale” alert and blocked a total of 26,354 purchases.14 This
represents a total of over 64,000 grams of pseudoephedrine. The
task force also released that 399,345 sales, with approximately
829,875 grams of pseudoephedrine, were purchased legally during
the same time frame. The Drug Abuse Task force estimates that
using the current methods of manufacturing methamphetamine, 1
gram of ephedrine or pseudoephedrine can manufacture 1 gram
of methamphetamine. This means that approximately 64,000
grams of methamphetamine were kept off of the streets in the first
three months of 2011, thanks to the implementation of this new
electronic system. The current street value of methamphetamine
is approximately $150/gram, meaning that $9.6 million of
methamphetamine was prevented from entering our society.14
CURRENT STATE OF PSEUDOEPHEDRINE SALES
In a statement released by the Alabama Drug Abuse Task
Force, as of April 12, 2011, the new electronic system used to
track OTC sale of products containing pseudoephedrine, issued
a “stop-sale” alert and blocked a total of 26,354 purchases.14 This
represents a total of over 64,000 grams of pseudoephedrine. The
task force also released that 399,345 sales, with approximately
829,875 grams of pseudoephedrine, were purchased legally during
the same time frame. The Drug Abuse Task force estimates that
using the current methods of manufacturing methamphetamine, 1
gram of ephedrine or pseudoephedrine can manufacture 1 gram
of methamphetamine. This means that approximately 64,000
grams of methamphetamine were kept off of the streets in the first
three months of 2011, thanks to the implementation of this new
electronic system. The current street value of methamphetamine
is approximately $150/gram, meaning that $9.6 million of
methamphetamine was prevented from entering our society.14
WHAT CAN BE DONE
Pharmacists can play a unique role in limiting the
amount of pseudoephedrine that is sold to questionable buyers.
Pharmacists and pharmacy technicians are the main gateway
which illegitimate purchasers must go through in order to acquire
pseudoephedrine. Pharmacists can get involved in the process
by not letting technicians handle all of the pseudoephedrine
sales. If the pharmacist recognizes that the person comes in every
month to buy the legal limit and does not exhibit signs of a cold
or allergies, then they can refuse to sell the pseudoephedrine
to the person. Other states have recognized that even increased
monitoring systems will not prevent pseudoephedrine abuse and
have created laws requiring a prescription from a doctor to buy
pseudoephedrine. Mississippi and Oregon are the only states
in the United States that have prescription pseudoephedrine
laws. The Oregon Board of Pharmacy adopted a rule requiring a
prescription for all pseudoephedrine products on July 1, 2006.16
There were 473 meth labs discovered in 2003, 448 in 2004, 192
in 2005, and 48 in the first 6 months of 2006. Since the law went
into effect there were only 15 labs shut down from July-December
W W W. A PA R X . O RG
55
of 2006, 20 in 2007, 21 in 2008, and 26 in 2009-2010 combined.
The initial drop in busts between 2005-2006 was due to requiring
pseudoephedrine products to be kept behind the counter and
logging each sale. Since the state required a prescription for
pseudoephedrine the meth lab busts have drastically dropped
compared to when the state required products to be kept behind
the counter and logging each sale. Mississippi’s law requiring a
prescription for all pseudoephedrine products went into effect
on July 1, 2010. Two hundred and three meth labs were found
from July 2010 to February 2011 which was a decrease of about
70% from the 607 busted in July 2009 to February 2010.17
Ninety-eight percent of the meth labs found since July 2010 were
operating with pseudoephedrine purchased from other states.
Legislators from other states such as Missouri, West Virginia, and
Oklahoma have initiated bills to require a prescription for all
pseudoephedrine products.18,19,20 Requiring a prescription for
all pseudoephedrine products can increase the price of care for
patients who rely on pseudoephedrine to treat their allergies.
CONCLUSION
Methamphetamine has been, and continues to be, a problem
in Alabama. With the new NPLEx system now in place, precursor
acquisition has been reduced, as evidenced by the number of
patients denied access to pseudoephedrine products in the first
three months of 2011. But the NPLEx system is only part of the
solution; the pharmacists of Alabama must also be able to recognize
and report problems as well. Without proactive pharmacists,
methamphetamine use in Alabama could continue to rise or the
Alabama legislature could follow the examples of Oregon and
Mississippi to further restrict patient access to pseudoephedrine.
TABLE 2
CHEMICALS FOUND IN LABS
Typical
Chemicals Found
in Lab Sites
Acetone
Methanol
Ammonia
Benzene
Ether
Freon
Common
Legitimate Uses
Fingernail polish
remover, solvents
Brake Cleaner fluid,
fuel
Disinfectants
Dye, varnishes,
lacquers
Starters fluid,
anesthetic
Refrigerant,
propellants
Flammable
Toxic Vapors
X
X
X
Reproductive disorders
X
X
X
Blindness, eye damage
X
Explosive
X
X
X
X
X
X
X
Corrosive
Common Health
Hazards
Poison
X
Blistering, lung damage
X
Carcinogen, Leukemia
Respiratory Failure
X
X
X
Frostbite, Lung damage
Burns, Thyroid Damage
Hydriodic Acid
Driveway cleaner
X
X
X
Hydrochloric
Acid(HCL Gas)
Iron ore processing,
mining
X
X
X
Iodine Crystals
Antiseptic, Catalyst
X
Lithium Metal
Lithium batteries
X
Muriatic Acid
Swimming pool
cleaners
X
X
Phosphine Gas
Pesticides
X
X
Pseudoephedrine
Cold medicines
X
Red Phosphorus
Matches, fireworks
X
Sodium Hydroxide
Drain cleaners, lye
X
X
X
Burns, Skin Ulcers
Sulfuric Acid
Battery Acid
X
X
X
Burns, Thyroid Damage
Toluene
Paint, thinners,
solvents
X
*taken from http://www.kci.org
56
A L A B A M A P H A R M A C Y A S S O C I AT I O N
S U M M E R 2012
X
X
X
Respiratory, Liver
Damage
Birth Defects, Kidney
Failure
X
Burns, Pulmonary Edema
X
Burns, Toxic Vapors
Respiratory Failure
Abuse: Heart Damage
X
X
X
X
X
X
Unstable, Flammable
Fetal Damage, Pneumonia
CONTINUING EDUCATION
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To receive continuing eduation credit, please provide the following information:
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2. Mail the completed form for scoring to the address listed below. The quiz must be postmarked by the expiration date. Faxed
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W W W. A PA R X . O RG
57
CONTINUING EDUCATION QUIZ - PSEUDOEPHEDRINE ACPE#: 0178-0000-12-103-H04-P
1. How much methamphetamine can be manufactured from 1 gram
of pseudoephedrine?
a. 0.5 grams
b. 0.75 grams
c. 1.0 grams
d. 0.25 grams
2. Of the following options, which is not included in the database
once a person purchases a product containing ephedrine or
pseudoephedrine?
a. Patients address
b. Total quantity (in grams) purchased
c. Patients phone number
d. Time and date of purchase
3. Which of the following have access to the ENTIRE NPLEx system?
a. Pharmacists
b. Patients
c. Law Enforcement
d. A and C are correct
4. The manufacture of 1 pound of methamphetamine produces
approximately how many pounds of waste?
a. 1 pound
b. 3 pounds
c. 6 pounds
d. 10 pounds
5. The NPLEx System for tracking the sale of pseudoephedrine is
provided for:
a. A yearly subscription fee
b. Free to law enforcement agencies
c. Free to Retailers
d. B and C are correct
6. What is the brand name of Methamphetamine HCl currently on the
market?
a. Dexedrine®
b. Desoxyn®
c. Adipex-P®
d. Adderall®
7. What is the precursor mainly used to produce methamphetamine by
drug cartels in Mexico?
a. Pseudoephedrine
b. Ephedrine
c. Phenyl-2-propanone
d. Coca
8. What is the maximum amount of pseudoephedrine that can be
purchased in 1 calendar day?
a. 3.3 grams
b. 3.6 grams
c. 4.0 grams
d. 2.8 grams
60
A L A B A M A P H A R M A C Y A S S O C I AT I O N
S U M M E R 2012
9. What is the maximum amount of pseudoephedrine that can be
purchased in 30 days?
a. 7 grams
b. 8 grams
c. 9 grams
d. 10 grams
10. Which of the following is not a common method of making
methamphetamine?
a. Nazi Method
b. Shake and Bake Method
c. Allied Method
d. Red, White, and Blue Method
11. Which of the following is the preferred pseudoephedrine product
for making methamphetamine?
a. Liquid products
b. Multiple ingredient tablets
c. Gel capsules
d. Single ingredient tablets
12. True or False. The street value of 1 gram of methamphetamine is
approximately $150.
13. True or False. The sale of pseudoephedrine after a “stop-sale”
notice is received is considered a class A misdemeanor for the
first offense.
14. True or False. If a patient picks up a prescription medication that
has contained pseudoephedrine, you are still required to scan this into
the NPLEx system.
15. True or False. According to recent data methamphetamine lab
busts are on the rise.
16. True or False. Methamphetamine use in Alabama is lower than the
national average.
CONTINUING EDUCATION QUIZ - PSEUDOEPHEDRINE | ACPE#: 0178-0000-12-103-H04-P
NOTE:
APA WILL
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BEGINNING WITH
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CE Assessment Answers
Please circle your answers (one answer per question).
1. A
B
C
D
2. A
B
C
D
3. A
B
C
D
4. A
B
C
D
5. A
B
C
D
6. A
B
C
D
7. A
B
C
D
8. A
B
C
D
9. A
B
C
D
10. A
B
C
D
11. A
B
C
D
12. TRUE
FALSE
13. TRUE
FALSE
14. TRUE
FALSE
15. TRUE
FALSE
16. TRUE
FALSE
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