Changing over-the-counter ephedrine and pseudoephedrine products to prescription only: impacts on methamphetamine clandestine laboratory seizures

The impact of precursor regulations on illicit drug markets: An analysis of Cunningham et al.'s studies

This review examines a series of twelve studies led by James K. Cunningham and his team, focusing on the effects of precursor regulation on illicit drug markets. Their research shows that the regulation of chemicals essential for the production of drugs such as heroin, cocaine, and methamphetamine is associated with several positive outcomes. These include a decrease in drug purity, a reduction in seizures, lower demand for treatment and hospitalization, and an increase in drug prices. According to the research, this decrease in harmful outcomes results from a combination of diminished overall consumption and a reduction in harm per dose. However, this review identifies some inconsistencies within their studies. These inconsistencies include premature assumptions about the timing of intervention impacts, uneven influences of similar interventions, variations in the implementation of these interventions, and the disregard of alternate explanations for sudden shifts in drug markets. Cunningham's work can be considered one of the most substantial contributions in this field. However, to secure the full confidence of the drug policy community in the authenticity of their findings, they must effectively address the issues identified in this review.

The impact of pseudoephedrine regulation at Australian pharmacies through Project Stop: A narrative review

ISSUES

Project Stop, a real-time monitoring program for pseudoephedrine-containing medicines, was initiated in 2005 by the Pharmacy Guild of Australia in collaboration with police in the state of Queensland. The program implemented an online database to record pseudoephedrine purchases (and attempted purchases) to prevent large-scale diversion to methamphetamine production.

APPROACH

This narrative review aims to understand the overall impact of Project Stop, what evidence exists for this kind of intervention in Australia, and what lessons can be learned from its introduction. Systematic database searches were conducted in Embase, PubMed, Web of Science and Google Scholar, with 20 relevant sources selected for inclusion.

KEY FINDINGS

Project Stop successfully prevented some pseudoephedrine from being diverted from pharmacies to methamphetamine production. The intervention has been most effective in jurisdictions that made the program mandatory. Project Stop was also associated with a temporary decline in clandestine laboratory seizures in Queensland, changes in methamphetamine production methods and reduced voluntary treatment admissions for methamphetamine use. Implementation was not associated with an appreciable effect on secondary indicators, such as methamphetamine production and harmful use.

IMPLICATIONS

Future applications of a Project Stop model must ensure ongoing impact evaluation, assessment of its effect on individual's drug-related behaviour and combine it with policies that address drug use as a health issue.

CONCLUSION

Project Stop has been narrowly successful in terms of reducing pseudoephedrine diversion and demonstrates the potential for third-party policing practices directed at the consumer level, in collaboration with healthcare practitioners, rather than only regulating precursor wholesalers.

Up-scheduling and codeine supply in Australia: analysing the intervention and outliers

BACKGROUND AND AIMS

Over-the-counter codeine products were up-scheduled to prescription only in Australia from February 2018. This trend study aimed to identify changes in codeine supply before and after the February 2018 implementation.

DESIGN, SETTING AND CASES

Time-series regression analysis of monthly medicine supplies in Australia from 2014 to 2018. The February 2018 up-scheduling was pre-specified as the intervention; outlier analysis was used to detect automatically sudden unexpected changes before February 2018.

MEASUREMENTS

Per-capita supplies based on national data for pharmaceutical wholesales and population exposure. Weight of supplies in milligrams for low-dose codeine (≤ 15 mg per tablet or ≤ 1.92 mg per ml, originally sold over the counter but up-scheduled after February 2018), high-dose combination codeine (30 mg per tablet, prescription only throughout the study period) and all codeine.

FINDINGS

Several level shifts in supply occurred during the 5 years, led by one of -4.4% [95% confidence interval (CI) = -6.6 to -2.1%] in high-dose codeine in 2015, followed by shifts in low-dose codeine of -40.0% (CI = -46.9 to -32.3%) and -82.2% (CI = -84.3 to -79.9%), respectively, before and after February 2018. High-dose codeine supply increased by 4.4% (CI = 1.8-7.1%) immediately after up-scheduling. Also detected were transient increases and decreases in 2016 and 2017. Compared with pre-2015 levels, the February 2018 up-scheduling was associated with reductions of 45.7% (CI = 43.2-48.0%) and 89.3% (CI = 87.9-90.6%), respectively, in all and low-dose codeine supply but no change in high-dose codeine supply. The level shifts and transient changes were located around various regulatory activities, including public announcements and expert advisory meetings on up-scheduling.

CONCLUSION

Up-scheduling of over-the-counter codeine products in Australia in 2018 appears to have been associated with a near halving of Australia's national codeine supply. The transition occurred in multiple forms and phases.

Supplying synthetic opioids during a pandemic: An early look at North America

International commerce and travel have been restricted in order to limit the spread of COVID-19. The illegal trafficking in drugs, which is often concealed in other commercial activity, will be affected by these disruptions. This is particularly true for precursor chemicals, controlled substances of synthetic origin, and new psychoactive substances coming from Asia. China hosts large and under-regulated pharmaceutical and chemical sectors that provide many of the active ingredients used both in legitimate medicines and illicit fentanyl and methamphetamine. Unregulated producers and vendors in China have been supplying drug trafficking organizations in Mexico or using the internet and postal service to directly sell fentanyl to buyers in North America. The magnitude of supply shortages and interrupted trade of chemicals and synthetic drugs coming from China will depend on the breadth and depth of COVID-19’s disruptions. In turn, this could impact vulnerable drug-using populations. Drawing on historical accounts of prior supply disruptions, this commentary offers some initial speculation as to the possible effects of COVID-19 on the supply of synthetic drugs like fentanyl and precursor chemicals supplied to North America from China, which may have important lessons for other parts of the globe. Prior supply disruptions coincided with elevated prices and reduced purities of street drugs as well as increases in the number of users entering treatment. However, it is challenging to predict how developments will unfold given the unprecedented nature of this pandemic. A short-term breakdown in supply chains, interrupted trade, or social distancing mandates may not have much of an effect on the availability of synthetic drugs. Yet, disruptions in trade for months or years could shape how drugs are supplied or used. Drug policy will need to evaluate market indicators as soon as they are available but responding now with expanded medication therapies, like methadone, may help save lives. The drug policy landscape could look different in a post-COVID world.

A review of the newly identified impurity profiles in methamphetamine seizures

Forensic intelligence of synthetic illicit drugs suffers a problem of continuous introduction of new synthetic methods, modification of the existing routes of manufacture, and adulterations practiced by criminal networks. Impurity profiling has been indispensable in methamphetamine intelligence based on precursors, synthetic routes, and chemical modifications during trafficking. Law enforcement authorities maintain the credibility and integrity of intelligence information through constant monitoring of the chemical signatures in the illicit drug market.

Changes in the synthetic pattern result in new impurity profiles that are important in keeping valuable intelligence information on clandestine laboratories, new synthetic routes, trafficking patterns, and geographical sources of illicit Methamphetamine.

This review presents a critical analysis of the methamphetamine impurity profiles and more specifically, profiling based on impurity profiles from Leuckart, Reductive amination, Moscow, Emde, Nagai, Birch, Moscow route; a recent nitrostyrene route and stable isotope signatures. It also highlights the discrimination of ephedrine from pseudoephedrine sources and the emerging methamphetamine profiling based on stable isotopes.

Can new psychoactive substances be regulated effectively? An assessment of the British Psychoactive Substances Bill

The regulation of new psychoactive substances (NPS) has confounded governments throughout the western world. In 2014 the UK government convened an NPS Review Expert Panel to consider a range of approaches. Ultimately the Panel recommended that the government ban all new psychoactive drugs and allow only psychoactive substances specifically exempted, such as alcohol, tobacco and those allowed as medicines. The government introduced the Psychoactive Substances Bill (PSB) in response to that recommendation. Passed in 2016, the Bill has attracted a torrent of criticism from scientists and experts. The Bill could be improved with revision, but the problems of the total ban, as envisioned by the PSB, with respect to the NPS, may be inherent: (1) defining psychoactivity is conceptually fraught, with great consequence for the scope of the prohibition; (2) operationalizing psychoactivity as a usable concept for legal control purposes is extremely difficult, perhaps impossible; and (3) the detachment of penalties for violating a total ban from establishing the harmfulness of a substance is normatively troubling. Given the uncertainties about the effects of a total ban, it is appropriate at this time for other governments to assess more fully the nature of the NPS problem, and the potential control approaches.

Essential/precursor chemicals and drug consumption: impacts of US sodium permanganate and Mexico pseudoephedrine controls on the numbers of US cocaine and methamphetamine users

BACKGROUND AND AIMS

In December 2006 the United States regulated sodium permanganate, a cocaine essential chemical. In March 2007 Mexico, the United States' primary source for methamphetamine, closed a chemical company accused of illicitly importing 60+ tons of pseudoephedrine, a methamphetamine precursor chemical. US cocaine availability and methamphetamine availability, respectively, decreased in association. This study tested whether the controls had impacts upon the numbers of US cocaine users and methamphetamine users.

DESIGN

Auto-regressive integrated moving average (ARIMA) intervention time-series analysis. Comparison series-heroin and marijuana users-were used.

SETTING

United States, 2002-14.

PARTICIPANTS

The National Survey on Drug Use and Health (n = 723 283), a complex sample survey of the US civilian, non-institutionalized population.

MEASUREMENTS

Estimates of the numbers of (1) past-year users and (2) past-month users were constructed for each calendar quarter from 2002 to 2014, providing each series with 52 time-periods.

FINDINGS

Downward shifts in cocaine users started at the time of the cocaine regulation. Past-year and past-month cocaine users series levels decreased by approximately 1 946 271 (-32%) (P < 0.05) and 694 770 (-29%) (P < 0.01), respectively-no apparent recovery occurred through 2014. Downward shifts in methamphetamine users started at the time of the chemical company closure. Past-year and past-month methamphetamine series levels decreased by 494 440 (-35%) [P < 0.01; 95% confidence interval (CI) = -771 897, -216 982] and 277 380 (-45%) (P < 0.05; CI = -554 073, -686), respectively-partial recovery possibly occurred in 2013. The comparison series changed little at the intervention times.

CONCLUSIONS

Essential/precursor chemical controls in the United States (2006) and Mexico (2007) were associated with large, extended (7+ years) reductions in cocaine users and methamphetamine users in the United States.

Analysing pseudoephedrine/methamphetamine policy options in Australia using multi-criteria decision modelling

BACKGROUND

In this paper we capture and synthesize the unique knowledge of experts so that choices regarding policy measures to address methamphetamine consumption and dependency in Australia can be strengthened. We examine perceptions of the: (1) influence of underlying factors that impact on the methamphetamine problem; (2) importance of various models of intervention that have the potential to affect the success of policies; and (3) efficacy of alternative pseudoephedrine policy options.

METHODS

We adopt a multi-criteria decision model to unpack factors that affect decisions made by experts and examine potential variations on weight/preference among groups. Seventy experts from five groups (i.e. academia (18.6%), government and policy (27.1%), health (18.6%), pharmaceutical (17.1%) and police (18.6%)) in Australia participated in the survey.

RESULTS

Social characteristics are considered the most important underlying factor, prevention the most effective strategy and Project STOP the most preferred policy option with respect to reducing methamphetamine consumption and dependency in Australia. One-way repeated ANOVAs indicate a statistically significant difference with regards to the influence of underlying factors (F(2.3, 144.5)=11.256, p<.001), effectiveness of interventions (F(2.4, 153.1)=28.738, p<.001) and policy options (F(2.8, 175.5)=70.854, p<.001).

CONCLUSION

A majority of respondents believed that genetic, biological, emotional, cognitive and social factors are the most influential explanatory variables in terms of methamphetamine consumption and dependency. Most experts support the use of preventative mechanisms to inhibit drug initiation and delayed drug uptake. Compared to other policies, Project STOP (which aims to disrupt the initial diversion of pseudoephedrine) appears to be a more preferable preventative mechanism to control the production and subsequent sale and use of methamphetamine. This regulatory civil law lever engages third parties in controlling drug-related crime. The literature supports third-party partnerships as it engages experts who have knowledge and expertise with respect to prevention and harm minimization.

Is Mississippi's prescription-only precursor control law a prescription to decrease the production and raise the price of methamphetamine?

BACKGROUND

In 2010, Mississippi became the second state to require a prescription to purchase pseudoephedrine-based medications. Proponents of "prescription-only" laws argue that they are necessary to disrupt methamphetamine markets, but critics note the costs to legal consumers of cold medications may offset some of the laws' intended benefits.

OBJECTIVE

We evaluated the effect of prescription-only restrictions for methamphetamine precursors on state-level methamphetamine lab seizures and methamphetamine prices.

METHODS

We used a synthetic control approach to create a control state comparable to Mississippi and then used permutation testing to determine if the resulting difference was statistically significant.

RESULTS

We found that Mississippi's prescription-only law removed 2637 small methamphetamine labs in the two years after the law became effective, which represents a 77% reduction in small labs relative to the synthetic counterfactual. We found no evidence that the law impacted methamphetamine prices.

CONCLUSION

We conclude that while prescription-only laws can reduce the number of domestic small methamphetamine labs in operation, methamphetamine availability is unlikely to be materially impacted.

US federal cocaine essential ('precursor') chemical regulation impacts on US cocaine availability: an intervention time-series analysis with temporal replication

BACKGROUND AND AIMS

Research shows that essential/precursor chemical controls have had substantial impacts on US methamphetamine and heroin availability. This study examines whether US federal essential chemical regulations have impacted US cocaine seizure amount, price and purity-indicators of cocaine availability.

DESIGN

Autoregressive integrated moving average (ARIMA)-intervention time-series analysis was used to assess the impacts of four US regulations targeting cocaine manufacturing chemicals: potassium permanganate/selected solvents, implemented October 1989 sulfuric acid/hydrochloric acid, implemented October 1992; methyl isobutyl ketone, implemented May 1995; and sodium permanganate, implemented December 2006. Of these chemicals, potassium permanganate and sodium permanganate are the most critical to cocaine production.

SETTING

Conterminous United States (January 1987-April 2011).

MEASUREMENTS

Monthly time-series: purity-adjusted cocaine seizure amount (in gross weight seizures < 6000 grams), purity-adjusted price (all available seizures), and purity (all available seizures).

DATA SOURCE

System to Retrieve Information from Drug Evidence.

FINDINGS

The 1989 potassium permanganate/solvents regulation was associated with a seizure amount decrease (change in series level) of 28% (P < 0.05), a 36% increase in price (P < 0.05) and a 4% decrease in purity (P < 0.05). Availability recovered in 1-2 years. The 2006 potassium permanganate regulation was associated with a 22% seizure amount decrease (P < 0.05), 100% price increase (P < 0.05) and 35% purity decrease (P < 0.05). Following the 2006 regulation, essentially no recovery occurred to April 2011. The other two chemical regulations were associated with statistically significant but lesser declines in indicated availability.

CONCLUSIONS

In the United States, essential chemical controls from 1989 to 2006 were associated with pronounced downturns in cocaine availability.

Item response theory analyses of DSM-IV and DSM-5 stimulant use disorder criteria in an American Indian community sample

BACKGROUND

Native Americans experience some of the highest rates of DSM-IV stimulant dependence (SD) of all U.S. ethnic groups. This report compares DSM-IV and DSM-5 stimulant use disorder (SUD) diagnostic criteria in an American Indian community sample.

METHODS

Demographic information, stimulant (methamphetamine or cocaine) use, and lifetime DSM-IV and DSM-5 diagnoses were assessed in 858 adult American Indians. Item Response Theory (IRT) analyses were used to assess SUD criteria in both DSM-IV and DSM-5 criteria sets along an underlying latent trait severity continuum and the effect of demographic variables on differential item functioning (DIF) in those criteria.

RESULTS

The overall rate of DSM-IV SD was 33%, of DSM-IV SUD was 38%, and of DSM-5 SUD was 36% with no gender differences. All SUD symptoms in both the DSM-IV and DSM-5 datasets functioned on the moderate portion of the underlying severity continuum. "Craving" discriminated better than any other criterion at its level of severity in indicating the presence or absence of SUD. There was little DIF in groups defined by gender or any other demographic variable in either the DSM-IV or DSM-5 datasets.

CONCLUSIONS

These findings indicate that in this American Indian sample, diagnostic criteria for DSM-IV and DSM-5 SUD function similarly in terms of severity and DIF and that the abolition of the DSM-IV distinction between stimulant abuse and dependence in DSM-5 is warranted.

Essential ("precursor") chemical control for heroin: impact of acetic anhydride regulation on US heroin availability

BACKGROUND

To reduce heroin availability, the United Nations (UN) has encouraged nations to control acetic anhydride, an essential ("precursor") chemical typically necessary to the drug's production. This effort, a major environmental prevention policy, has received little evaluation. The United States, per the UN's lead, implemented acetic anhydride regulation in 11/1989. The present study examines whether the US regulation impacted US heroin availability.

METHODS

Monthly series of three heroin availability indicators-heroin purity, heroin price, and amount of heroin seized-were constructed for the conterminous United States, the US Southwest (supplied predominantly with Mexican-produced heroin), and the US Northeast (supplied predominantly, at the time, with Southeast Asian-produced heroin). Data came from the System to Retrieve Information from Drug Evidence (01/1987-04/2011). Impacts were assessed using ARIMA-intervention time series analysis.

RESULTS

In each US area, heroin purity and amount seized rose and price decreased throughout the pre-intervention period. All of the indicators then reversed course at the time of the regulation. In the conterminous United States, the US Northeast, and the US Southwest, purity decreased (-40%, -25% and -50%, respectively); amount seized decreased (-27%, -37% and -39%, respectively); and price rose (+93%, +102% and +296%, respectively). Impacts lasted 2-5 years.

CONCLUSION

US heroin availability decreased in association with the US acetic anhydride regulation. The impacts in the US Southwest and US Northeast suggest that heroin production in Mexico and Southeast Asia, respectively, was constrained. This study lends support to the contention that essential ("precursor") chemical control can be used to help address heroin.

Mexico's precursor chemical controls: emergence of less potent types of methamphetamine in the United States

BACKGROUND

This study examines whether Mexico's controls on ephedrine and pseudoephedrine, the two precursor chemicals that yield the most potent form of methamphetamine, d-methamphetamine, impacted the prevalence/availability of less potent types of methamphetamine in the United States-types associated with the alternative precursor chemical P2P.

METHOD

Using ARIMA-intervention time series analysis of monthly drug exhibits (a prevalence/availability indicator) from the System to Retrieve Information from Drug Evidence (STRIDE), we tested whether Mexico's controls, which began in 2005, were associated with growth/decline in d-methamphetamine and growth/decline in P2P-associated, less potent l-methamphetamine, racemic methamphetamine (a 50:50 ratio of d- and l-isomers), and mixed isomer methamphetamine (an unequal ratio of d- and l-isomers). Heroin, cocaine and marijuana exhibits were used for quasi-control (01/2000-04/2011).

RESULTS

Mixed-isomer exhibits constituted about 4% of the methamphetamine exhibits before Mexico's controls, then rose sharply in association with them and remained elevated, constituting about 37% of methamphetamine exhibits in 2010. d-Methamphetamine exhibits dropped sharply; l-methamphetamine and racemic methamphetamine exhibits had small rises. d-Methamphetamine exhibits partially recovered in the US West, but little recovery occurred in the US Central/South. Quasi-control series were generally unaffected.

CONCLUSION

The US methamphetamine market changed. Widespread emergence of less potent methamphetamine occurred in conjunction with Mexico's controls. And prevalence/availability of the most potent type of the drug, d-methamphetamine, declined, a partial recovery in the West notwithstanding. Granting that lower potency drugs typically engender less dependence and attendant problems, these findings suggest that, following Mexico's controls, the potential harm of a sizeable amount of the US methamphetamine supply decreased.