The Health Consequences of the Stimulant Shortage

Last year, the US Food and Drug Administration (FDA) announced a shortage of stimulant medications that psychiatrists use daily to treat patients with attention-deficit/hyperactivity disorder (ADHD). The consequence of this shortage has cost us dearly—our patients must scramble to find a pharmacy with an adequate supply to fill their prescriptions. Physicians routinely receive frantic phone calls telling us there are no pharmacies within a reasonable travel distance to obtain their medication. It is not unusual for patients to call 10 or more pharmacies to get adequate information about the amount of available medication or when a new supply might be shipped. Some pharmacies will not even give out this information. The mail-order pharmacy alternative is no better. I have sent in electronic prescriptions for patients, assuming they will be filled. Often, if it is not available, I am not notified, and patients do not receive their shipment.

Why Did the Shortage Occur?

According to an article in Time, "When the FDA announced the Adderall shortage last year, it pointed to 'ongoing intermittent manufacturing delays' at Teva Pharmaceuticals, a major supplier of Adderall." However, other factors combined with manufacturing issues caused a "perfect storm" of medication shortage. A study by the General Accountability Office looked at the rise of telehealth use by Medicaid participants in five states and found the number of telehealth services in those states increased to 15 times the pre-pandemic level.

Although the surge in prescriptions for ADHD medication during the pandemic has been attributed to the expansion of these services, a new research study disputes this fact. What is not in dispute is the fact that prescriptions for adults with ADHD rose by 10 percent during the first year of the pandemic, according to data from the Centers for Disease Control and Prevention.

Because Adderall and other stimulants are controlled medications and have the potential for abuse, the US Drug Enforcement Administration (DEA) and the FDA regulate the amount of these medications that can be manufactured. To avoid more supply of drugs in circulation than necessary, the DEA caps the amount of amphetamine available to manufacturers in a given year. This means that manufacturers may apply to receive a portion of the total supply and can request more if necessary, but the DEA may deny a request if the full quota has already been met.

In addition, On October 23, 2019, the DEA launched the Suspicious Orders Report System (SORS) Online, a new centralized database required by the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act. The SUPPORT Act states the term "suspicious order" may include but is not limited to an order of a controlled substance of unusual size, an order of a controlled substance deviating substantially from a normal pattern, and orders of controlled substances of unusual frequency as per 21 U.S.C. 802."

Due to the sustained Adderall shortage, providers like me must come up with creative ways of providing our patients with appropriate doses of medication. Sometimes, I have to switch to alternative medications or devise innovative ways of creating the correct amount by combining several different prescriptions. You can see how this might trigger a report by a pharmacy to the SORS. Some pharmacies following "red flag laws" can refuse to fill a physician's legitimate prescription. (Under various state laws and DEA regulations, every pharmacist must resolve "red flags" before dispensing a prescription for controlled substances.)

Cost to Physical and Mental Health in Adults With ADHD

The estimated prevalence of adult ADHD in the United States is more than 4 percent. This means that ADHD affects more than nine million people. Individuals with ADHD experience an ongoing pattern of inattention, impulsivity, and, sometimes, hyperactivity. This causes problems staying on task, sustaining focus, and remaining organized. Some individuals fidget excessively, talk excessively, and remain restless, affecting their ability to sleep well. The impulsivity they experience can cause them to act without thinking, take dangerous chances, make poor decisions, and interrupt others. Because stimulant discontinuation (due to unavailability) can lead to transient withdrawal symptoms, patients often experience fatigue, mood swings, increased anxiety, disrupted sleep, irritability, and lack of motivation.

Because of the stimulant shortage, patients often ration their dose so that they do not run out of medication before their next prescription can be filled. This impacts their ability to perform adequately at work and at home.

From a health standpoint, patients with ADHD who cannot obtain their prescription often forget to take their other prescribed maintenance medications, impacting their overall physical status. It can make it harder to maintain a routine, so regular meals, exercise, and sleep schedules become disrupted. Individuals with ADHD have an increased risk of developing dependence on nicotine, alcohol, marijuana, and other drugs. Due to deficits in executive functions, which include the ability to self-regulate, problem-solve, and inhibit impulse control, these individuals also have a greater risk of obesity, and higher rates of nicotine use and consumption of excess alcohol, contributing to overall increased rates of heart disease and stroke. People with untreated ADHD also have increased risks of unprotected sex with multiple partners, which can lead to sexually transmitted infections and unintended pregnancies. The result of these behaviors either alone or in combination can decrease life expectancy by more than 10 years.

What Can Be Done?

Contact your local congressional representative. Earlier this month, representative Abigail Spanberger of Virginia spearheaded an effort urging the DEA and the FDA to provide more answers on their work to end the shortages of these medications. Talk to your provider about alternatives to your usual prescriptions. There are many options besides Adderall. Finally, try modifying your behavior: Improve sleep hygiene, engage in regular exercise, and, as best as you can, stick to a routine. All of these measures have been proven to help with the symptoms of ADHD.