The current Adderall shortage is of serious concern to both patients who have attention deficit hyperactivity disorder (ADHD) and clinicians. This shortage cannot be quickly alleviated by a simple increase in the amount of medication manufactured, unless the upper limit to the amount of Adderall’s active ingredient that can be manufactured in a given year is raised by the Drug Enforcement Agency (DEA). The limit has been imposed because the active ingredient can be abused as a recreational drug. It is necessary to control the supply of any medication with abuse liability, but this must be achieved without compromising the legitimate treatment of patients in dire need.
The medical practitioner is ultimately responsible for accurate diagnosis and subsequent provision of the best treatment. If any alternative or substitute treatments are necessitated by the current shortage, they must be determined by a clinician who knows the patient and is expert in the complexities of psychopharmacology in general and of ADHD in particular. In the case of ADHD, board-certification or board-eligibility in psychiatry or as a psychiatric mental health nurse practitioner is a useful indicator of sufficient training to deal with eventualities such as the current shortage.
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Could there be an “Adderall crisis” like the “opioid crisis”?
According to the Centers for Disease Control (CDC), opioid addiction is the most frequent cause of overdose deaths in the United States. The opioid crisis is so severe and widespread that people are either aware of it or have experienced it firsthand. Its ripple effects continue to harm countless families. What can we learn about the Adderall shortage from this sobering episode?
Inability to access prescription medication can result in the creation of an underground market, as people desperately seek relief from the medical issues for which the medication was originally prescribed. Any scenario in which people are treating themselves rather than consulting with expert medical practitioners leads to the sort of disasters we are all too familiar with from the opioid epidemic.
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The case of Adderall is completely different from that of opioids. Opioids are prescribed for both chronic and acute pain of moderate, severe or even mild intensity, and thus have a potential patient population in the U.S. alone of many tens of millions, if not hundreds of millions.
Adderall is a member of the class of psychostimulants, a class that neither chemically nor pharmacologically has any relation to opioids. Its legitimate medical uses are limited to ADHD and narcolepsy, a potential U.S. patient pool of around 10 million. The potential for unmitigated disaster posed by the specter of Adderall abuse is far lower than that for opioids. But due to factors which are not entirely clear, access to Adderall has reached a new level of difficulty.
When Covid-19 hit, psychiatric issues were exacerbated and healthcare in general was forced to go online. Some blame the online venue for the increase in demand for Adderall, but the reality is a rare example of a cloud that has a silver lining! Telepsychiatry eased barriers so that previously unrecognized and/or untreated cases of ADHD, including severe, life-threatening examples, came to light and were treated.
Concerns about too much Adderall, and about too little
The ease with which abusable substances can be procured is a function of the ethics and training of the providers, not of the setting in which they are prescribed. Despite this, the concerns about obtaining Adderall “too easily” are currently focused on telehealth platforms. A comprehensive evaluation protocol and practitioners of the highest quality are far more important to prevent abuse than whether care is provided virtually or in-person
Unfortunately, state-of-the-art evaluation is to no avail if the prescribed treatment is abruptly unavailable. In the case of Adderall, sudden unavailability can create a withdrawal syndrome, depression with all its attendant risks, and severe stress from impaired concentration at work, at home and in the never-ending search for a way to resume treatment.
At least two online platforms that offer ADHD evaluation and treatment have been asked to provide documents to the U.S. Drug Enforcement Agency. Those current proceedings are best characterized as “routine” investigations. No reasons for investigation have been given, and there has been no allegation of “misusing” or inappropriately prescribing controlled substances. It is a commonplace for any significant healthcare player to be subjected to official scrutiny, and in fact, all major pharmaceutical companies, hospital chains and HMO’s have been under governmental investigations.
In part due to hard lessons learned from the preventable “opioid epidemic,” there is motivation for strong safeguards relating to the diagnosis and treatment of ADHD, because of the identifiable risk of a treatment with dependence potential.
The Adderall shortage: NOT from over-prescribing
ADHD has been under diagnosed at both extremes of the lifespan. Its existence in adults was completely denied until recently. Recent studies have shown that when ADHD is untreated in patients 4-6 years of age, there is a dramatically increased risk of serious depression, including suicide, as the child enters adolescence and adulthood.
If medicine is to fulfill its goals of alleviating human suffering and treating disease, the improved access facilitated by telepsychiatry must not be regulated out of existence. The increased demand for stimulant medications such as Adderall for ADHD is not the result of abuse or misdiagnosis but is caused by a previously unmet need for treatment of ADHD, which telepsychiatry finally satisfied. If regulators allow manufacturers to appropriately increase production, the Adderall shortage can be managed.
Contrary to some popular beliefs, ADHD is not mild, but a severe neuropsychiatric disorder that entails shockingly high risks of career and relationship failure, reductions in life expectancy, and deaths from accidents, substance abuse or suicide. However, because effective treatment is available, ADHD could become a premier example of afflictions that have been managed or cured using our hard-won understanding of the physical basis of diseases of the brain or of the body.
Effective treatments are already well known. Whether they fulfill their vast potential is a matter not of medical science, but of whether government and society at large can rise to the challenge.
David Brody, MD is the clinical president at Done. He has worked in psychiatric medicine for decades and has an abundance of experience diagnosing and treating ADHD.
Dr. Brody completed his education and training in California, beginning with a medical degree from the University of California, Irvine. He completed his residency in psychiatry at Stanford University School of Medicine, followed by a postdoctoral fellowship in Stanford’s Department of Neurobiology. He is certified in psychiatry by the American Board of Psychiatry and Neurology.
During his distinguished career, Dr. Brody has served as the medical director for several inpatient and outpatient psychiatric facilities, including St. Luke’s Hospital in San Francisco and Sonoma County Behavioral Health, and he has been an instructor in psychopharmacology and a clinical instructor in psychiatry at many universities in California and Arizona.
