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Untreated ADHD is A Public Health Issue

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In October 2022, the FDA announced a shortage of stimulant medication used to treat patients with ADHD. ADHD is one of the most common neurodevelopmental disorders of childhood that often persists into adulthood. The estimated prevalence of adult ADHD in the U.S. is at least 3.5%. This means 9 million people are affected by the shortage. Below, we discuss how the shortage is affecting patients, why it’s occurring, and what clinicians can do to help close the care gap.

What the ADHD Medication Shortage Means for Patients

A common misconception is that stimulants are only used by college students who want to study more effectively. This is not the majority of cases. The prolonged medication shortage without explanation has led to severe consequences for children and adults appropriately diagnosed with ADHD.

Individuals with ADHD experience an ongoing pattern of inattention, impulsivity, and, sometimes, hyperactivity. This causes problems staying on task, sustaining focus, and remaining organized. The impulsivity can cause them to act without thinking, take dangerous chances, and make poor decisions. Because stimulant discontinuation (due to unavailability) can lead to transient withdrawal symptoms, they often experience fatigue, mood swings, increased anxiety, disrupted sleep, irritability, and lack of motivation.

One of the primary arenas in which adults and teens with ADHD face challenges is driving. Adults with ADHD tend to be at greater risk of having accidents, receiving traffic tickets, and driving without a license. In 2021, more than 3,500 people died in distraction-affected crashes caused by texting or answering a phone call while driving. Drivers with ADHD are particularly at risk of distractions during periods of low stimulus or dull driving, such as long-distance and highway driving, where high speeds can raise the chance of serious accidents.

From a health standpoint, patients with ADHD who cannot obtain their prescription often forget to take their other maintenance medications, impacting their overall physical health. Going without needed ADHD medication can make it harder to maintain a routine, so regular meals, exercise, and sleep schedules become disrupted. These individuals also have a greater risk of obesity, higher rates of nicotine use, and increased quantities of alcohol consumption, 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 STIs and unintended pregnancies. The result of these behaviors, either alone or in combination, can decrease life expectancy by more than 10 years. Clearly, the ADHD medication shortage is a public health issue.

Factors Causing the ADHD Medication Shortage

As psychiatrists, we routinely receive frantic phone calls from patients or their parents telling us that no pharmacies within a reasonable travel distance have enough medication to fill their prescriptions. It is common for patients to call 10 or more pharmacies to get adequate information about the number of available medicines or when a new supply might be in stock. Some pharmacies will keep this information private. The mail-order pharmacy alternative is no better. We have sent in electronic prescriptions for patients, assuming they will be filled. Often, if it is not available, we are not notified, and patients do not receive their shipment.

The shortage is the result of several factors. According to Dr. Emily Tucker, who studies drug shortages, one factor was intermittent manufacturing delays at Teva Pharmaceuticals, a major supplier of generic Adderall, a commonly used stimulant medication. Another factor was the rise of telehealth companies during the pandemic. The Government Accountability Office looked at telehealth services used by Medicaid participants in five states during the pandemic and found an increase of 15 times the pre-pandemic level. Some of their practitioners were prescribing stimulants without ever evaluating the patient in person. Several of these companies are now under investigation by the DEA.

Because Adderall and other stimulants are controlled medications and have the potential for abuse, the DEA and the FDA regulate the quantity of these medications manufactured. To avoid having more of the drug in circulation than necessary, the DEA caps the amount of amphetamine available to manufacturers in a given year. 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.

To set such quotas, the DEA estimates how much Adderall American patients will require the following year. However, if the agency underestimates demand and fails to increase its percentage in response to new information, the result can be widespread shortages. In 2011, Shire Pharmaceuticals alleged the DEA’s sluggish approval system led to that year’s shortage of Adderall XR, a related ADHD medication.

In addition, in October 2019, the DEA launched the Suspicious Orders Report System (SORS), a new centralized database required by the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT). 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 regular pattern, and orders of controlled substances of unusual frequency as per the section of the SORS that describes various categories of controlled substances, 21 U.S.C. 802.

How Clinicians Are Responding to the ADHD Medication Shortage

Due to the sustained Adderall shortage, clinicians like us must come up with creative ways of providing our patients with appropriate doses of medication. The national ADHD advocacy organization Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) lists a variety of ways to manage the shortage on its website, including contacting the manufacturer of the medication you are seeking. 

Personally, we sometimes have to switch to alternative medications or devise innovative ways of creating the correct amount by combining several different prescriptions. Unfortunately, these solutions are not silver bullets, as such innovation can 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. 

For this issue to be resolved, practitioners will need to contact their local representatives and specialty organizations to urge them to treat the shortage as a serious public health concern. Dr. Trachman has sent emails to the Surgeon General and Representative Abigail Spanberger due to her interest in having hearings on this issue. And Dr. McCarthy has created an online questionnaire for practitioners who treat ADHD. 

The state of child mental health was declared a national crisis by the U.S. General Surgeon General Dr. Vivek Murthy in his May 2023 Advisory Report. During the current national mental health crisis, the added stress caused by the shortage places an undue burden on families already on the brink. We invite you to join the “Call to Action” initiated by CHADD.

These are just a handful of examples of efforts clinicians can take on to resolve this issue. We urge you to join us — the shortage must end.

How is the ADHD med shortage affecting your patients? Share in the comments!

Dr. Trachman is an award-winning psychiatrist who has been in practice for over 30 years. She specializes in psychosomatic medicine and forensic psychiatry. Dr. Trachman is the author of the Psychology Today blog, “It's Not Just In Your Head,” and is on the volunteer faculty at George Washington University and Virginia Commonwealth University.

Dr. McCarthy is a Duke-trained child and adolescent psychiatrist with over 25 years of experience. She is in private practice in McLean, Virginia. In addition to clinical work, she is a co-author of the recently published acclaimed parenting book “Raising a Kid Who Can: Simple Strategies to Build a Lifetime of Adaptability and Emotional Strength” (Workman Publishing/Hachette Book Group, September 2023).

Image by Alphavector / Shutterstock

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