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Interviewer: In October of 2022, the FDA announced a potential shortage of ADHD medications in the United States, most notably the drug known as Adderall and its generics. And while a few drug manufacturers have recently issued statements that they are no longer experiencing shortages of manufacturing issues, in spring of 2023 many of the 45 million U.S. ADHD patients with prescriptions are experiencing intermittent delays in being able to access their medications. For the neurodivergent patients who may rely on this medication to function, there is concern about what they are supposed to do if they cannot get their prescription filled.

To discuss what a patient can expect if they are unable to find a medication and what options they have available to them, we're joined by Anthony May. He is the Pharmacy Director at Huntsman Mental �ǿմ�ý Institute. Now, Anthony, what exactly causes prescription shortages, and what's going on right now?

Contributing Factors of the Adderall Shortage

Anthony: We've been dealing with a lot of shortage issues. We always have in pharmacy, but COVID and the supply chain disruption have certainly exacerbated it a little bit. The stimulant one is a little unique in that there's a multitude of factors impacting this. So a couple of things come into play here.

A lot of these stimulant medications are controlled substances, and the DEA sets limits on the manufacturing of these. So that, you know, limited supply coupled with increased demand during the COVID period has really drained our normal channels or put a strain on them, resulting in what we are dealing with today, where some of these more utilized formulations are just not available at the local pharmacy level.

So some of the things that came into play with COVID, the public health emergency allowed for telehealth prescribing of these stimulants, which previously required an in-person visit. So as you can imagine, access to these medications increased. So as you can see, kind of the perfect storm of factors leading us to where we are today.

Interviewer: Wow. So I guess what kind of delays are we seeing? I mean, I went to fill one last week because I'm taking some of these medications, and they told me not to expect anything till July.

Anthony: Yeah. It's a tough landscape too. Manufacturers aren't required to disclose what's causing the shortages. So as this has played out, you know, there's a couple of different things. We've heard about staffing shortages. So Teva is one of the largest manufacturers of generic Adderall, and there were staffing issues at their biggest manufacturing plant. That has since been resolved, but we still haven't seen supply come back the way we had hoped. So for the pharmacists and people on the front lines, sometimes we don't even have all the information. We're checking our wholesalers. We're seeing dates that come in there as an update, and many times those get pushed back.

Interviewer: Yeah.

Anthony: So it is a little challenging. We want to be transparent with our patients on what to know, but sometimes we don't have all the answers ourselves.

Interviewer: You're not keeping a secret from us.

Anthony: Yeah. No, we promise you.

Interviewer: You don't have answers either. Yeah.

Anthony: We promise. Yeah, we're sharing what we know. I have also heard that you know, May, June-ish, we can see supply come back a little bit. But we were kind of also hoping this would be resolved by now. So time will tell.

Adderall as an ADHD Medication

Interviewer: So why don't we go a little bit into these ADHD medications and what exactly are they doing for a patient? I mean, I know we don't want to go too deep into it, but just on the basic level, what is this drug and what is it doing?

Anthony: So at the highest level, you know, when we talk about our stimulants, things like Adderall and methylphenidates, like your genetic Ritalin, they are affecting downstream certain neurotransmitters, specifically norepinephrine and dopamine. While I'm not an expert in diagnosis and all that, they have profound effects on patients with ADHD, kind of meeting the brain's demands for these neurotransmitters, improving focus/functionality, and reducing impulsivity. So very, very high-level answer, but it's those effects on those neurotransmitters where these drugs really get their benefit from.

Withdrawal Symptoms and Effects of Discontinuing ADHD Medications

Interviewer: And I guess one of the first concerns I had when I was told I might not have, you know, access like I was expecting, are there withdrawal symptoms for coming off of a medication like this? I mean, I hear stimulant, I hear, you know, some of the names that this stuff is called, and it's just like, "Oh, man, am I going to have a bad crash? What is it going to be like?" You know?

Anthony: Yeah. So I think when we hear "withdrawal," you know, you think your traditional things, like withdrawal from opiates or alcohol. But anytime you're stopping a medication that you've used for a long time, there's going to be a response to that, you know, whether it be abruptly stopping a blood pressure medication or even these other meds used with ADHD, like the alpha-2 agonists, that your body tries to compensate when that stops. So while we might not see, you know, severe withdrawal, as we do with opioids, people are going to feel differently, whether that's a sensation of fatigue and crashing all of a sudden, irritability, anxiety. Those are probably some of the most commonly reported things we see.

But also just how you're going to function all of a sudden. People who use these medications rely on them because they have a diagnosis or a disease, and that's how they manage it. So all of a sudden you're taking that treatment away. It's going to be really hard for these people to go back into those environments, work, school, whatever it may be, and function to the level they were previously. So maybe not so much traditional withdrawal, but managing how are we going to cope without this medication that's provided us benefit.

How Patients Can Manage ADHD Medication Shortages

Interviewer: Yeah. And I hate to put you on the spot, but how are we supposed to cope?

Anthony: Yeah. Not an easy answer either, unfortunately. So I guess a couple of things is trying to do anything you can to prevent it from getting to that point, where we're in a situation where tomorrow we don't have any medication at all and we haven't spoken to our provider about it and we don't have a plan, right? We want to avoid that at all costs.

So a couple of strategies. You know, Adderall, the XR formulation, things like Concerta, those are the hardest hit right now, that we're having a really hard time getting. There are other stimulants out there, other formulations. So there's all sorts of short-acting, long-acting, different dosage forms, things like that. My sense, from our pharmacy, has been the shorter-acting products are in somewhat better supply. Granted that might not work as well for everybody, but I think that's worth a conversation with your doctor. "Is this something we can use to bridge me or get me by until my normal medication comes back?"

Other strategies might be considering, "Do I need to take my medication all the time?" "Are there certain days where I think I can maybe get by without using it?" "Maybe I have a less demanding day during the week and I can make that sacrifice to preserve this for when I really need it."

So no easy answers, right, but I think doing anything we can to avoid that 'I'm completely out of medication situation and now I have to figure things out.'

Non-Stimulant Medications

There are non-stimulant medications as well, so things like Strattera or atomoxetine are the generic names, that are out there. But again, that's a shared decision with your physician to change therapy. And in some cases, those don't work quite as well. Stimulants are usually a first-line treatment because of how effective they are and how quickly they have that effect.

So some of those other things to consider, we want to be thinking ahead and get ahead of that.

Interviewer: Sure.

Behavioral Therapy

Anthony: So cognitive behavioral therapy as well. But we know that that works, but it works really well in conjunction with medication. When patients have both on board, there's that synergistic effect.

Interviewer: Sure. So what I'm hearing is be proactive, right? Talk to your doctor, call pharmacies, whatever you can do to not have a lapse in medication, like make sure you have some.

Anthony: Absolutely.

Interviewer: If you are finding it difficult to find some, maybe ration what you do have. You know, find the days where you can maybe function without it or it's not quite as necessary. Maybe skip that afternoon dose if it's not the most helpful. And then really just keep having a conversation with your doctor about what you should be doing, how you can be solving this, are there other drugs you can be taking, etc.

Anthony: Yeah.

Interviewer: Did I get that right?

Anthony: Yeah. And I think proactivity is key. What I didn't mention and, you know, is pretty well-known, but these are controlled medications, so there are more restrictions on sending new prescriptions and things like that at the pharmacy level. So giving your doctor that lead time to make those changes is essential as well, right . . .

Interviewer: Sure.

Anthony: . . . because it's not like we can just call the pharmacy and make that change. A lot of times a new prescription might be required, which, as we know, takes time, you know, to get doctors or they're busy.

Interviewer: Yeah.

Anthony: So anything you can do to be proactive and have that conversation. It's pretty well-known out there now that there are struggles with these products in terms of availability.

Interviewer: Sure.

Anthony: So doctors are, you know, aware that these questions are going to be coming if they haven't already.

Be Caution of Online, Social Media Answers to Medication Shortage

Interviewer: I guess I did want to ask I've been seeing . . . I mean, when we don't have straight answers, we turn to social media, right? After looking through a little bit on TikTok, some on Instagram, etc., I'm seeing a lot of people coming up with their like, you know, home hacks for what to do to like supplement if you can't access Adderall. And I've seen everything from, you know, people taking heinous amounts of caffeine to people swearing there's a bunch of, you know, over-the-counter like supplements that you can take that'll get your brain working just as good, etc. In your professional opinion, is there any validity to any of these? Is this something worth checking out? Or really you should be talking to your doctor?

Anthony: I recommend steering clear of a lot of those things and where it's coming from, right? Like you don't know the sources of that information. And not to say, you know, everyone is different and responds to things differently. But I would not all of a sudden just abandon the treatment plan that has been working for me and pivot to something I saw on TikTok or YouTube.

Interviewer: Sure.

Anthony: There are risks with that too, using a lot of caffeine and things like that. There are withdrawal symptoms from caffeine.

Interviewer: Sure.

Anthony: So it works in a different way than these stimulants do. Yes, they're both activating, but those downstream effects, as we talked on norepinephrine and dopamine, aren't exactly the same.

Interviewer: Sure.

Anthony: So, you know, at the highest level, it seems like, oh, yeah, just swap it. But it's probably not going to be as effective.

Interviewer: Sure. Not all stimulants are the same.

Anthony: Yeah, yeah, exactly. Not all are created equal. You know, there are a lot of people out there advertising these things because they realize there are people struggling and trying to find solutions. So I think any path you're going to go, just do it in conjunction with your provider, your doctor, or therapist, whatever it is, so that you're all informed, right?

Interviewer: Sure.

Anthony: I think all of us in healthcare are out to help our patients. Sometimes that's in a non-traditional way. But do it responsibly.

Interviewer: Sure.

Anthony: Yeah.

The Impact of ADHD Medication Shortages on Patients

Interviewer: As a pharmacist, as a healthcare provider, someone who wants to see your patients like, you know, feel good and succeed and be healthy, what do you tell to people who might be really concerned right now or stressed right now or not sure how they, their loved ones, their family members are going to maybe function during this time period?

Anthony: Yeah. I think just meeting people where they are, right? For me, it's acknowledging that this is a challenging situation and not judging people. You know, sometimes you get people calling for these medications, they're C2, and just not passing judgment. People are calling around because they need these medications to function. So helping them in any way we can, talking about the strategies we just mentioned. If it's something we can facilitate within our system, we work with our doctors to check on inventory, to suggest alternative therapies. There's a lot of resources out there showing, you know, all these stimulants, their release properties, their time to effect so we can find something maybe similar to what a patient was having success with before.

Counseling on alternative therapies. People are hesitant to change from something that works. But when we don't have those tools we usually have, sometimes we have to pivot, and just helping people do that as smoothly as possible is our goal here in the pharmacy.

And being honest with people that we don't have an anticipated date. So there's no magic answer to this, right? So we're hopeful it will resolve soon, but we also don't know. So if you're thinking of talking to your doctor, or maybe you're like, "I'm fed up, I'm ready to switch and try something else," it might be worth it.

 

_{updated: May 9, 2024
originally published: May 3, 2023}