For at least a year already, American patients and providers have struggled to obtain Adderall and other ADHD medicines that are generally prescribed to treat attention deficit hyperactivity disorder (ADHD). Initially, the situation was just a temporary supply disruption and not a prolonged shortage that affected millions. In this brief perspective, we will discuss the complex nature of the shortage, its prolonged effect on those living with ADHD, and possible alternatives before the normal supply is back.
Adderall Shortage and ADHD:
The magnitude of the Adderall Shortage can be appreciably understood only when we contextualize ADHD and the current treatment approaches to it. ADHD is a neurodevelopmental disorder, which is a term used to define a condition characterized by difficulties with attention, hyperactivity, and impulse control. Although stereotyping is still ongoing, ADHD affects people from all backgrounds and is a genuine medical condition that should be treated with professional care. ADHD left unattended can cause relationship problems, academic, and career failures, and a worse quality of life in general.
American Psychiatric Association
The American Psychiatric Association recognizes ADHD as one of the most common mental disorders among children and often persisting into adulthood. Current estimates indicate that 4-5% of school-aged children live with ADHD globally. However, diagnosis and treatment rates vary significantly worldwide.
In the US, prescription medications are the frontline treatment for ADHD recommended by leading medical organizations like the Centers for Disease Control and the American Academy of Pediatrics. These include stimulant and non-stimulant options proven effective through clinical research.
Stimulant Medications
Stimulant medications, like amphetamine salts and methylphenidate, increase the level of these neurotransmitters. They alleviate equally up to 70-80% of the ADHD symptoms when taken as prescribed by the physician. But one of the top ones is Adderall, a mixture of four amphetamine salts that produce both immediate and prolonged-release effects. Despite the emergence of ADHD treatments like Vyvanse, Adderall is still the #1 named brand, with over 41 million prescriptions dispensed in 2021 alone, according to IQVIA data.
Non-Stimulant Alternatives
For those who do not respond to or tolerate stimulants, non-stimulant alternatives include atomoxetine, clonidine, and guanfacine. However, these options generally produce milder effects and require longer to take full effect compared to stimulants. Combined with behavioral therapies, medications enable many with ADHD to manage symptoms and meet their goals successfully.
Origins and Evolution of the Shortage
The Adderall shortage came to light in October 2022 when the FDA announced the disruption of its supply pointing to the immediate-release Adderall, which was causing the shortage of its generics. This drug was held back by the shortages of production at Teva Pharmaceuticals, one of the biggest generic manufacturers. Initially expected to last only a few months, contributing factors enabled the shortage to persist well into its second year:
Increased Demand:
ADHD diagnoses have risen approximately 45% from 2012 to 2021, according to the CDC, likely spurred by reduced stigma and expanded telehealth access during the pandemic.
Inadequate Supply:
While demand grew, the FDA found drugmakers were producing well below the allowed quotas set by the DEA, leaving over 1 billion additional doses able to be made.
Dependence on Key Producers:
Teva and other major suppliers face ongoing challenges meeting heightened needs. Overreliance on a few manufacturers exacerbates supply vulnerability.
Regulatory Barriers:
The DEA approval process for quota increases was criticized for not keeping pace with rising demand. Manufacturers claim lengthy wait times and limited, timely supply adjustments.
By late 2022, shortages expanded beyond immediate-release Adderall to various long-acting formulations and generics. The disruption also rippled through supplies of alternate ADHD medications as patients sought available options. While some stability has since returned, full recovery will likely take months.
Impact on Patients and Providers
For those living with ADHD, the effects of inconsistent or absent medication can be profound. Some of the challenges experienced include:
Inability to Access Treatment:
With Adderall often back ordered for months, many patients could not fill or refill prescriptions on schedule.
Symptom Exacerbation:
It is going without stimulant medication results in lost focus, organization, and emotional regulation for those with ADHD.
Academic/Work Difficulties:
In a school or employment setting, ADHD symptoms untended by medication negatively impact performance and success.
Mental Health Toll:
The stress of the Adderall Shortage and coping without treatment worsened anxiety and low mood for some. Feelings of stigma or shame also emerged.
Financial Burden:
Those with high deductible plans or no insurance faced paying thousands of dollars out of pocket for alternative medications.
Providers likewise needed help to care for patients amid inconsistent supplies adequately. Prescribing required extensive coordination to find pharmacies stocking preferred medications. Some resorted to less optimal treatment substitutions that only met some patients’ needs. Overall, the shortage created an access crisis for those reliant upon ADHD medications.
Changes in Prescribing Patterns
Healthcare professionals adjusted prescribing habits over the past year to accommodate medication shortfalls. National prescription fill data tracked by GoodRx revealed notable shifts:
Adderall Fills Declined:
As Adderall grew scarce, fills for the medication dropped while other ADHD drugs saw relative increases.
Vyvanse Gained Popularity:
Fills for Vyvanse and its generic equivalent, lisdexamfetamine, rose to compensate, becoming one of the most filled ADHD medications.
Methylphenidate Uptake Increased:
Drugs containing methylphenidate active ingredients, such as Ritalin or Concerta, also experienced higher utilization.
Non-Stimulant Alternatives:
For those unable to use stimulants, non-stimulant atomoxetine saw a moderate rise in demand as an alternate option.
The FDA approval of Vyvanse’s generic form in August 2023 aided medication access changes. With over a dozen manufacturers now producing the lower-cost generic, lisdexamfetamine prescriptions have surged and may continue to do so. Overall, prescribing trends highlight efforts to adapt treatment amidst Adderall’s unavailability.
Seeking Solutions and Alternatives
With the Adderall Shortage’s resolution still uncertain, stakeholders continue exploring solutions. The FDA and DEA have pressured drugmakers to maximize production and reallocate unused quotas. Congress has also demanded accountability from these agencies.
In the interim, patients work closely with providers to identify suitable substitutes or coping strategies:
- Drugs like dextroamphetamine or mixed amphetamine salts provide comparable, albeit shorter-lasting, stimulant effects to Adderall.
- Once-daily formulations like Concerta, Vyvanse, or Adderall XR help provide consistent lasting coverage, though with higher costs.
- For those who cannot tolerate stimulants, options like Strattera and Intuniv offer non-stimulant options, albeit with a slower onset of action.
- Behavioral therapies and daily planners aid executive function skills, especially when used alongside medication.
- Some compounding pharmacies create customized ADHD formulas if preferred brands remain unavailable.
Substitution Programs:
Manufacturer programs help patients acquire available medications if their usual option is backordered. While far from ideal, these alternatives afford patients means to manage ADHD until preferred treatments become consistently accessible once more. Ongoing communication between patients and providers remains key to navigating options through this prolonged shortage.
Concluding Thoughts
Over a year since emerging, the Adderall shortage continues disrupting treatment for millions living with ADHD in the US. While demand surges and regulatory hurdles stall supply adjustments, stakeholders work to bolster domestic manufacturing capacity. In the interim, healthcare professionals strive to meet patient needs through alternative prescriptions or ancillary supports.
For individuals with ADHD, the shortage underscores a need for personalized care and contingency planning. With treatment interruptions posing real risks, close provider collaboration helps navigate options when usual medications cannot be obtained.