With little warning, panic swept through many patients and families of patients with ADHD when they began to be less able to obtain prescribed medication this year—especially Adderall.

When the US Food and Drug Administration (FDA) announced on October 12 there was a shortage of Adderall that would last indefinitely, many patients, prescribers, and pharmacies were left scrambling to figure out the right course of action.

For some, the idea was to keep trying different pharmacies until they find one still stocked with Adderall. For others, it was to switch to another regimen for ADHD, in hopes of finding a suitable replacement. And for others still, unfortunately, it was to forgo treatment altogether.

In an interview with HCPLive®, Theresa R. Cerulli, MD, a neuropsychiatrist with Beth Israel Deaconess Medical Center, explained just how damaging this shortage, even if it is only a few months, could be on patients with ADHD.

“So not having Adderall is an enormous problem. Picture the amount of anxiety and mood dysregulation that goes along with the frustration for all of us at especially this time of year.” Cerulli said. “And it’s also a problem sometimes financially, because even if we write a substitute, it doesn't mean that the insurance will cover the substitute even though the Adderall is not available. So these poor patients are getting hit from all sides right now, literally, including financially.”

One of the main issues is that patients with ADHD often have at least 1 other psychiatric comorbidity. Approximately 75% of patients with ADHD meet the criteria for at least 1 other psychiatric disorder and 60% of the time they meet the criteria for 2 or more.

“So you take someone who's probably already struggling with some of those symptoms, tell them that they can't get their medication, or tell them you know, we're going to try but now they've been to their fourth or fifth pharmacy, that picture that they can't call ahead to the pharmacy to see if the prescription is in stock, they're not allowed to they won't pharmacy won't disclose that information,” Cerulli said.

The First Choice for ADHD

Adderall is currently considered the top-line stimulant for patients with ADHD for a number of reasons. The treatment is comprised of 4 salts of amphetamine, having been approved by the FDA since 2001 for pediatric patients with ADHD, and 2004 for adult patients. Cerulli said Adderall dwarfs the prescriptions per month of all other ADHD medications.

In addition, Adderall is often accepted by the majority of health insurance companies and has an available genetic, making it a viable option for many.

However, the biggest reason Adderall is so commonly the first option for patients is that it is long-acting—making it a better match for the school or workday compared to some of the shorter-acting stimulants. What’s more, there are many issues with some of the alternatives—the primary being that a lot of them are not accepted by insurance companies.

Why Is This Happening?

There are likely multiple factors that has led to the cause of the shortage. Like many other goods, supply chain and labor issues caused by the COVID-19 pandemic likely is a major factor leading to the current problems.

However, another factor, specific to this medication, is the rise in virtual care during the pandemic may have resulted in an increase in ADHD medication prescriptions.

And there was no true way to prepare for this shortage.

Cerulli could not recall receiving so much as a warning sign of a shortage occurring; she and her peers generally found out through patients letting them know they were unable to get their medicine.

While shortages in medicines have been unfortunately frequent throughout pharmaceutical history, the Adderall shortage might be the most unprecedented and significant.

“There have been shortages before, but I don't recall and I've been I've been working in the ADHD field for 25 years,” Scott Kollins, PhD, chief medical officer of Akili, said. “I don't recall one that's been this sort of significant. So there'd been shortages here and there. They've been generally not as widespread and not as abrupt actually.”

Kollins said the expectation is that the shortage will go on until at least March 2023, but is likely to gradually improve over the next few months.

The obvious concern is what long-term effects the ongoing shortage will eventually have on patients.

What Should Patients Do

Cerulli split her patients into 3 separate categories: those going without medication entirely, those who switched to an ineffective medication, and those who switched medications to something that actually works better than Adderall.

Her first suggestion to peers is to try other pharmacies in hopes 1 of them may have Adderall.

She tells patients to try at least 3 pharmacies before deciding to switch to a different medication.However, for patients in Boston or other major cities, finding 3 pharmacies is a lot easier than patients who live in more rural or isolated parts of the country.

A potential challenge is that patients are not allowed to call ahead to pharmacies asking about Adderall because the treatment is a labeled controlled substance by the Drug Enforcement Agency (DEA). In addition, a legally controlled substance cannot be transferred from one pharmacy to another.

This means that a patient must call the doctor to cancel the prescription with the pharmacy that is out of stock and reissue the prescription should they find another pharmacy with Adderall in stock.

“It ends up being a lot of extra legwork to first resend the prescription to multiple pharmacies that the patient is trying to fill that is indeed, in some situations medically necessary,” Cerulli said. “And when that doesn't work after a period of time, rather than having the patient go without it, we are trying to find a substitute ADHD medication. So it means less optimal care for the patient.”

However, with many switching medications in the short-term, it has become much more difficult to even find some of the other ADHD medications.

The Frustration is Building

Another critical issue with the shortage is the stigma attached to Adderall; both pharmacies and practitioners have become frustrated with the process since the shortage that has made it even harder on the patients trying to earnestly continue their ADHD treatment.

“My heart goes out to patients. They are now getting to the point that they're feeling like they're substance abusers,” Cerulli said. “They are feeling stigmatized because the pharmacist don't want to deal with this. It's hard frankly, for the clinicians that have to keep canceling out and rewriting the prescriptions for these patients that so the clinicians like myself and we specialize in ADHD so we're a little bit more hopefully understanding and try to minimize the fallout to the patient.”

Looking to the future, this shortage could go a long way in undermining treatment and care for many patients with ADHD.

“What I can say is that their trust has been undermined: their trust in practitioners, their trust in the system, their trust in the pharmacy,” Cerulli said. “And that that's what I mean, with regard to the long term fallout. I think it remains to be seen, but we're losing credibility here.”