ADHD
In the United States of Adderall.
What the Adderall shortage really means.
Reviewed by Vanessa Lancaster

KEY POINTS-
The Adderall shortage highlights the great demand for these products in our country.
In 2022, the DEA approved a total of 133,525 kilograms or about 31 tons of legal stimulants for the U.S.
The National Institute on Drug Abuse found that 400,000 adults who used prescription stimulants met the criteria for abuse and addiction.
The current national Adderall shortage has inadvertently brought to the nation’s attention the potential over and misdiagnosis of attention deficit hyperactivity disorder (ADHD) and the possible over-prescription of Adderall and similar medications like Ritalin, Concerta, and Vyvanse, all prescription stimulant drugs.

As an M.D., who wrote his first Ritalin prescription in 1978, I’ve never been against using these medications in children. But beginning in the mid-1990s, when doctors began prescribing these drugs to adults, I grew concerned because I had studied the history of these substances here and throughout the world.

Since its synthesis in 1929, amphetamine, the active ingredient in Adderall and Vyvanse, and its virtually identical twin, methylphenidate (in Ritalin and Concerta) cycled through new indications (in the past used for problems as varied as asthma, depression, and obesity). Misuse, abuse, and addiction problems invariably followed, so much so that ultimately the cycle ends with society rejecting these medications (usually due to tightened government regulations and high negative publicity).

The Adderall shortage highlights the great demand for these products in our country. American manufacturers of prescription stimulants must apply for an annual production quota from the Drug Enforcement Administration (DEA) by law because these drugs are categorized as Schedule II (the strictest control for legally prescribed drugs). In 2022, the DEA approved a total of 133,525 kilograms or about 31 tons of legal stimulants for the U.S. This translates to 405 mg. of the stimulant drug for every man, woman, and child in America (or about 20–20 mg. Adderall pills).

This may seem like a lot of legal speed. It is–if you also compare American use rates of prescription stimulants to other developed countries. The U.N.’s International Narcotics Control Board (INCB) maintains annual consumption data of countries signatory to a 1972 treaty. Thus in 2020 (the last year of data collected), the average German used 4 percent of what Americans used daily, those in the United Kingdom, 3 percent, and France, 2 percent.

There are now 30 different varieties of prescription stimulants available in the U.S. There are different lengths of action ranging from three to sixteen hours. They come as pills, capsules, different chewable tablets or liquids flavors, and even a transdermal skin patch. Most other countries get by with only five varieties, a short and long-acting generic amphetamine and methylphenidate pill, and lisdexamphetamine (Vyvanse).

There are many reasons for this vast difference in how these Europeans and Americans cope with attention, distractibility, and performance. But we as a nation should be concerned because the dark side of our current use of prescription stimulants is the misuse, abuse, and addiction problem.

The National Institute on Drug Abuse (NIDA) was the last agency to closely examine the stimulants in 2015-2016. Sixteen million adults (6.6 percent of American adults) had tried a prescription stimulant. Five million had obtained the medication illegally (1.9 percent). Four hundred thousand (0.2 percent) met the criteria for abuse and addiction. Rates for all three categories were higher in the 18-29 year age group.

Maybe only 400,000 people with a substance use disorder doesn’t sound like much. At the time, this was about a quarter of those who reported prescription opiate addictions. But since then, in the wake of the opiate crisis and the consequent negative publicity, opiate prescriptions have plummeted. In contrast, prescription stimulants have greatly risen (a 10 percent increase in just the past year).

A historical inevitability will likely create a major backlash to Adderall and the diagnosis of A.D.H.D. that will also affect its use in children, which paradoxically is safer than in adults. Children don’t have access to the medication and don’t like the higher dosages. They complain and say, “I feel weird.” Adults can access their pills and say, “I feel grand,” when taking higher dosages. I don’t know what it will take for America to wake up to this growing public health crisis. Certainly, please not more Adderall.

ADHD-
Addressing the Stimulant Shortage.
The difficulties in getting medications to people who benefit from them.
Reviewed by Lybi Ma

KEY POINTS-
There is a shortage of all stimulant medications, and it's not a manufacturing issue.
People who would benefit from them can't get their medication.
This is affecting many people who are consequently not able to focus well, with personal and societal consequences.
We hope that our suggestions will help resolve this.
In the last six months, many ADHD patients have been having trouble filling medication prescriptions. The stimulant shortage started out as a manufacturing problem for one medication—one of the generic versions of Adderall. However, it has since ballooned into a crisis of supply and demand affecting essentially all stimulant medications.

Prior to the last couple of decades, it was unusual for an adult to be diagnosed with this disorder, because it was commonly (though incorrectly) believed that ADHD tended to go away after childhood. ADHD is now understood to be a lifelong condition commonly creating challenges across the lifespan. Not only is it problematic on its own, but it is also often comorbid with other common psychiatric conditions, such as anxiety and depression, in both kids and adults.

The COVID pandemic increased the demand for ADHD diagnosis and medication because of new challenges it created for adults trying to work from home while juggling other tasks and distractions, as well as kids trying to do schoolwork without the structure and presence of in-person teachers and classmates. Another potential driver might be our “crazy-busy” lifestyle, which includes an increasing diet of electronic distractions and screens.

The lack of a biological test for ADHD, and the lack of a consensus standard around the utilization of objective psychometric tests for ADHD, contributes to a perception that the disorder, which is undoubtedly a significant challenge for many, is instead “made up” or simply a matter of subjective opinion. But no matter the causes, what is not in dispute is that the diagnosis of ADHD and the use of stimulant medications to treat it has been rising, especially among adults, and that there is no sign of a slowdown.

A lot of people are:
reporting significant daily challenges from poor attention
wanting medical assistance to address these challenges
ADHD is a disorder in regulating attention, impulsivity, hyperactivity, and according to recent research, certain types of emotional reactivity. This type of regulation is an important factor not just for getting “A’s” in school when you’re a kid, but for virtually every aspect of life into adulthood.

It can make the difference between life and death while driving. It can make a difference in relationships: “You never listen” has prompted many breakups. It is important to school success, yes, but also to success at work. It can make the difference between holding or even excelling at your job, versus being chronically or serially unemployed.

It is a significant contributor to alcoholism, other types of drug abuse, exposure to all kinds of trauma, and risk-taking behaviors. These behaviors can result in many types of medical problems as well as early pregnancy. The growth in stimulant prescriptions is a reflection of people wanting to address such challenges in their lives—and we believe that is good for them personally and also for society as a whole.

As physicians, we are thrilled when people ask for help with their attention—because we can help them. The stimulant medications (that is, chemicals found in Ritalin, Adderall, and their derivatives) that doctors have to treat poor attention are among the most effective and useful in all of pharmacopeia, certainly when it comes to behavioral conditions. They work extremely well (non-stimulants also work, but many people with ADHD find them less effective). If you’re an ADHD patient, and we’re your doctor: you’ve got a problem, we’ve got a solution—we should be good to go.

Except we’re not good to go. Due to stimulant medications being classified as having a high abuse potential, they are tightly regulated. Pharmacies are only allowed to sell a certain amount per month. At this point, given the growth in people seeking help for these challenges, demand is outpacing these allotted amounts.

And thus, there is a general stimulant shortage. This leads to significant difficulties in getting medications to people who benefit from them. Some of our patients have been out for months.

The thing is, stimulants are not actually so problematic for addiction at the doses and in the forms typically prescribed for ADHD. The classification of stimulants as having a high potential for abuse is based on what can happen when very high doses of immediate-acting stimulants are ingested, inhaled, or injected.

Yes, you can abuse stimulants in that way and get addicted to them: Crystal meth abuse is a huge problem—but crystal meth is a street drug, not a prescription medication, and Adderall and Ritalin are not crystal meth. At doses and in the forms commonly used to treat ADHD, the addiction potential for prescription stimulants is low and manageable.

Our patients easily stop using their stimulants altogether, and many more use them only intermittently—a few days per week. Many people with ADHD take these medications only as needed Monday-Friday (for school or work) and routinely skip taking them on weekends and vacations. Unlike opioids, where an almost bottomless tolerance can lead to a need for greater and greater doses over time, the effective dose of stimulant medication for any individual ADHD patient tends to remain stable once clinically established in the first few months of treatment—stable over decades or even over an entire lifetime.

In short, the addiction potential of prescription stimulants at doses used for ADHD is significantly less than that of coffee or nicotine (the world’s most common non-prescription stimulants, which unfortunately don’t work well for ADHD). If you doubt that, try drinking espresso or smoking cigarettes just on weekdays and not at all on Saturdays and Sundays—the way many ADHDers routinely take prescription stimulants.

Stimulants come in both long-acting (extended-release) and short-acting (immediate-release) forms. The short-acting forms tend to have slightly higher addiction potential (although still low at prescribed doses). The long-acting forms tend to be less addictive in general, and some have been manufactured in a way that renders them even less so.

Yet all of these medications are classified and regulated exactly the same—as though they are as addictive as opioid medications and more addictive than many other commonly prescribed psychiatric medications, such as benzodiazepine tranquilizers (Xanax, Ativan, Valium). Yet the abuse and addiction of prescription tranquilizers are arguably more of a clinical and societal problem than that of prescription stimulant drugs.

Stimulants usually can’t be prescribed, even at a completely steady dose, for more than 30 days at a time, no refills are allowed (they can’t be put on auto-refill) and prescriptions can’t be transferred from pharmacy to pharmacy (which has been extremely problematic for patients trying to obtain their regular medications amidst the current supply shortage).

We should partially down-regulate the long-acting prescription stimulant formulations so that they could be prescribed more easily. These prescriptions could still be monitored along with other controlled substances—but at a level that is more appropriate to their actual observed abuse potential.

Aside from being more clinically appropriate, this would likely lead to an increase in the percentage of ADHD patients taking long-acting stimulant formulations at the expense of the arguably more problematic short-acting forms. Presumably, this is desirable from a public-health safety perspective.