Lets talk about Adderall and America's crisis with stimulant medications

https://fordhamobserver.com/35325/recent/sports-and-health/the-history-of-amphetamines-a-story-of-abuse-and-stigmatization/

*Disclaimer.  Psychiatry is my specialty, so I treat hundreds of patients with confirmed PhD neuropsych tested ADHD.  

The above article is very interesting and I recommend reading it.  But todays post is about the real world issues of Adderall and other stimulants.  For the record, if you can get off Adderall, I recommend you do.  

We are currently in an Adderall (and nearly every other stimulant) shortage crisis in America. It started becoming noticeable to us prescribers in early 2022.  Currently, it is such a problem that finding a pharmacy with stimulants in stock has become a needle in a haystack type of hunt.  It has spread beyond Adderall now, as we were notified this past week that Concerta is “no longer produced by generic companies” so your only option is brand name, which is $200 per month.  So now we have the Adderall shortage AND a Concerta generic manufacturing full stop.  This is getting ugly.  

Yes, there are patients who truly have ADHD, and truly do benefit from stimulants.  I see them daily in my office.  I call it “shiny squirrel” where they cannot keep on track, focus, they cannot multitask, go from one thing to another and return back to the original task.  Big red flags are they have had employers reprimand them for not getting work done on time, forgetting a project due date.  They cannot handle social environments because they constantly interrupt others, finish others sentences, jump from topic to topic and their peers cannot even understand where they are headed with the conversation.  The other 4 members in a group were discussing a new book they were reading and the ADHD compadre suddenly interrupts jumps into OMG did you see that TikTok video about the dog and the squirrel playing together?   Their dopamine and norepinephrine do not properly tactile release neurotransmitters and they in turn experience inattention, lack of focus, hyperactivity, or all of the above.  Kids suffer academically, adults cannot manage their jobs well, and it has academic and professional consequences.  This is also the group of people who most frequently forget to take their “Adderall”.  Not kidding.  The most significantly affected by ADHD need a reminder to take their Adderall on most days.  Their distracted brain forgets to take the med.  Another thing I have noticed anecdotally in practice: most ADHD patients do not like to take their stimulants/Adderall.  They will take it on work days, but they do not take it on weekends or on vacations.  They do it out of necessity, not from something they enjoy.  Most of my most “squirrely” patients will fill their Adderall well after the date they should have, because they do not take it regularly.  In my practice, you do not get stimulant ADHD meds without a documented diagnosis from a previous provider, and/or a neuropsychiatric evaluation with a PhD to confirm you do indeed have ADHD.  Sadly, that is not the standard across the board.  

The Adderall crisis has been long coming.  It was caused by a 25 year unfolding problem of many facets.  First off, Adderall is a controlled II drug, meaning it is of the highest level of regulation by the DEA.  Adderall is an amphetamine.  It is highly addictive, high abuse potential, and is a stimulant or “speed”.  Adderall is in the same DEA regulation category as opiate pain medications such as hydrocodone, Percocet, and hydromorphone. You cannot even put refills on the prescription.  You have to get a new prescription every month for it.  The pharmacy cannot even substitute anything on an Adderall prescription.  For example, if I send Adderall XR 30mg to the pharmacy, they cannot just give you 2 15mg capsules if they are out of the 30mg, they require an entirely new prescription to be sent.  That is how regulated it is.  We got where we are the same way we got into opioid trouble: prescribers hearing a patient say they were having a hard time focusing, they wrote a prescription for Adderall, and on their way they went.  What they failed to do was find the true CAUSE of the lack of focus before writing that prescription.  ANYONE can come into my office and read off the checklist they found online and tell me they think they have ADHD and want it treated.  And for decades, this is exactly what happened.  Pediatricians, primary care providers, psychiatry, etc just took a verbal report of symptoms as “enough” to write the Adderall prescription.  What was never investigated was “is there another reason for focus problems?” Anxiety, PTSD, depression, other medications (such as Gabapentin, Baclofen, opiates), diabetes, menopause, insomnia, and life changes such as divorce, having a baby, job changes, etc can all lead to trouble focusing and “zoning out”.  (Which is why I send all new patients without a confirmed diagnosis in the past to neuropsych for evaluation).  More than a handful have come back with a neuropsych report that finds no ADHD but finds other things going on.  Which we then treat with things like therapy or medications that are not Adderall or a stimulant. 

By the mid 2000’s, Adderall was the most abused prescription drug on college campuses, because it is effectively speed.  Need a pick me up?  Need to cram for an all nighter study session?  Pop an “addy” and it will get you through.  Primary care readily handed it out to tens of thousands of patients for tiredness and fatigue.  It is sold, borrowed, etc by people all the time.  People share it, sell it, buy it by the tablet, and not because they have ADHD.  They do this for the upper quality of the drug.  I see this on a weekly basis in my office.  Patients who have been on it for years/decades for tiredness, prescribed by their primary care provider.  With each passing year, more and more patients started taking Adderall or another stimulant for many things, not necessarily for true ADHD.  But in 2015, the big shift began. With the opiate trials well underway for deceptive marketing of opioids, and pharma companies and pharmacies and doctors in court paying fines in the billions of dollars for giving highly addictive opiates to patients in doses and quantities they never should have, the availability of pain medication became non-existent.  (For the record, I don’t support not treating pain.  But I do not support the high doses of pain meds that patients have been prescribed in the past.  It should be treated responsibly, patients should not suffer because a provider historically overprescribed opiates.  Chronic pain should be treated.)  What the opiate crisis did to primary care made them pull back and go “whoa, Adderall is in the same DEA category as opiates are, so we are not going to prescribe those any longer either”.  So their answer was they sent their “ADHD” patients to psychiatry to manage their Adderall.  Except their patients were not all ADHD diagnosed patients.  They decided to ship even the ones that were taking Adderall for tiredness over to psychiatry.  Let psych manage it, even though we started the med and created the problem, we will let someone else clean it up.  (Same thing happened with opiates but that is another chapter in and of itself).  

I believe the shift of sending patients to psych to manage their Adderall was appropriate.  We are the specialty who has been educated and trained to screen for ADHD, to treat it, and there are many ways to treat it that do not involve using a controlled II stimulant.  But when you have been on Adderall from your primary care provider for 10 years, you do not want to stop taking it.  Even if it truly is not being given to you for ADHD.  Psych is very careful to keep the doses low, to use extend releases versus the immediate release that gives a quick jolt that dissipates 3-4 hours later.  We KNOW it is a highly abused class of drugs, and our goal is to treat appropriately, within proper dosing guidelines, IF the patient has ADHD.  The first few years of the transition from primary care to psych managing the med were a little bumpy, as we had a lot of patients taking really high doses of adderall multiple times per day, that were out of the boundaries of responsible prescribing doses per day, and risky.  We worked with those patients to confirm the ADHD diagnosis with a PhD via neuropsych testing, to get to a responsible goal dose that managed symptoms, but as safely and at as low of a dose as possible.  Those who were taking it for “tired and fatigue” reasons were put onto other medications that were not amphetamines.  My practice has a dosage we will not exceed per day.  Within a few years, this process was working well. 

Until Covid.

During covid, we had a sudden pop up of telehealth clinics to treat ADHD, namely one called Cerebral.  We also saw the advent of an internet based “ADHD test” that was marketed as a “neuropsych test” that patients could pay $140 for, it would diagnose them with ADHD without a provider ever meeting them face to face, and they took that readout as “I need my ADHD treated”.  It was a money grab.  Just like Cerebral was.  (My office does not allow the online diagnostic form to be used.  You have to see an actual PhD in person for a true neuropsych evaluation).  The consequences of this was 200,000-300,000 patients were started on Adderall during the pandemic by online telehealth companies such as Cerebral.  With zero diagnostics beyond a few basic questions to a patient, and if the answer was yes, here is your Adderall prescription.  This is when the proverbial apple cart of Adderall really got turned upside down. 

Were there true ADHD patients who were started on Adderall by Cerebral?  Of course.  However, how many people started Adderall through Cerebral due to pandemic consequences?  Many.  During covid, people had sudden life changes, stopped working out, delegated to working from home, online teaching their kids, lost their social networks, etc.  Anxiety was at an all time high.  There are MANY conditions that could lead to poor focus and attention that were NOT ADHD.  But those avenues were never explored, no neuropsych testing was done, the Adderall was just given.  Cerebral was making a ton of money.   Until they were placed under investigation for the large numbers of Adderall prescriptions they were sending out.  They have since had their DEA number suspended and prescribing of Adderall privileges removed.  So what happened to those patients? They were left to find an in person provider.  We are back to 2015 again when the primary care to psych for Adderall shift happened.  But this time it was a pill mill dispenser online that left hundreds of thousands of patients without their Adderall abruptly.  Many of which were not on Adderall until the pandemic started.  Here we go again.  

The consequences this time around are worse.  Not only are patients looking for new providers, but pharmacies are out of Adderall.  Many pharmacy’s admit that they stash their Adderall supplies for their “regular customers” and when a new customer calls they tell them they are out.  I receive NUMEROUS calls per day to “re-route adderall” to a new pharmacy that has it in stock.  Patients are angry.  Providers have zero control over this situation, but we hear the wrath about it daily.  

We are in a bad situation here, not unlike the opioid crisis.  The “loosy goosy” prescribing has gotten us into a crappy situation yet again.  I hope I am wrong, but I have a feeling that regulations are going to clamp down even further, production of stimulants is going to go down, and the ease of getting generic Adderall is going to remain difficult.  There are other treatment options for ADHD, and I am recommending them as much as possible right now.  The writing is on the wall that the days of Adderall use for a quick pick me up are coming to an end, and those who prescribed it both in person and online without doing the proper testing for ADHD, or without documentation of a proper historical diagnosis of ADHD, who were giving out prescriptions in such a cavalier manner, should be the ones getting yelled at by patients for what they have done.  Because for the population with TRUE ADHD, they are the ones suffering here.  But nope.  Primary care and pop up online telehealth companies looking to make fast cash has YET AGAIN thrown psych into the spin cycle.  Primary care no longer prescribes anything controlled substance.  They have sent psych hundreds of thousands of patients that are on Adderall, Xanax, and other stimulants and benzodiazepines, at high doses with multiple doses per day, washed their hands of it and said “here, let psych fix this and take responsibility for the mess we created”.  Sadly, primary care providers outnumber psychiatry providers by at least 10:1, if not more.   There are not enough of us to manage the patients that primary care has decided they no longer want to manage, despite their role in starting the controlled meds in the first place. 

As I said above, if you can get off of Adderall or other stimulants, I recommend you do so.  Not because I want you to suffer without it, or because you don’t need it with an ADHD diagnosis.  I know many people who do.  I know many personally who would not do well without it.  But if you can stop that med, I recommend you do, because I do not know how much longer it will be available.  And it is much easier to taper a patient down to lower doses and off the medication than it is to throw them into chaos with a sudden stoppage.  We are here to help the best way we can, but we cannot control the shortage issue that I fear is here to stay, and will only worsen.