About four years ago, Wendy Steele, the owner of a film and television production company, started taking Adderall to treat attention deficit hyperactivity disorder (ADHD), and “it’s helped me in every aspect of my life”, she said.
But in recent months, in part because of an increase in the number of people who have turned to such stimulants, Steele has struggled to find the drug.
Sometimes she has driven to different pharmacies around Baltimore with a paper prescription and asked whether they could fill it. She briefly switched to Vyvanse, another stimulant medication. Unlike Adderall, there isn’t a nationwide shortage of Vyvance, but her insurance wouldn’t cover it, so she had to spend five times as much, she said.
“It just was the worst headache ever because it was all during the holidays, and here I am having to take matters in my own hands,” said Steele, a 47-year-old mother of two.
Meanwhile, the US Drug Enforcement Agency (DEA) has warned drug manufacturers that it is concerned about telehealth startups’ “aggressive marketing practices”, leading to oversupply and abuse of ADHD drugs, similar to what occurred during the opioid crisis, according to a Wall Street Journal report.
In short, the federal government is trying to determine how much of the increased demand is legitimate. While they do so, people like Steele are struggling to fill the prescriptions they say they need to be successful.
“We are seeing shortages of stimulant medications in the community, and so maybe for teenagers and adults that truly meet criteria for ADHD, they are not able to access their medication that they really need to perform well at school, at work,” said Danielle Stutzman, a psychiatric pharmacist at Children’s Hospital Colorado.
The Food and Drug Administration announced a shortage of Adderall in October. Teva, the largest manufacturer of the drug, blamed the shortfall on a “significant rise” in prescription rates across the country.
Public health providers and the federal government have said the increased demand for Adderall could be because of startups like Cerebral and Done, which flourished after the government, prompted by the threat of Covid, relaxed regulations to allow clinicians to prescribe controlled substances online, without an in-person evaluation.
Cerebral ran advertisements offering $30 memberships that provide access to prescribers and home delivery of medication. Done rans ads on social media featuring pills offering a “60-second assessment” and “comprehensive ADHD care for $79/month all from the comfort of your home”.
Some clinicians working for the startups said they felt pressured to prescribe the stimulants and did so after appointments as short as 10 minutes, the Journal reported.
Cerebral announced in May that it would stop prescribing controlled substances to new patients and would taper existing patients off the medications or transition them to providers for in-person care.
Last month, Done still used social media to promote a free assessment for an ADHD diagnosis and stated that most of its consultations were 30 minutes.
But Done stated in an email to the Guardian that the company “does not engage in the prescription business”.
“The prescription process is decided between the clinician, the member, and their preferred local pharmacy,” Dr Zoe Martinez, a psychiatrist and Done regional medical director, stated. “It is also important to note that clinicians using the Done platform are not paid based on the number of prescriptions they assign, so there is no incentive to overprescribe or prescribe when it is not needed.”
In addition to the DEA’s efforts to prevent the oversupply of prescription stimulants, a group of providers who specialize in ADHD announced in August that it would establish guidelines for the diagnosis and treatment of the disorder.
“Doctors are often surprised to hear that there are no guidelines for adult ADHD in the US,” Ann Childress, president of the American Professional Society of ADHD and Related Disorders, stated in a press release. “Whether diagnosis and treatment is provided in office or online, the standard of care should be the same throughout the country.”
There are already such guidelines for treating ADHD in children.
“I think when we have clear practice parameters, we can hold people accountable for following them,” Margaret Sibley, an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine who has studied attention problems in adolescents and young adults. Without such guidelines, “it leaves windows of opportunity for” providers “to do whatever they want”.
At institutions like Children’s Hospital Colorado, providers may spend more than an hour evaluating a patient and interview teachers to determine if a patient has ADHD, Stutzman.
Otherwise, “providers could potentially be overtreating ADHD and undertreating other comorbidities like anxiety and depression,” said Stutzman, who see patients alongside child psychiatrists and helps make medication decisions.
Still, telemedicine can provide “access to medical and mental health care to people who might not otherwise be able to afford seeing somebody in person or who are geographically removed from their needed clinicians”, said Dr David Goodman, an assistant professor of psychiatry at Johns Hopkins University School of Medicine.
He now sees more than half of his patients virtually.
“The unfortunate aspect of the model that has existed thus far with the online companies is that the time spent doing the evaluation for an accurate diagnosis has been brief,” said Goodman, who directs the Adult Attention Deficit Disorder Center of Maryland.
Even if they received the right prescription, patients must now often contend with the drug shortages. That could mean trying multiple pharmacies or changing doses or switching to a different stimulant or taking a break from stimulant treatment entirely, Stutzman said.
About a quarter of the patients at the Colorado hospital who used prescription stimulants have been affected by the shortage. In one case, a middle school student had to switch from Adderall to Ritalin and did not respond well to the medication, Stutzman said.
“This individual has had tremendous difficulty at school, with sport activities and has nearly required hospitalization,” Stutzman said.
Asked about the concerns regarding Adderall, Stutzman said: “The risk of untreated or undertreated ADHD is so much higher than the potential risks for misuse.”
Steele, the Baltimore producer, said much of her family has ADHD, and some need medication for it.
“I’m about ready for a refill, and I’m dreading it because I have to go on two huge business trips,” and “I don’t have time to sit there and try to poke around to figure out who has [Adderall] and who doesn’t”, Steele said. Amid the struggle to ensure proper prescription of the drug, “it’s unfortunate that people that really do need it are feeling the consequences”.