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Saturday, June 22, 2024

America’s Adderall Shortage Could Kill People

Earlier this month, the US Food and Drug Administration announced a nationwide shortage of immediate release amphetamine mixed salts. For many people who take this medication, the announcement just stated what they’ve known for months. Right now, it can be tricky, wildly inconvenient, and sometimes outright impossible to get hold of this drug, commonly referred to by its brand name Adderall. Pharmacies across the country do not have it in stock. People are rationing pills, driving for hours, and pleading with their doctors for alternative treatments. 

Drug shortages are not uncommon; there are over 200 happening right now in the United States alone. But this one requires special attention. The Adderall shortage may worsen the American overdose crisis. People could die.

“It’s a really big deal if I don’t have access to it,” a freelance writer named Kitty tells me. (She asked to be identified by only her first name for privacy reasons.) Kitty was diagnosed with attention deficit hyperactivity disorder (ADHD) as an adult, and has found that extended-release Adderall is the most helpful medication for her, helping her focus without side effects. 

Kitty ran out of Adderall two weeks ago and has not been able to refill her prescription. Without her regular supply, she’s sought out replacements. “I’m taking my friend’s meds, which is complicated,” she says. “It isn’t my exact prescription.” It’s a higher dosage, possibly too high. She’s grinding her teeth more.

How did this happen? Teva Pharmaceuticals, the largest manufacturer of these drugs in the United States, couldn’t hire enough workers for its packaging line this summer. Teva fixed that issue, but a recent Bloomberg report claims its shortage may last until March. (A company spokesperson told WIRED it will be resolved “in the coming months.”) 

In addition to Teva, several other manufacturers are now also having supply issues. As a Schedule II controlled substance, Adderall is closely monitored by the US Drug Enforcement Administration, which places strict caps on how much of the drug can be produced by each company. One can’t just kick into high gear and make up for the other’s back orders. Even if all the manufacturers suddenly had thousands of extra workers and the world’s most efficient supply chain, they’d still be constrained by the DEA’s quotas.

Then there’s demand. America loves Adderall. Between 2006 and 2016, prescription stimulant use more than doubled in the United States. Since then, it’s gone up again for adults, with health care analytics firm Trilliant Health reporting a 22 percent increase in prescriptions from 2019 to 2021 for people between the ages of 22 and 44. This surge was driven by a rise in ADHD diagnoses, although Adderall is prescribed for other conditions as well, such as narcolepsy. New off-label uses are still springing up, too; some doctors, for instance, treat post-Covid-19 fatigue with prescription stimulants.

When telemedicine regulations were relaxed to help people access health care while they stayed home during the pandemic, a slew of mental health startups flooded social media with advertisements encouraging people who feel like they are easily distracted to seek ADHD treatment, no in-person meeting required. Those ads worked. Diagnoses shot up yet again. 

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The rapid rise of these companies raised major concerns about overprescription. Were they providing vital services to people who would otherwise be left untreated for mental health issues, or were they simply pill mills for the TikTok era? Major pharmacies like CVS and Walgreens stopped filling prescriptions for controlled substances from the popular startups Cerebral and Done, and Cerebral is under federal investigation for its prescribing practices.

Is Adderall overprescribed in the United States? It’s a thorny question, and one well worth asking. It’s also completely beside the point. The issue at hand right now is what will happen—what is already happening—when Americans are abruptly cut off from the stimulants they have already been prescribed or have otherwise been regularly taking.

When someone accustomed to taking stimulants suddenly stops, they can sometimes feel withdrawal symptoms, especially if they are taking a high dose. Stimulant withdrawal is not as serious as opioid or alcohol withdrawals, which often require medical supervision to keep people safe. But abrupt cessation can still manifest unpleasant feelings like drowsiness and irritability that people will want to avoid. Even patients who aren’t worried about withdrawal will still grapple with losing access to drugs they see as helpful for their day-to-day lives. 

This is a medication many people feel dependent on to function normally and are unprepared to stop unexpectedly. While some patients manage to white-knuckle losing legal access to their prescription, others are buying Adderall from unregulated online or real-life dealers. Others still may be considering black market stimulants as substitutes. “If you have lots of people moving at the same time from the pharmaceutical market to the illicit market, lots of bad things can happen,” says Leo Beletsky, an epidemiologist and the faculty director of Northeastern University’s Health in Justice Action Lab. “Conditions are very much ripe for that to happen here.”

We’ve heard this one before. The parallels with the beginning of the opioid crisis are alarming. In 1996, Purdue Pharma began aggressively marketing OxyContin as a safe painkiller. Health care providers bought into the hype and whipped out their prescription pads. OxyContin was a pharmaceutical blockbuster. By the 2010s, many doctors changed their prescribing habits after realizing the pill was intensely habit-forming after all. (It was also reformulated in an attempt to prevent misuse.) But at that point, many pain patients had already become dependent on the drug. When they lost easy access to OxyContin, they swapped in heroin or other illicit opiates, which were easy to buy and cheaper to boot. Overdoses and deaths rose. 

Now, we have another large wave of patients who have been prescribed a controlled substance who have been unexpectedly cut off from their supply, and who will be tempted to look for replacements or alternatives from other sources. “All they have to do is make a quick call, and it’s readily available elsewhere,” Beletsky says. These conditions are setting people up to fail.

The United States is in the middle of a prolonged and profoundly deadly overdose epidemic. Illicit drugs are often adulterated with the powerful synthetic opioid fentanyl. Although it is far more common for heroin and other opioids to be laced with fentanyl, stimulants occasionally get cross-contaminated, too. “Just as with opioids, we are in the middle of a spiraling crisis involving stimulants,” Beletsky says. 

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Horror stories abound: Even before the shortage, Ohio State University and the city of Columbus, Ohio, issued warnings about counterfeit Adderall pills tainted with fentanyl after the overdoses of two students last spring. Around the same time, three young professionals in Manhattan ordered cocaine from the same drug delivery service and died because the powder they sniffed also contained fentanyl. And the illicit market’s stimulant supply is unreliable in other ways. A pressed pill sold as Adderall might be methamphetamine, for instance. You don’t know what you’re getting.

It’s difficult to imagine a more dangerous time for a huge population of stimulant users to suddenly lose access to their medication. Yet there is a distinct lack of urgency from government and public health leaders. “I think this is a true public health emergency,” addiction medicine and primary care physician Eric Kutscher says. “We haven’t sounded the alarm loudly enough.”

Kutscher, who has studied stimulant use disorders, wants the FDA to provide guidelines to doctors about alternatives they can offer patients. “There should be no reason that a patient who was previously stable on Adderall doesn’t get some sort of replacement therapy, whether it’s another short acting stimulant or a long acting stimulant that can tide them over and provide at least some degree of symptomatic support,” he says. 

Kutscher is especially worried about people who have been taking Adderall without a prescription—who buy it from friends or otherwise illicitly—because they will be especially vulnerable to switching to more dangerous substances, and they won’t be able to depend on their physicians for help with a replacement therapy. Without access, people who decide to risk buying drugs illicitly can make themselves safer by using drug-testing strips and keeping Narcan on hand, but these harm reduction measures cannot eliminate danger entirely. The shorter the shortage, the better.

“The FDA has the ability to waive or fast-track or otherwise facilitate the approvals that are necessary,” Beletsky says. He hopes the agency will find a way to relax importation limits for a quick influx of Adderall manufactured abroad. A spokesperson for the FDA declined interview requests, but said that the agency is working with Teva “to assist as needed to resolve the shortage.” 

When asked what people who can’t get their medication should do, the spokesperson encouraged patients taking amphetamine mixed salts “to discuss options with their prescriber”—not an especially reassuring answer. For now, watching the Adderall shortage unfold is like watching a reboot of an especially grim melodrama, hoping the screenwriters have a twist in store. This story doesn’t need to end the same way twice.

Updated 10-27-22, 12:30 pm EST: This story has been updated to further clarify symptoms of stimulant withdrawal.

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