A national Adderall shortage is affecting patients in Oregon who rely on the medication to manage symptoms related to attention-deficit/hyperactivity disorder. We check in with Craigan Usher, a professor of Child & Adolescent Psychiatry at Oregon Health & Science University, to learn more about how the shortage is affecting patients in Portland.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Last October the Food and Drug Administration announced that there was a nationwide shortage of Adderall. It’s one of the most common medications for attention-deficit/hyperactivity disorder (ADHD). The shortage has not gotten better since then, and in fact prescriptions for other common medications for ADHD are now also hard to fill. We wanted to know what this has meant in the Northwest, especially for young people. So we’ve called up Craigan Usher; he’s a professor of psychiatry at OHSU who specializes in treating children and adolescents. Welcome back to Think Out Loud.
Craigan Usher: Thanks so much for having me.
Miller: When did you start hearing about a shortage of prescription drugs for ADHD?
Usher: I started hearing about it last fall as well, maybe October and November.
Miller: And at that point what were you hearing from patients or their families?
Usher: I was hearing that there were delays in getting it, that if I wrote a 30 day prescription, maybe somebody was able to get two weeks of it. But the pharmacy said that they would probably get it in later, there were rumblings about things like supply chain issues. So it caused some frustrations, but it certainly was something that worsened by last month, by January of this year.
Miller: If we had talked in October, would you have said that this is most likely going to be solved. Would you have assumed it would actually get worse since then?
Usher: Since most things do get solved . . . and maybe pre-pandemic, I had that space in my mind, like “yeah, this is a speed bump and we’ll get over this in a couple of weeks.” But it’s been a persistent problem.
Miller: So I want to come back to the shortage itself and what it’s meant for your patients and their families. But we should probably spend some time on the reasons for these drugs to begin with. What does ADHD look like in kids? What’s the spectrum of possibilities for ADHD?
Usher: So ADHD Is a brain-based behavioral disorder that involves extreme difficulties with regulating attention or impulsivity. And our hearts should go out to all children and all families, parents, caregivers, guardians, teachers who work with and love kids with ADHD because it can be very taxing. It can be taxing on the individual and it can be taxing on those around them. But it really means having a lot of difficulty with focus, like initiating one’s attention, especially for tasks that require a lot of mental effort: the capacity to sustain attention through a long work project, shift your attention in really flexible ways. And for teenagers, for example, and young adults and older adults with ADHD, this can cause all kinds of problems in terms of safety, in terms of driving. So we know that stimulant treatment for these things can be lifesaving, absolutely key.
Miller: “Lifesaving” is a big phrase, but I imagine, as a doctor, you don’t use that lightly.
Usher: I’ve certainly seen it in individuals that I work with, where… I’m going to focus, for example, on car accidents. And this is anecdotal and comes from the experience of my practice, but certainly I’ve seen people with multiple traffic violations and motor vehicle accidents, or self esteem problems stemming from academic struggles or struggles in the workplace. And so truly from an emotional safety standpoint and actually from a physical safety standpoint, these meds mean a lot to a lot of people.
Miller: How effective are they, in general?
Usher: In general, they’re about 70-80% effective. And I think what makes this shortage so difficult is that they work for 70-80% of people, but these can be hard fought victories, to get on the right medication, to get the timing of the medication right, to get the dosage accurate. And people have to contend with things like decrease in appetite, weight loss, sometimes moodiness when the medication wears off or while it’s active, headaches, jitteriness, insomnia. The list could go on and on, in terms of side effects. And so finding the right formulation for someone can be absolutely key and that can take, sometimes weeks, sometimes months, even years for some people. To have difficulty accessing that thing which, again, might be a hard fought victory to find that thing that works, can be really, really problematic.
Miller: Can you help us understand the brain chemistry here, just for a second? Because I think for a lot of people, the fact that a kind of drug that can, in people who don’t necessarily have ADHD, actually maybe work in the opposite way, could make them lose focus or get jittery or make it harder for them to stay on a task. For people who do have ADHD, it seems like it does the exact opposite. What’s happening in our brains?
Usher: Stimulants are medications that really make the neurotransmitter dopamine more readily available. And of course we know that recreational drugs can make dopamine extremely available, and actually, they sort of turn on the faucet of this neurotransmitter and overflow the bathtub of the brain, so to speak, in terms of substance misuse. But when we use them in smaller doses, what they really do is stimulate key areas in the frontal cortex and the temporal cortex so the front of your brain and the interior section of the temporal lobes, and they wake them up. Simply put, it’s a little bit like a cup of caffeinated coffee or tea stimulants really wake up the areas of the brain that are responsible for sustained focus for attention to details for impulse control.
Miller: Are there differences in the presentation broadly, of ADHD based on gender? I mean, for adolescent girls and boys do you see differences in general?
Usher: So young women are more often diagnosed with inattentive-type ADHD, and I think there’s some there’s some stigma against the diagnosis where people will say, “well you don’t look like you have ADHD, you don’t look like the classic…” Adults will say this to me, every now and again: “When I was in kindergarten, or when I was in fifth grade, I definitely knew…” And it was usually the boy and their name, “that boy who had ADHD,” he was fidgety, restless, “at lunchtime, he flicked peas onto the ceiling of our classroom.” That’s not the only way to have ADHD.
In fact if you just look at it, mathematically, you look at the criteria, there are 81 different ways that you can just meet the mathematical criteria for inattentive-type ADHD, or hyperactive-impulsive type. So it is a highly heterogeneous disorder. Young women, again, more often, tend to have more what we call “internalizing disruptions,” more anxiety, more depression, and more, if I can say it, “quiet suffering,” when it comes to ADHD. So they might be missed. They are not the squeaky wheels that get the grease, so to speak.
Miller: What do you see as some of the biggest societal misconceptions about ADHD?
Usher: Again, I think there’s this perception that everyone is getting diagnosed and that maybe, the criteria by which people are being diagnosed are too loose. That may be the case, but I just don’t know that it’s the case. We don’t have clear data. And I think when people talk about that, “well, too many people are being diagnosed with ADHD,” it tends to erode how we might honor people who really meet the criteria. They’ve gone through evaluation where we know that they’ve taken questionnaires against the national norm. So we know that they’ve maybe been observed in the classroom or at work, their spouses, their partners for adults. And for kids, it’s parents, guardians, teachers, who have all been involved in thinking about that child.
And so I think there’s some stigma that’s associated with the diagnosis sometimes, like, “well, too many people are diagnosed with it, you may not have this disorder.” And especially, I think, we can imagine that with… we were just talking about young women who might have more of an inattentive-type… or a teacher, or someone else might say, “well, you’re doing fine in school,” but we really have no idea just how hard some people work in order to achieve the things that they’re achieving.
Miller: So let’s turn back now to this shortage. What kind of disruptions could an unfilled prescription cause?
Usher: Well, I think sometimes people just have the strict withdrawal phenomenon. Those of us who drink coffee every day, we know that we get a bit of a headache on the day that we don’t have access to our lattes. The same could be true for kids. So there’s the physiologic disruption, just not having this thing that helps sustain them for so long. People also really count on these things. We saw this as students approached midterms and finals, they were counting on being able to work collaboratively with groups. Maybe if somebody has a big work project and they knew the deadline was coming up and then they have the anxiety of not knowing, “will I have my prescription, won’t I?” That’s caused a lot of anxiety.
We also think about the executive function difficulties, meaning planning, sequencing, and carrying out tasks. Folks with ADHD, when they can’t count on when they’re going to be able to get to the pharmacy or if they’re at the pharmacy, whether they’ll actually be able to get their meds, it really causes major disruptions.
Miller: So if patients or their families have been running into these issues, filling their prescriptions what have you been telling them?
Usher: There are about five things that they can do: first, you can call around to other pharmacies and see if the stimulant medication is available at another location. Some folks encourage them to collaborate with their providers to see if their insurance company will cover the cost of a name-brand formulation as opposed to generic, because often the generics are what pharmacies are having difficulty stocking. Some families may be able to cut higher dose pills in halves or quarters, and this can’t be done with all medications including most of the long acting versions, so you’ll need to talk to the pharmacist or provider to see if that’s possible.
The last couple of things that I’ve been encouraging families to do is maybe switch to a close cousin medication that might be available, to see if that might be of use. And then, finally, some folks have chosen to go back to a medication that might have been useful in the past and is readily available. So for example, if someone really benefited from a medication like Ritalin, long-acting Ritalin and Ritalin LA, and they’re now on Adderall, they might be able to go back to that old medicine, temporarily, until the supply is restored.
Miller: But I imagine for those cases, there would have been a reason, hopefully a good reason, that they would have switched in the first place, say to Ritalin. So that, as you’re noting, that’s not an ideal situation, but I guess it’s better than not having some kind of stimulant medication.
Miller: What is behind this shortage? It’s been going on long enough that my understanding is there are a few theories that maybe have some meat on them. What’s your take on what’s happening?
Usher: I’m going to offer you my speculation and then something a little bit more anchored in data. So my speculation is that the competing demands [of] work from home life have really exacerbated people’s underlying tendencies towards poor focus and difficulty with impulse control. And that may be driving what we’re seeing in terms of the data in terms of adults who are seeking stimulant medication. So we know that the demand rose in 2021 about 7.5% for Adderall, and rose 15% in 2022. And in fact, there’s going to be data coming out soon really looking at increased rates of diagnosis of ADHD through the pandemic in adults. And I think that’s clashing with a plateau in terms of how much medication is actually being manufactured. So we have the same amount of medication, but a lot more people seeking those meds.
Miller: What you’re describing there is about the demand side, I guess, and changes in our collective behavior. Making it more clear to people that they have issues with focus or attention. I was struck by an article I saw in Vox just a couple days ago, and they said that one potential major cause of this problem could be remote-only telehealth companies which, because of a pandemic era rule change, allow providers to prescribe controlled substances like these stimulants without ever seeing their patients in person. And they also mentioned pretty aggressive marketing campaigns on social media encouraging people to be diagnosed and to get meds. I’m curious what you make of this theory?
Usher: It’s really hard for me to speculate on it because I think the folks that I’m seeing via telehealth . . . we’re really trying, as a field, child and adolescent psychiatric pediatrics, to be scrupulous about the diagnosis. Certainly, I do think that, into the space of the pandemic, we have seen some, at best, suboptimal practices, where folks who are never coming into the office, never getting a good physical exam may be diagnosed. But again, it’s really hard.
I leave that to investigative reporters. I only know the folks that I have in my office, and in our adjacent pediatrics practice, and I think we’re really trying to do a good job… a good enough, for an optimal diagnosis of ADHD really should involve questionnaires that are performed against a normative national sample. And it should involve a clinical interview as well as, for kids, a good physical exam ruling out inattention or hyperactivity that could be arising from difficulties like problems with your hearing or a visual impairment.
Miller: Finally, is there hope on the horizon until in terms of this specific supply chain?
Usher: That’s another great question. I was hoping you had another article about that…
Miller: No, I’m out of hope.
Usher: I’ll make a big difference. I think we’ve always adjusted. There have been areas where we’ve questioned the safety, for example, of Adderall in 2007, while I was in my residency, we converted everyone back over to Methylphenidate or were looking at non-pharmacologic treatments, because we really wanted to know whether or not Adderall was cardiac safe for youth. So I think as a field, we’ve always been able to make those adjustments and work collaboratively with families and so I guess that’s the hope is that we’re all in this together and even if they don’t solve the problem, we’ll at least work around it.
Miller: Craigan Usher, thanks very much.
Usher: Thanks for your time.
Miller: Craigan Usher is a professor of Psychiatry at Oregon Health and Science University, specializing in children and adolescents. He joined us to talk about the ongoing nationwide shortage of various ADHD medications.
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