Months Later, Stimulant Shortage Persists

On a Sunday in June, Robin Weiss, M.D., a psychiatrist in Baltimore, was notified that there were problems filling Adderall prescriptions for two of her adult patients with attention-deficit/hyperactivity disorder (ADHD). One pharmacy had no Adderall available, so for about 20 minutes she spoke with the pharmacist to determine if one of the few stimulant medications that the pharmacy did have in stock would work for the patient.

On the same day, Weiss received a fax communication from CVS Caremark, a pharmacy benefit manager, that the double dose of 15 mg Adderall XR she had ordered for another patient was now on back order, with no estimated availability date. This was after the pharmacy benefit manager had required a cumbersome prior authorization process to allow two 15 mg tablets a day to substitute for the patient’s usual, equivalent dose of Adderall XR 30 mg a day, on which she had been stable for years. So now Weiss was back to the drawing board for this patient.

“Multiply that by the number of patients I have on stimulants, and you have a good idea how time consuming this situation is,” said Weiss, a past president of the Maryland Psychiatric Society.

For months, psychiatrists across the country have struggled to help their patients access their stimulant medications. The Food and Drug Administration (FDA) announced a shortage of Adderall in October 2022, but that shortage has spread to other stimulant medications such as Ritalin and Concerta, as psychiatrists and other physicians have been forced to switch their patients’ medications.

The causes of the shortages are likely multifactorial. When the FDA announced the Adderall shortage, it was linked to manufacturing delays. But further issues may be influencing the ongoing shortage, including supply chain issues and an overall increase in stimulant prescriptions since the COVID-19 pandemic. In late March, the Centers for Disease Control and Prevention reported that stimulant prescriptions spiked during the pandemic, particularly among women.

As of June 6, the FDA’s drug shortage database stated that Adderall is currently available, but Teva, the medication’s manufacturer, is experiencing an unprecedented increase in demand. Psychiatrists continue to experience challenges helping their patients access stimulant medications, including Emily Wood, M.D., Ph.D., chair of the Government Affairs Committee of the California State Association of Psychiatrists.

Wood said the shortage has been a constant struggle since last fall and worsened this spring. She treats children, adolescents, and adults in a small private practice in Los Angeles. She and her administrative staff find themselves spending hours calling around to different pharmacies to find out if they have Adderall or another stimulant medication in stock. Some of her patients’ families spend days driving around to area pharmacies. A mother of one of her patients took an entire day off work to drive to a pharmacy to get medication for her daughter.

“It’s getting worse all the time,” Wood said. “On top of their ADHD symptoms, patients are dealing with a whole new level of anxiety over whether or not they’ll get their medications.”

Existing Problems Exacerbate Shortage

The shortage is complicated by further problems that psychiatrists like Wood, her staff, and her patients’ families encounter. Stimulants are controlled medications, and pharmacies will not always share what they have available until the physician places a prescription. “I may have to put in four prescriptions at different pharmacies before we find what we need, and meanwhile the patient is going days without this medication,” Wood said.

Further, long-standing problems with the prior authorization process add another grueling layer of complexity to psychiatrists’ workloads. After spending what can amount to hours trying to identify an alternative medication that is available, psychiatrists are often stymied again by receiving a prior authorization request from pharmacy benefit managers. “You feel like you’re in a black hole of extra work,” Weiss said.

APA and the American Academy of Child and Adolescent Psychiatry have written letters to the FDA and the Drug Enforcement Administration (DEA), describing the urgency of the situation and expressing hope that the agencies are prioritizing actions to improve access to stimulant medications. “The disruption to the daily lives of affected children and adolescents and their families cannot be overstated,” the organizations told the FDA and the DEA.

The letters include stories from psychiatrists from across the country, detailing the efforts that they and their patients’ families have gone through to find available medications for ADHD. They shared how patients’ behaviors in school have worsened, how the additional time and energy to deal with administrative work takes time away from other patients, and how the shortage is overall hindering patient care.

Wood emphasized that the current struggles related to the shortage are on top of existing problems for patients with ADHD. “The system already is designed to make my patients who have ADHD feel like they are drug seeking because their medications are so highly regulated,” she said. “I have to explain to my patients that they’ll sometimes feel like they’re doing something wrong when they pick up their prescriptions, even though this is the absolute best medication that is available for them.”

Psychiatrists Advocate at the State Level

APA’s district branches have been taking action to support their members in light of the stimulant shortage. The California State Association of Psychiatrists (CSAP) met with the state attorney general’s office and has been raising attention about the impact that the opioid settlement has had on the stimulant shortage.

The settlement was reached between major pharmaceutical distributors and 46 state attorneys general. It placed limits and greater scrutiny on pharmacies’ drug supplies. Physicians have reported that an unintended consequence of the settlement has been increased challenges accessing certain controlled medications, said Paul Yoder, CSPA’s lead lobbyist.

The Maryland Psychiatric Society also sent a letter to its attorney general, noting that the hurdles presented by the shortage “can exacerbate the patient’s condition, limit their functioning, and create additional stress for families.”

Weiss pointed out that the additional administrative burden imposed by the stimulant shortage and worsened by existing systemic problems with the prior authorization process are burning psychiatrists out. She urged her colleagues to work with their district branches, not only to advocate at the state level but also to share experiences with fellow psychiatrists facing similar issues. “It helps a lot to stay connected and hear from others who are also going through this,” she said. ■