The ongoing, persistent shortage of prescription stimulants in the US is a cause for concern. In 2016, approximately 16 million patients were prescribed stimulants – a 250% increase over the previous decade. More stimulant prescriptions have been written since the start of the COVID-19 pandemic, with an increase of nearly 6 million more prescriptions in 2021 compared to the previous year. When prescription drugs are no longer available from pharmacies and trusted sources, people who depend on these pills often feel abandoned and desperate for solutions to continue functioning as they did before the shortages began. For some, the solution might be to turn to the unregulated — and increasingly toxic — drug supply.
We’ve been here before – at the start of the opioid crisis. In the early 2000s, the number of patients prescribed opioids skyrocketed, peaking at over 255 million opioid prescriptions in 2012 (an opioid administration rate of 81.3 per 100 people). Due to concerns about the increasing supply of opioids, a systematic reduction in prescription began, with patients with previous prescriptions unable to refill their medication and those dependent on opioids turning to alternative sources at higher risk of overdose. As fentanyl began to infiltrate the drug supply, we have seen overdose deaths reach record highs in recent years.
Similar to opioids, people use stimulants for a variety of reasons, including medical reasons (eg, attention-deficit/hyperactivity disorder). [ADHD]) or without a prescription to function at work or school, stay awake in dangerous situations, and counteract the effects of other drugs. Although there is debate about the level of dependency that prescription stimulants can have, many patients describe feeling depressed, tired, and dysfunctional when they go “cold turkey” on their medication. Similar to opioids, withdrawal itself is uncomfortable but medically not a risk of death. Instead, there is a risk of unhealthy and desperate use, and therefore overdose.
The US still has an illicit market for unregulated stimulants, including diverted pharmaceutical pills, counterfeit pharmaceutical products, and more traditional recreational stimulants such as methamphetamine and cocaine. It’s only a matter of time before patients who can’t get their medications at their usual pharmacy will go elsewhere to feel normal again and maintain the quality of life they had while taking stimulants.
Our patients deserve better – and deserve partnerships and real solutions when our healthcare infrastructure fails them.
First, we must recognize that stimulant addiction for any reason—either from a stimulant prescription or from stimulant use disorder—must be treated with compassion and without stigma. As clinicians, it is our job to validate the symptoms associated with acute and chronic stimulant withdrawal. It doesn’t matter to take a moral stance towards those who use non-prescription stimulants; With disparity in ADHD diagnoses and increasing demands for functioning, we must acknowledge the many valid reasons that may have chosen to use non-prescribed stimulants.
We need to meet patients where they are and develop individual treatment plans that are patient-centric and inherently harm-reducing. For some, this may mean prescribing alternative stimulants that are still available, or trying different types of medication to manage symptoms (e.g., bupropion). [Wellbutrin]tricyclic antidepressants, viloxazine [Qelbree]Atomoxetine [Strattera] for focus, clonidine [Catapres] in hyperactivity). For others, nonpharmaceutical interventions may be more useful: cognitive-behavioral therapy (CBT), work and school exemptions, or suicide prevention hotlines. For patients with a true stimulant use disorder and interest in treatment, extended-release naltrexone with bupropion or referrals to emergency management may be appropriate.
Third, it’s important to break down barriers to safe prescription stimulants. As doctors begin prescribing second- and third-line stimulants to those previously taking Adderall (mixed amphetamine salts), we must remove prior approvals and forgo higher co-payments for more expensive drugs.
Our patients need access to accurate information – either by establishing a hotline for patients and doctors to ask questions and get advice, or by providing better coverage for off-net providers when they need help related to the use of seek stimulants.
Finally, we must recognize that some patients may need to continue using non-prescription stimulants. This is an opportunity to invest in public health information about fentanyl contamination of non-opioid drugs and to make fentanyl test strips available not only in harm reduction centers but also through pharmacy prescriptions. Messaging can teach the public how to recognize an opioid overdose and how to manage Narcan administration. To have any real impact, narcan kits need to be made more widely available.
Deaths from stimulant overdoses (usually intentionally or accidentally mixed with opioids) have skyrocketed in recent years. Patients with ADHD and those who use stimulants are often treated or self-treated for impulsivity and decreased executive function, conditions that are associated with a high risk of substance use. We need to work with our patients to find a solution so we can keep some of our most vulnerable patients safe – and alive – until this Adderall shortage ends.
Eric Kutscher, MD, is an internist and fellow in addiction medicine at NYU Grossman School of Medicine.
