A widespread shortage of Adderall (amphetamine and dextroamphetamine) in the latter part of 2022 left millions of patients looking for an alternative treatment strategy or dealing with withdrawal symptoms.

A Sermo survey found that about half of 348 physicians had encountered patients dealing with the Adderall shortfall.

Of the physicians surveyed, 82%, were concerned about the impact of the shortage on adult patients’ quality of life, jobs and relationships. And 87% of physicians were worried about the effects of the shortage on children with ADHD and their parents.

Reasons for the Adderall shortage

Making sense of the situation remains challenging. The Drug Enforcement Administration (DEA) limits the production of Adderall and its generics. The federal agency is concerned that aggressive marketing practices contributed to the shortage, according to WSJ.

Teva (NYSE:TEVA) partly blamed labor shortages for low stockpiles of the drug. Novartis subsidiary Sandoz has also acknowledged manufacturing shortages related to generic Adderall.

The criteria for diagnosing ADHD have matured over the years. In 1968, the DSM-II included an entry for “hyperkinetic reaction of childhood,” a disorder involving “overactivity, restlessness, distractibility, and short attention span.” In 1980, the DSM-III had an entry for Attention-Deficit Disorder (ADD), which may include hyperactivity. Finally, the DSM-V, published in 2013, reframed the disorder as Attention-Deficit/Hyperactivity Disorder (ADHD).

Although the diagnostic criteria have grown more sophisticated, there’s still a lack of data about the long-term use of drug therapy for managing ADHD. However, a 2019 study published in the Journal of the American Academy of Child and Adolescent Psychiatry notes that currently available data “support continued effectiveness” of long-term drug therapy.

DEA signaled in December 2022 that it believes proposed Aggregate Production Quotas (APQs) for amphetamine are “sufficient to supply legitimate medical needs, reserve stocks, and export requirements for 2023.”

The impact of the pandemic on ADHD diagnoses

The pandemic also exacerbated ADHD symptoms for some patients, said Dr. Heidi Moawad, a neurologist on Sermo’s medical advisory board. The lockdown phase of the pandemic was trying for many people and likely amplified many ADHD symptoms.

“Think of all of the people who were inside and bored. Sports for kids weren’t as active as they normally are,” Moawad said. Additionally, many children could not go to school, leaving them with fewer outlets to blow off steam.

“Experts seem to agree that ADHD symptoms can change depending on the environment,” Moawad said. “And staying home during the pandemic was pretty bad for all of us.”

The pandemic also served as an opportunity to deal with symptoms that had been “on the back burner,” Moawad said. It may be that accounts of growing ADHD diagnoses involve people who were avoiding or too busy to go to the doctor before, she said.

Another factor contributing to the Adderall shortage is the growing popularity of telehealth paired with loosened restrictions on remotely prescribing controlled substances such as Adderall.

Last year, federal officials began investigating online mental health services startups Cerebral and Done Global over potential violations of the Controlled Substances Act. Both companies offered ADHD drugs such as Adderall via telehealth.

“Telehealth became so big during the pandemic,” Moawad said.

During the pandemic, many physicians realized how straightforward it could be to prescribe medications to patients where there are clear diagnostic criteria.

“But the biggest shortcoming of telehealth is you can’t do a good physical exam,” she said.

Telehealth, thus, can make physicians more reliant on questionnaires than an in-person visit would. Telehealth visits, however, can be more convenient for patients.

“Some people may try to just continue to get pharmaceutical prescriptions through telehealth because it was so easy [early on during the pandemic], and they don’t waste their time,” Moawad said.

Lobbyist Bart Stupak has asked the federal government to continue allowing physicians to keep prescribing controlled substances via telehealth, according to Bloomberg. Under the Ryan Haight Act passed in 2008, prescribing controlled substances requires a patient to visit a doctor in person. The DEA, however, relaxed that requirement in the early days of the pandemic.

How patients are dealing with the Adderall shortage

It is difficult for patients with ADHD to abruptly stop drug therapy without an alternate treatment in place. Adderall shortages could also impact behavioral modification efforts to treat ADHD.

“A lot of people with ADHD also will go to therapy and counseling,” said Moawad. “It’s believed to be effective if that’s happening at the same time as medical treatment.”

But an ADHD patient prescribed Adderall who suddenly doesn’t have access to the drug could suffer withdrawal symptoms, including depression, insomnia, fatigue and nausea. Those symptoms could interfere with behavioral modification.

In addition, while it has been established that behavioral modification and drug therapy work well in tandem, how well the former will work on its own is less clear.

“Are you putting too much of the burden on therapy?” asked Moawad.

The Adderall shortage can also prevent children from obtaining a medication that helps them effectively manage ADHD symptoms. Untreated ADHD can affect a child’s learning and social interactions, Moawad said.

The shortage could likely cause some children with ADHD to label themselves bad at academics or socializing, Dr. Moawad said.

“To not get treated would reaffirm that child’s belief that they’re not good at these things. And then it can make it a self-fulfilling prophecy,” she said, adding that such beliefs can have a long-lasting impact once entrenched.

The dangers of non-prescription stimulants and black market Adderall

In the Sermo survey, 74% of the physicians who took part in the survey feared that patients would look for alternative treatments to established medications such as Adderall. One option includes non-prescription stimulants, which are ill-suited for managing ADHD symptoms.

While some patients may look for prescription alternatives to the medication, counterfeit Adderall poses an array of dangers. The black-market product may be legitimate Adderall that is expired, while counterfeit Adderall may contain high levels of fentanyl, as Bloomberg noted.

“Patients might not take [the medication] according to instructions if they don’t have clear instructions from a pharmacist,” Moawad said. “And then if something is wrong, they can’t take it to their pharmacist and ask if it is OK.”