The ongoing, prolonged prescription stimulant shortage in the U.S. is cause for alarm. In 2016, approximately 16 million patients were prescribed stimulants -- an increase of 250% over the preceding decade. Since the onset of the COVID-19 pandemic, more prescriptions for stimulants have been written, with an increase of almost 6 million more prescriptions in 2021 compared to the year prior. When prescription medication is no longer available from pharmacies and trusted sources, people who depend on these pills are often left feeling abandoned and desperate for solutions to be able to continue functioning as they had before the shortages. For some, the solution may be to turn to the unregulated -- and increasingly toxic -- drug supply.
We've been here before -- at the beginning of the opioid crisis. Throughout the early 2000s, the number of patients prescribed opioids skyrocketed, with a peak of over 255 million opioid prescriptions in 2012 (an opioid dispensing rate of 81.3 per 100 persons). Over concerns about the increasing supply of opioids, a systematic restriction on prescribing started, where patients with previous prescriptions were no longer able to refill their medications, and those dependent on opioids turned to alternative sources with a higher chance of overdose. As fentanyl began to infiltrate the drug supply, we've seen overdose deaths reach record highs over the past few years.
Similarly to opioids, people use stimulants for a wide variety of reasons including as prescribed for medical reasons (e.g., attention-deficit/hyperactivity disorder [ADHD]) or without prescription to function at work or school, to stay awake in dangerous situations, and to counteract the effects of other drugs. Though a debate exists on the degree of dependence prescription stimulants may have, many patients describe feeling depressed, fatigued, and unable to function when going "cold turkey" on their medications. Similarly to opioids, withdrawal itself is uncomfortable but not medically a risk for death. Instead, it's a risk for unhealthy and desperate use, and thus overdose.
An illicit market of unregulated stimulants remains available in the U.S., including diverted pharmaceutical pills, counterfeit pharmaceutical products, and more traditional stimulants for recreational use such as methamphetamine and cocaine. It is only a matter of time before patients who can't get their medications from their usual pharmacies turn elsewhere to feel normal again and maintain the quality of life they had while taking stimulants.
Our patients deserve better -- and deserve partnership and real solutions when our healthcare infrastructure fails them.
First, we must acknowledge that dependence on stimulants for any reason -- either from a stimulant prescription or because of a stimulant use disorder -- must be met with compassion and without stigma. As clinicians, it is our job to validate the discomfort associated with acute and chronic stimulant withdrawal. There is no role for taking a moral stance against those using non-prescribed stimulants; with disparities in ADHD diagnoses and increasing demands for functioning, we must recognize the many valid reasons individuals may have chosen to use non-prescribed stimulants.
We must meet patients where they are, and come up with individualized treatment plans that are patient-centered and harm-reductionist in nature. For some this may mean prescribing alternative stimulant medications that are still available, or attempting to use different types of drugs to treat symptoms (e.g., bupropion [Wellbutrin], tricyclic antidepressants, viloxazine [Qelbree], atomoxetine [Strattera] for focus, clonidine [Catapres] for hyperactivity). For others, nonpharmaceutical interventions may be more reasonable: cognitive behavioral therapy (CBT), work and school exemption notes, or suicide prevention hotlines. For patients with a true stimulant use disorder and interest in treatment, extended-release naltrexone with bupropion or contingency management referrals may be appropriate.
Third, it is essential to decrease barriers to safe prescription stimulants. As physicians start prescribing second- and third-line stimulants to those previously on Adderall (mixed amphetamine salts), we must remove prior authorizations and waive higher copays for more expensive medications.
Our patients need access to accurate information -- either through establishing a hotline for patients and doctors to ask questions and obtain guidance, or through providing increased coverage for out of network providers when seeking assistance related to stimulant use.
Lastly, we must recognize that some patients may continue to need to use non-prescribed stimulants. This is an opportunity to invest in public health messaging around fentanyl contamination of the non-opioid drug supply, and make fentanyl test strips available not just at harm reduction centers but also through prescriptions to pharmacies. Messaging can teach the public about identifying an opioid overdose and acting with Narcan administration. To make a real impact, Narcan kits must be made more widely available.
Overdose deaths from stimulants (usually mixed with opioids either intentionally or accidentally) have skyrocketed over the past few years. Patients with ADHD and individuals who use stimulants often are being treated or self-medicating for impulsivity and decreased executive function, conditions that come with a high risk of substance use. We must partner with our patients to find a solution so that we keep some of our most vulnerable patients safe -- and alive -- until the end of this Adderall shortage.
Eric Kutscher, MD, is an internal medicine physician and addiction medicine fellow at NYU Grossman School of Medicine.