Reva Bajjuri (Author) and Sonya A. Ashikyan (Mentor)

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder which tends to be misunderstood and overlooked. Harmful misconceptions, rooted in disbelief of the legitimacy of ADHD, understate the breadth and complexity of its symptoms. 4.4% of Adults in the United States are clinically diagnosed with ADHD, and 32.7% of ADHD adults rely on stimulants for treatment (National Institute of Mental Health, 2022). Deconstructing the stigma surrounding people with ADHD, especially those who take stimulants, is a key step in effectively understanding their struggles and evaluating the extent to which these struggles have been amplified during the Adderall Shortage.

ADHD is a neurological disorder characterized by persistent hyperactivity, inattention, and/or impulsivity (American Chemical Society, 2015). Many people experience these feelings daily, but people with ADHD experience them so frequently and severely that it impedes on their social, academic, and emotional functioning. The most common treatments for ADHD are stimulant medications such as Adderall Slow-Release (SR) and Adderall Extended-Release (XR) (National Institute of Mental Health, 2022).

On October 12, 2022, the Food and Drug Administration (FDA) announced that there was a drug shortage due to “intermittent manufacturing delays” from Teva, one of the biggest manufacturers of amphetamine salts (U.S. Food and Drug Administration, 2022). Amphetamine salts are a key ingredient of Adderall and Adderall XR, two of the most common stimulant medications for ADHD in the United States (American Alliance of Psychiatric Pharmacists, National Alliance on Mental Illness, 2016). The decreased manufacturing of amphetamine salts is the main contributor for the ongoing Adderall shortage (U.S. Food and Drug Administration, 2022).

Both Adderall SR and Adderall XR work by increasing the amount of the dopamine and norepinephrine, a derivative of dopamine, in the brain’s reward centers. These reward centers refer to the parts of the brain which mediate the physiological and cognitive processes that signal that something positive or beneficial has happened. Activation of these centers is accomplished through the systemic increase of dopamine (Lewis, 2021). The amount of dopamine and reward system activity is remarkably lower in people with ADHD, so they experience decreased motivation and require additional stimulation to perform everyday tasks (American Alliance of Psychiatric Pharmacists, National Alliance on Mental Illness, 2016). Stimulant medications such as Adderall have been beneficial in restoring levels of dopamine and norepinephrine to promote normal reward system functioning, consistently increasing patients’ attention spans, impulsive behaviors, and executive functioning (Lerner, 2019).

While other manufacturers continue to produce amphetamine salts, they have not supplied enough to keep up with the market demands. The reasons for the Adderall shortage, cited by the FDA include an increased demand for the drug from Teva and a decreased supply of its active ingredient. More specific reasons for the shortage are not available on the FDA website. Increased market demands, possibly due to the growth of COVID-19 Telehealth prescriptions, likely contributed to the national Adderall shortage (U.S. Food and Drug Administration, 2022). The FDA has also not indicated why the shortage has persisted for this long.

Many patients reliant on Adderall have abruptly stopped taking their medications due to the shortage. Not only has this shortage presented a large inconvenience for patients, it also has also presented considerably dangerous mental and physical health implications. Adderall is a Schedule II controlled substance which means that taking it regularly poses the risk of physical and/or emotional dependence over long periods of time (American Alliance of Psychiatric Pharmacists, National Alliance on Mental Illness, 2016). Moreover, Adderall withdrawal usually occurs within a couple days of suddenly stopping the medication (Shearer, 2004). Withdrawal effects can be physical such as nausea, stomach cramping, insomnia, extreme fatigue, or vomiting or emotional such as depression, irritability, anxiety, or other mood changes. Acute withdrawal from stimulant use generally persists for 2-4 weeks. Because of Adderall’s classification as a Schedule II substance, patients should normally stop the medication by gradually taking lower doses under the close supervision of a doctor (Lerner, 2019).

The decreased availability of Adderall has resulted in a growing concern regarding withdrawal effects for patients unable to access their medication. While the severity of the Adderall shortage has varied across regions in the US, the present system relies on the unmedicated patients to cold-call new pharmacies amidst the shortage, as there is no centralized system through which healthcare providers can view the availability of this drug (Porterfield, 2014). This is because Adderall is considered to be a Schedule II Drug and is therefore subject to increased restrictions and more stringent prescribing protocols (Gabay, 2013). As seen in the specific case of the Adderall shortage, these protocols have contributed to an overall lack of transparency.As someone who relied on Adderall for years to manage my ADHD symptoms, I can attest to the frustration that came with being unable to find a pharmacy with Adderall in stock. After hearing rejection after rejection from numerous pharmacies in the Los Angeles area, I lost motivation and gave up. This has been the reality for most patients in heavily impacted areas of the Adderall shortage.

References

American Association of Psychiatric Pharmacists, National Alliance on Mental Illness. (2016, January). Amphetamine (Adderall). NAMI. https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Amphetamine-(Adderall)#:~:text=Amphetamine%20sulfate%2C%20mixed%20amphe
tamine%20salts%2C%20dextroamphetamine%20and%20lisdexamfetamine%20are%20prescription,to%20severe%20binge%20eating%20disorder

American Chemical Society. (2015, May 11). How does AdderallTM work?. ACS. https://www.acs.org/pressroom/newsreleases/2015/may/how-does-adderall-work-video.html

​​Gabay M. (2013). Federal controlled substances act: controlled substances prescriptions. Hospital pharmacy, 48(8), 644–645. https://doi.org/10.1310/hpj4808-644

Lerner, A., & Klein, M. (2019). Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development. Brain communications, 1(1), fcz025. https://doi.org/10.1093/braincomms/fcz025

Lewis, R. G., Florio, E., Punzo, D., & Borrelli, E. (2021). The Brain’s Reward System in Health and Disease. Advances in experimental medicine and biology, 1344, 57–69. https://doi.org/10.1007/978-3-030-81147-1_4

National Institute of Mental Health. (2022, September). Attention-deficit/hyperactivity disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd

Porterfield, A., Engelbert, K., & Coustasse, A. (2014). Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. Perspectives in health information management, 11(Spring), 1g.

Shearer, J., & Growing, L. (2004). Chapter 8, Section: “Amphetamine Dependence.” In A. Baker, L. Jenner, & N. Lee (Eds.), Models of intervention and care for psychostimulant users (2nd ed., Ser. Monograph Series No. 51, pp. 125–126). essay, Australian Government Department of Health and Ageing.

U.S. Food and Drug Administration. (2022, October 12). FDA drug shortages. FDA Drug Shortages. https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Amphetamine%2BAspartate%3B%2BAmphetamine%2BSulfate%3B%2BDextroamphetamine%2B
Saccharate%3B%2BDextroamphetamine%2BSulfate%2BTablets&st=c&tab=tabs-4&panels=0+WebMD.+%28n.d.%29.+Adderall+Withdrawal.+Retrieved+May+2%2C+2023%2C+from+https%3A%2F%2Fwww.webmd.com%2Fadd-adhd%2Fadderall-withdrawal