Adderall is in short supply, and the backlog is having a domino effect on other stimulants.
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
On October 12, 2022, FDA announced a shortage of instant release Adderall. Like a lot of companies, Teva pharmaceuticals, the main manufacturer of generic Adderall, had trouble hiring people. The Adderall shortage has had a cascading effect as patients switch to other meds to replace it. Many of us are now counseling patients over amphetamine withdrawal symptoms, which include mood swings, irritability, depression, headaches, jitteriness, intense fatigue and gastrointestinal distress.
Stimulant withdrawal is not fatal, but it can have a very fatal consequence in today’s world. Many street versions of Adderall are last with fentanyl, and that could lead to unexpected deaths if patients turn to non-prescribed sources to get the med. Not to mention the risks of automobile and other accidents with untreated ADHD.
Teva is still struggling with the manufacturer, and expects the shortage to continue at least until March 2023.
CHRIS AIKEN: Part of the reason for the shortage comes from an increase in demand. During the pandemic, online practices like Cerebral and Done took advantage of the relaxed prescribing laws to offer easy access to controlled substances. Clinicians at these practices blew the whistle to the Wall Street Journal, with tales of pressure from upper management to prescribe stimulants and benzos without a proper evaluation. The Department of Justice and the Drug Enforcement Agency have been investigating those companies, and last month they took a step that might limit access to controlled substances beyond this supply shortage.
On December 15, 2022, the DEA began investigating not just practices but also pharmacies like TruePill that filled those prescriptions. The DEA has had guidelines to alert pharmacists to suspicious prescribing for years, and pharmacists are starting to pay more attention to it. Some are refusing to fill controlled substances to avoid triggering an investigation. Here’s what the DEA says – they should watch out for patients on high doses of controls, who get early refills, get meds from multiple doctors, change pharmacies often, pay privately to avoid insurance scrutiny, or take multiple controlled substances.
KELLIE NEWSOME: We expect that last red flag will affect a lot of clinicians, based on a study from Rhode Island that arrived at some concerning statistics on this kind of polypharmacy.
The authors dug through the state’s controlled substance database, and found 142,000 residents who were prescribed a benzodiazepine in 2018. That’s 13% of the Rhode Island population - a bit higher than the national average of 8% - but then again Rhode Island came out #1 in a recent survey of states that had the highest rates of unhappiness and stress. But that’s not what raised our eyebrows.
Among those prescribed a benzo, 7% were also given a stimulant, which means that 1 in 115 people in Rhode Island were taking a stimulant and a benzo in 2018. The rates of co-prescription were double that when they looked at benzos with opioids.
And these were just 2018 numbers – we know stimulant prescriptions increased 16% during the pandemic. The most common benzo-stimulant combo is Adderall with Xanax, and these are the most rewarding drugs in their respective classes.
CHRIS AIKEN: Lax prescribing during COVID is just one reason we might see more regulation of stimulants. Another is a looming stimulant overdose crisis. The CDC has noticed an uptick in stimulant overdose deaths over the past 10 years, particularly in those taking stimulants and opioids. That rate has risen further since the pandemic, they estimate that stimulants are now involved in 1 in 4 overdose.
KELLIE NEWSOME: If the stimulant shortage forces you to change your patient to a new medication, check out Dr. Aiken’s two part webinar at the CarlatReport.com on how to choose a stimulant. Part II – on how to select a specific formulation – has the math on how to convert from one stimulant to another. Some conversions are exact, but for others we gave our best estimate based on animal and clinical studies. One fuzzy one is converting from Adderall to Vyvanse, you’ll usually need to double the Adderall dose to get a Vyvanse equivalent.
For more tips on how to manage dicey combinations of controlled substances, check out our November 2022 podcast on the benzo-opioid combo, and our print article on benzo-stimulant combos from our September 2022 issue.
Earn your CME for this episode through the link in the show notes, or subscribe to the print journal online and get $30 off with the promo code PODCAST. Keep up with the latest research with Dr. Aiken’s DailyPsych feed on LinkedIn and Twitter (handle @chrisaikenmd) where he posts a new research study every day. Today’s study is a small one, but a first of its kind: A head-to-head, randomized controlled trial comparing an SSRI against modafinil in major depression.