Today, Explained - The Adderall shortage

Episode Date: April 24, 2023

There is a nationwide shortage of medications to treat ADHD. One culprit: the DEA. Vox’s Dylan Scott explains. This episode was produced by Miles Bryan, edited by Matt Collette, fact-checked by Laura Bullard, engineered by Patrick Boyd and Michael Raphael, and hosted by Noel King. Transcript at vox.com/todayexplained Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

Adderall shortage update. I just had to leave work because I was so overstimulated. Couldn't tune out anything. I couldn't pay attention to anything. My anxiety is destroying me right now. Last October, the FDA sent out a press release titled, FDA Announces Shortage of Adderall, in which the FDA announced a shortage of Adderall, a medication that tens of millions of Americans use mainly to treat ADHD. This led to some worry, some panic. It's a fucking mess. So if anybody has any tips, because this is fucking insane.

Some hacks. It's not a good hack, but it's a hack. If you have to get shit done, nicotine gum. Don't do that. Many people, of course, wondered why there was a shortage of a medication that so many people need. Why don't the companies just make more of it and et cetera? We have some answers ahead on Today Explained. Get groceries delivered across the GTA from Real Canadian Superstore with PC Express. Shop online for super prices and super savings. Try it today and get up to $75 in PC Optimum Points. Visit

superstore.ca to get started. It's Today Explained. I'm Noelle King. What does the Adderall shortage look like if you're the one who needs the medication? My colleague Siona Petros posted a story on Instagram asking for people who knew they knew, and it turned out that her friend AJ was one of them. My name is AJ Musewe, and I am a historian. AJ is 34 years old. She lives in Seattle, and last fall she was diagnosed with ADHD, attention deficit hyperactivity disorder, and her therapist prescribed Adderall. Adderall was a lifesaver. I will definitely say

that one of the most difficult things that I was dealing with was having these intrusive thoughts and like around imposter syndrome or like, can I really do this? Or like, am I being a good child? Am I doing what I'm supposed to be doing? Like, you know, I'm in my thirties. Is this where I'm supposed to be? And then I start to spiral to the point that then I just don't do anything. And then it's like a self-fulfilling prophecy. And so before Adderall, all of those things could happen for days on end. And because I have high functioning depression and high functioning anxiety, I was very good at masking. And so nobody really knew, including my best friends, because I felt embarrassed about talking about it because I seemed like the friend who had it together. Then I got on Adderall and it's like, I could clearly see what my path is. I'd wake up,

brush my teeth, wash my face, take a shower and be like, oh, these are the tasks that I need to do today. And I'd literally just accomplish the tasks. And it like freaked me out like for a second. And I was like, holy crap. Like this is, is this how the other half lives? Like you just make a list and then you just like do the list. And like almost in order, like I do the list. It wasn't like, oh, I'll just like save this for Thursday. And then like Thursday comes and I just like don't do it

because I'm onto something else. And so like understanding and also having real experience about what the Adderall was able to assist me in accomplishing, not having access to it, almost feels worse than like before I even knew what it felt like to have it. At what point did you realize there was an Adderall shortage? Like, how did this hit you? About December is when I started noticing it being a little difficult to find. And to the point that I was talking to some of my friends and they were telling me to go to different parts of the city to say, oh, there's less young people in this area. So maybe it might be a little easier for you to like receive it or to find it. And then it started becoming like me

trying to stretch my pills, right? So instead of taking them every day, like taking them every other day, but then that wasn't working because then it wasn't as effective as I needed it to be. Then it's like, well, do I save them for like closer to a time when I have a big project coming up so that at least I can try and concentrate on that project. And then I went to Kenya and I couldn't bring it with me because we were flying through Dubai. And so it was considered a controlled substance. So then for a month, I just didn't have it, which was bad news bears for me. Then I got back and my therapist and I worked really hard to try and find Adderall just like literally anywhere. At one point, I drove almost an hour to a pharmacy that said that they had it.

And then by the time I got there, they didn't have it. And that adds the anxiety that I'm already feeling. And so it just makes it's almost like it adds to the spiraling that I was already doing and like intensifies it because I know what I'm missing out on. And I have projects to do that I want to work on, you know, things that I want to try and figure out what to do. But like, I get into this paralysis of like, I can't do it because I know I could do it better or more efficiently when I have medication rather than just like trying to do it. Okay, so how does a drug that a lot of people need and a lot of people will pay for and a lot of people are prescribed by licensed medical professionals just run out? Senior health correspondent Dylan Scott has been writing about this at Vox.com.

And Dylan tells us Adderall isn't the only drug that we're seeing shortages of. Antibiotics and cancer drugs have also seen shortages, mostly because of pandemic-related supply chain messiness. But I think what's interesting about the Adderall shortage is that, you know, usually drugs go on shortage because of a manufacturing problem. You know, there's some kind of glitch at the factory, or there's an ingredient that's in short supply, and like, that's the reason that not enough of this drug is being produced. And with Adderall, that's certainly part of the story. But there's another major factor, which has been a massive increase in demand for Adderall over the past decade or so.

And that is a reflection of the way that medical science has evolved in its understanding of ADHD. You know, people, I think, usually think of that as like, you know, little kids who are really hyper. This jitteriness, the constant motion is what neurologists call hyperkinetic behavior. Can't concentrate on anything and are running mad all over the house or all over school. For these children, just sitting still is an ordeal. All right, David. From a medical perspective, ADHD is basically the result of somebody not having enough dopamine,

which is a really important neurotransmitter in your brain. If you have enough of it, that's what helps to allow you to, you know, concentrate on something or keep yourself under control and control those impulses that you might have. But somebody with ADHD doesn't have enough of it. And that's, you know, what makes it difficult for them to concentrate or to control their impulses. It turns out that if dopamine levels are too low in particular circuits in the brain, that it leads to unnecessary firing of neurons in the brain that are unrelated to the task that one is trying to do and that is unrelated to the information that one is trying to focus on. And so what Adderall does is it's a stimulant that actually helps people to retain more dopamine that occurs naturally in their brain. And it also boosts the level of

dopamine artificially in their brain a little bit. And so by giving them that dopamine boost, it allows them to better control their impulses, better concentrate, and therefore relieves the symptoms that are most commonly associated with ADHD. Over time, we came to have a more medically sound understanding of what's happening with ADHD in terms of the dopamine deficit that patients are experiencing. And we also grew to appreciate the different ways that this condition can manifest, both, you know, in different genders and also across different ages. A study published in JAMA Open Network shows a 123% increase in ADHD in adults from 2007 to 2016. We've also come to understand that, like,

this doesn't just kind of dissipate over time. Like, this can persist, you know, through when somebody's a teenager and even into when they're an adult. It does tend to change form a little bit or become subtler. Like people do mature, even if they have ADHD, they maybe gain more control over their impulses, but like they still have that kind of underlying biological fact

of a dopamine deficit. They still struggle with inattention, maybe more than hyperactivity, but that's still there, the inattention, the lack of impulse control. That understanding and the research foundation for our understanding of ADHD has been building and building over time. And basically, doctors have just gotten a lot better at identifying it because they now know all of the diverse ways that it can manifest and the fact that it can persist with someone throughout their life.

And so naturally, if we're getting better at identifying it, identifying it more often, that's going to lead to more of the leading treatment for this condition, Adderall, being prescribed. And we've seen that, you know, over the last five years or so, the number of Adderall prescriptions in the United States has increased from about 32 million in 2017 to almost 42 million by 2021. So during the pandemic, we all got used to telehealth in which, you know, you get online with a doctor and it sometimes felt like getting a prescription was a bit easier. Did the rise of telehealth during the pandemic have anything to do with that big change in numbers? Yes. I don't think we know exactly how much the expansion of telehealth during COVID contributed,

because, you know, these trend lines were already heading in this direction before COVID ever showed up. But it is undeniable that, like, in recognition of the public health threat that COVID posed, the DEA and federal government said like, okay, we're going to make it easier for doctors to prescribe drugs, including Adderall, remotely through like a virtual visit or after consulting with somebody over the phone. And so that did unavoidably make it easier for people to get an Adderall prescription.

And it's likely that that is at least a factor contributing to this increase in demand that we've continue to see over the past few years. Last year, we did an episode on Cerebral, which is this telehealth startup that was maybe, maybe playing it a little fast and loose when it prescribed Adderall. The questions that people started asking were around the quality of the diagnoses that the company's nurse practitioners were providing. Like, how much can they actually know in 30 minutes? And were there cases where patients maybe don't have ADHD but are getting the meds anyway? Do we know if part of this increase is people who maybe don't have ADHD. Is anyone looking into that? So it's likely a factor. Sarah Morrison at Vox has done some great reporting

on some of the sketchy startups that have, yes, been maybe dispensing or issuing Adderall prescriptions when they're not necessarily warranted. I don't think we can say exactly how much that is contributing. Like I said, these trend lines were already heading up before the pandemic or the expansion of telemedicine ever happened, but it is likely a factor. And certainly it's something that the DEA is concerned about

because the federal government has, here in recent months, proposed like, actually, maybe we should roll some of this back. Maybe we should actually require somebody to consult with a doctor in person before they're prescribed Adderall. The Biden administration says patients who've started receiving prescriptions for controlled substances through telehealth during the pandemic could continue to do so for 180 days after the changes take effect. There's been this big increase in Adderall prescriptions. How much of the shortage is

because we just can't manufacture enough of it? We just can't make enough of it? Well, that is sort of the $64,000 question that nobody has a super satisfying answer for. So when a drug manufacturer is experiencing a shortage, they are required to tell the FDA, and usually they'll provide a reason why. But they don't have to be super detailed about why they're experiencing a shortage. And right now, there are at least five companies that produce Adderall or a generic version of Adderall that say they're experiencing a shortage. Those companies are citing both this increase in demand that we've been talking about, as well as a shortage of the active ingredient Adderall, which is an amphetamine, as the reasons for the shortage. So it seems to be a combination

of the two things. But what's unique here with Adderall is that this isn't like some supply chain disruption, some problem over in India and China that's preventing these companies from getting their hands on the raw materials that they need to produce Adderall. As I said,

Adderall, the active ingredient in it is an amphetamine, which is a controlled substance. Because this is a controlled substance, the DEA actually sets production limits on how much Adderall can be produced. And so what these companies are saying is, you know, we don't actually have enough of what we need to make Adderall. And that's the reason we're experiencing this shortage. But what's frustrating is we don't have access to the raw information here.

And the DEA, on the other hand, is saying that manufacturers aren't actually using enough of all the base materials for Adderall that they have been allotted. The DEA says most manufacturers have plenty of supply and have not fully hit their supply quota for three years. And so we don't know what production limits the DEA has actually set. And we don't know how much it's actually authorized for any of these individual companies. And so the real root cause of the shortage here is a bit of a black box that we, in the public, can't really open. Coming up, why would the DEA limit production on a drug that millions of people need? Dylan's going to come back.

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Please play responsibly. If you have any questions or concerns about your gambling or someone close to you, please contact Connex Ontario at 1-866-531-2600 to speak to an advisor free of charge. BetMGM operates pursuant to an operating agreement with iGaming Ontario. It's Today Explained. We're back with Vox's Dylan Scott. Dylan, you told us earlier in the show that the DEA has a quota on Adderall production. People are at the moment freaking out because they can't get their medication or their kids can't get their medication. Why doesn't the government raise the quota?

Well, you know, I think it's important to acknowledge that Adderall can be abused. There's the cliche of college students using it to study for an exam or finish up a project or what have you. Personally, in my social circle, it's literally everyone. Everyone. Every single person. You can go up to the second floor of the library

and see a full wing of people just cracked out. And we have data that several million Americans Americans based on what they report in like national surveys misuse Adderall or some kind of prescription stimulant every year. And, you know, a couple hundred thousand people have like misused it to the point that they have like a substance abuse disorder that's linked to stimulants. And so obviously like the DEA is a law enforcement agency. And a big part of their job is making sure that drugs don't get diverted from their legitimate uses and end up, you know, on the black market and being misused by people.

So that's why these production limits exist in the first place. And so what the DEA is supposed to do is, you know, evaluate how much of a legitimate medical need they think there is in the United States based on, you know, the levels of ADHD diagnoses. And they weigh that against the risks of diversion and abuse. And they come up with a number that admittedly, again, none of us really know that should be enough to meet the legitimate medical need without, you know, creating this huge surplus that could be diverted and abused. And all we really know for sure is that a couple of months after the FDA said that Adderall was experiencing a shortage,

the DEA put out a bulletin and said, we are not going to increase quotas, you know, in spite of a bunch of advocacy groups and physician groups saying that, like, we're experiencing a shortage. Can you please increase these quotas? And so it's sort of the implicit DEA position that, like, whatever is happening behind these shortages, we don't need to authorize the production of more Adderall because they are concerned about too much Adderall getting out into the world and people misusing it.

I mean, obviously, in this country, we have a huge problem with opioids and opioid addiction. Do you think the DEA is looking at what's happened over the last like 10, 20 years in the U.S. and saying to itself, we just have to be more conservative with stuff. We can only speculate from the outside. But a lot of smart people who followed this stuff, who followed the opioid epidemic and are now looking at this Adderall shortage, they do think that the legacy of the opioid crisis is kind of hanging over Adderall

and the DEA's stance on these production limits. You know, obviously, as you were saying, 20, 30 years ago, these opioids came on the market as legitimate drugs that were going to be able to relieve people's chronic pain. Once you've found the right doctor and have told him or her about your pain, don't be afraid to take what they give you.

Often, it will be an opioid medication. And sort of before anybody really got a handle on what was happening, you know, we had this proliferation of misuse. You eventually had people moving on to illegal drugs like heroin. Now we have fentanyl and Trank on the scene. It's a deadly, skin-rotting zombie drug that evil drug dealers are now mixing with fentanyl, with heroin, and with other drugs. The human costs of that mistake are obvious, I think, to anybody living in the U.S. right now. You know, we've got millions of people who misuse opioids regularly. We have tens of thousands of people dying from overdoses every year. And so you can understand why the DEA, looking at that

history, isn't necessarily eager to just turn on the faucet all the way and let as much Adderall production as is physically possible or possible from a manufacturing capacity standpoint go ahead when we know that this is a drug that can be misused. And we have that very recent history of falling behind in putting a check on the proliferation of opioids. And we're living with the consequences of that now. Overdose deaths topped 100,000 for the first time ever in 2021. And nearly 70% of those overdoses involve fentanyl. But I do think it's important to recognize that doctors who work with ADHD patients, they don't necessarily think that it's fair to compare Adderall to opioids.

You know, it is true that Adderall can be misused, but it does not incur the same kind of dependence that opioids do. It is not nearly as lethal, though it can be lethal, it is not nearly as lethal, though it can be lethal. It is not nearly as lethal as something like fentanyl. The folks that I have talked to, basically, they don't want the faucet opened all the way up necessarily, but they think it should be loosened. Like we should see, given the increase in diagnoses that we've seen over the last 10 to 20 years, and given that Adderall does not pose as much of a public health threat as opioids do, then we should be allowing more production because, you know, here we are six months into a shortage of a drug that millions of Americans rely on, you know, just to be able to get through their lives and function normally.

What are the odds of that happening? That the government loosens up a bit? I don't think they're particularly good. I think obviously right now the focus is on just trying to end this shortage as much as possible. At least some of the companies that are experiencing shortages right now say that they should be able to pick production back up here in the next few months. And so, you know, especially once the current shortage abates, that's going to decrease the pressure on the DEA or some other federal authority to try to increase production levels. There are ideas out there about how we might adjust our treatment of Adderall a little bit and try to at least distinguish it from opioids

and treat it a little more loosely, but that doesn't mean just having a free-for-all. For example, there was an op-ed in the New York Times a few weeks ago that proposed maybe the DEA shouldn't be in charge of overseeing Adderall production. Maybe that should be a job for the FDA. A doctor I talked to in the Cleveland area who treats ADHD patients, he made the point that, like, you know, Ohio, like all states, has a prescription drug monitoring program. They have to report information on both opioids and Adderall to that prescription drug monitoring database.

But for opioids, they have to check it like once a month, which makes sense because like the risk of misuse is really high if somebody becoming dependent is really high. And obviously the potential consequences in terms of somebody overdosing are really severe. For Adderall, they still check it, but it's only once a year. That shows is sort of a reflection of the relative risk that these two different drugs pose.

And so I think in general, that sort of distinction is what, you know, a lot of doctors, a lot of patient advocates would like to see the government make. I'm not really surprised that the government is being weird about it. I mean, the government was being weird about marijuana. And now, like, look at us, you know, once you start to see the benefits of, like, medical marijuana and all of the ways that it can assist people. So I'm not really surprised when it comes to that. On the flip side, a controlled substance that has the ability to be very, very dangerous when not regulated and has the potential to be abused, like that adds a layer to it, right? And I would

love in a perfect world for us to be able to find a solution in which those who need the medication have an easier way to access the medication while also creating programs that assist people who end up in situations where they are abusing the drug, right? Like there's ways for us to do both. We just need to kind of get out of our own way and do what's best for the people in these situations rather than like punishing everybody. A.J. Musewe is a historian in Seattle, and she would do anything for Siona. Dylan Scott is a senior health correspondent at Vox. Today's show was produced by Miles Bryan and edited by Matthew Collette. It was fact-checked by Laura Bullard and engineered by Patrick Boyd and Michael Rayfield. I'm Noelle King. It's Today Explained. Thank you.