DEA, Let Them Have Adderall!

I specialize in treating addiction and other psychiatric conditions. A clear connection has been established in the literature between addictive disorders and attention deficit disorders. The exact reason for the association can’t be proven, but I see a process where students who do poorly in school become labeled a certain way, both internally and externally, that eventually promotes greater use of illicit substances.

Whether that’s the process or not the association is clear. And it is clear to me that appropriate treatment of ADD can foster incredible functional improvement in patients treated for opioid use disorder. Some doctors have an attitude that ‘addictive stimulants’ shouldn’t be used in someone with a history of addiction. But I see my patients do very well when their ADD is treated, and I rarely run into problems with the overuse of stimulants that I prescribe.

But there has been a severe shortage of stimulant medication for the past few months, and that shortage isn’t expected to end soon. When I read about expectations for the shortage to continue I had to wonder, how can there be a shortage of a medication that any amateur chemist can manufacture in a bathtub?

Methamphetamine, a scourge across the midwest of our country, is one carbon atom away from the amphetamine that makes up Adderall and other stimulants. The only way there could be a shortage would be if some bureaucracy is making a mistake. And the mistake is buried in the linked article which mentions that the DEA limits amphetamine precursors used by pharmaceutical manufacturers to make amphetamine.

The article deflects blame by noting a 15% increase in stimulant usage following the pandemic, but the shortage has been far greater than such a mistake could create. Amphetamine usage increased by 7% the year before and increases most years due to a growing population and knowledge that ADD is grossly undertreated. DEA, let them have Adderall!

I spend over an hour each morning moving prescriptions from one pharmacy to another, only to find that the new pharmacy has also just run out of medication. Patients spend hours calling pharmacies and racing to them to get medication before it can be released to someone else.

The amphetamine shortage announced by the FDA in October has spread to many related medications as doctors and patients were left scrambling. Now many pharmacies cannot fill prescriptions for methylphenidate-based medications (Concerta, Ritalin, etc) or Vyvanse. Patients generally taper when stopping stimulant medications, but now are forced to suddenly discontinue prescriptions at refill time. That creates discontinuation symptoms or withdrawal that creates fatigue and depression, sometimes severe enough, when combined with loss of function, to cost a good job.

Stimulants can certainly be abused. Many people probably read that the FTX crew routinely relied on the activation provided by stimulants to improve focus and work long hours. But after 15 years as a psychiatrist, I have come to believe that ADD truly exists. I see it less as an illness and more as a difference in frontal lobe function between individuals, a difference that mattered less in an earlier era when digital devices were not around. Thousands of years ago it was likely helpful to have people who reacted to snapping branches near areas where others were focused on work. In today’s world, shipping clerks and farmers use computerized data to direct deliveries or fertilizer applications.

Trying to reduce diversion by limiting a useful medication is a backward-looking strategy. Ironically our government is making minimal effort to slow the flood of the largest killer entering our country, fentanyl. While limiting Adderall precursors to our pharmaceutical manufacturers, why not spend some time limiting the flow of fentanyl precursors to the US from China? China sends those products to the US because shipping to LA is more reliable than shipping to anywhere in Mexico… and the fentanyl precursors are driven to Mexico and transported back into the US, mostly by people crossing the border illegally. This flow isn’t ‘right wing’; it has been established by our own DEA! We just decide to ignore it. What’s 100,000 overdose deaths, anyway?

There is much more to the story… less Adderall at pharmacies pushes some people to purchase illicit tablets which contain or consist of fentanyl. Some people probably turn to methamphetamine, although thankfully I have not seen that in my patients so far.

If the DEA has a problem with the number of ADD prescriptions, they should make their case and argue with the studies showing undertreatment in adults and children. Blocking the production of prescribed medication creates nothing but chaos.