Over the past several months, a severe shortage of Adderall and similar medications has wreaked havoc on the lives of ADHD sufferers, children, and adults alike. There are many factors behind the rolling crisis, including manufacturing issues and increased drug demand. But Dr. David Goodman, director of the Adult Attention Deficit Disorder Center of Maryland, believes that one reason for the shortage’s persistence — or at least the sluggishness in addressing it — is the widespread public misapprehension of ADHD as a mild condition. I spoke with Goodman, who along with treating patients consults with several pharmaceutical companies on products in the ADHD arena, about the medicine shortage and its ramifications.
The FDA announced this shortage back in October, citing manufacturing delays. Now we’re in late March, and people who take the drug are still having a lot of trouble finding it. Do you have a good sense of why this is happening and why it’s persisting for so long?
The issues are severalfold, although nobody’s really going beyond the finger-pointing and getting to the bottom of this. The FDA recommends how much base compound gets made available to the pharmaceutical companies. The DEA then establishes an annual amount that they will permit, distributes it to the pharmaceuticals, and the pharmaceuticals then take that and generate their product. It became evident in October of ’22 that you had not only the DEA’s annual manufacturing threshold but also labor issues with manufacturing. Prescriptions go up in August because kids in grade school, middle school, college all go back. Generally, there’s a seasonality to this, and it was a perfect storm. And telehealth services that have been on the scene for the last year and a half have increased diagnosis and demand.
While we can explain what happened in the fall, the question now is, Why is it persisting? Why has manufacturing not caught up? Why has the problem actually gotten worse around the country, not better? Why are the delays for patients getting their medication longer now than they were three months ago? And those are the questions for which there aren’t very many answers and still a lot of finger-pointing.
There seems to be a lot of frustration about how authorities have communicated these issues to patients. Have you felt a certain lack of urgency?
I think there’s a certain lack of urgency in Congress to call for oversight investigations. There are only two members of Congress who have raised this issue with the DEA. My question is, Where’s the political will to try to get answers for the general public? My concern is that, given what we went through in the opioid crisis, people are gun shy about standing up and trying to support the prescriptions of yet another controlled drug. And yet this medicine is critical to those people with ADHD.
Do you think the muted response has to do with the image of Adderall in the public consciousness? It may be associated with, say, a college student taking it for an all-nighter and not thought of as a life-saving medication.
People who don’t experience ADHD, don’t have family members with it, don’t understand it, fail to realize that this is more than just an inattention problem. The negative consequences of untreated ADHD are increased risk of cigarette smoking, substance abuse, alcohol abuse, pregnancy, divorce, underachievement academically, criminal activity, impulsive risky behavior.
If you look at the emerging literature in the last five years, it’s very clear that treating ADHD reduces a lot of those risky negative consequences. So while everyone wants to yell and scream about the overprescription of stimulants, we don’t focus on the fact that these untreated people suffer terrible consequences in their life.
Yes, I don’t think that’s well understood.
Let me give you a historical perspective. In the ’50s and ’60s, schizophrenia was conceptualized as someone’s willful choice of an alternative psychological experience. People described the cause of schizophrenia as mothers who were cold, distant, not engaged. We don’t have those discussions anymore.
Then you get into the ’80s and ’90s and people are saying, “Depression’s a normal human experience. If you just pulled yourself up by your bootstraps, you wouldn’t have to be on these medications.” We don’t have those discussions anymore. Why? Because with the advance of science, we’ve come to prove that these psychiatric disorders are actually an outgrowth of brain abnormalities. We are now in the next iteration of that argument with ADHD. If you don’t really appreciate what ADHD is, you think it’s just a normal variation in cognition, and if you just worked harder and focused more, you’d be able to overcome it — you don’t need to be on these medicines. And you know what? Twenty years from now, this too will seem like a very archaic argument.
I think the other thing is that ADHD involves symptoms that everyone has to some degree, especially in a moment when everyone seems to have lost their attention span. So people extrapolate and say, “I experienced that too,” when they really haven’t.
That’s right on point. The general public doesn’t recognize the threshold beyond which the severity merits a psychiatric diagnosis.
There’s a long-standing concern, at least in some quarters, that too many kids are being prescribed these drugs. And now, as you mentioned, there’s the rise of telehealth medicine. Investigations have found that some telemedicine companies prescribe Adderall and other controlled substances pretty indiscriminately. Do you view overprescription as a widespread problem?
I think the widespread problem is the lack of education. So let’s just back up and think about who’s prescribing medication. The first thing to note is that adult ADHD is poorly covered in formal training programs. Whether you look at psychiatric residencies or nurse-practitioner residencies, the people in the mental-health field don’t receive very much formal training in their programs. So they then have to learn about this disorder out in the fields by seeing patients, talking to colleagues, and getting continued medical education. So you have a sector that may be poorly trained, which evaluates people inadequately.
The other element is telehealth. This is not to indict telehealth itself because it serves a lot of good in regards to access to care, but it is to indict the process by which they make a formal diagnosis. And the criticism has been that the way they’ve developed their process and policies, the comprehensive psychiatric evaluation that’s supposed to come to an accurate diagnosis is inadequate. So between those who are inadequately trained and well intended making inaccurate diagnoses and the increase of access at minimal cost to get a diagnosis, you’ve increased the demand. The question then becomes, Who legitimately should be prescribed and who is prescribed medication that ought not be on it? And that goes back to making an accurate diagnosis.
And presumably a lot of people getting these prescriptions via telehealth do actually need them.
I’ll just give you some numbers. The prevalence rate for ADHD in the U.S. for adults ages 18 to 44 is 4.4 percent. Of that 4.4 percent, 75 percent were never diagnosed as children, and only about 25 percent of those who presume to have ADHD are being treated. So you have a tremendously underserved population of people who have this disorder.
In the 1990s, Prozac came out and was then followed by Zoloft. These were very effective, easily prescribed medications. And if you go back and look at prescription practices between 1990 and ’95, the antidepressant market increased. Was that because too many people were getting antidepressants? No, it’s because there were a lot of people with major depressive disorders and anxiety disorders in the community, and they weren’t getting treated. And so now they had a comfortable medication that was effective, and it got prescribed. Be careful of interpreting increased prescriptions of medications as a bad thing. It may simply be that people with the disorder are now coming forward and getting treatment.
You said there had been increasing awareness of ADHD in the media. I also wondered to what extent the pandemic played a role in any of this.
I think it’s all of the above. The pandemic left people at home, and people who require structure with ADHD found themselves with no structure and saw their productivity level drop. Also parents were now spending more time with their children, and when they couldn’t get the children to sit still long enough to homeschool them, they became convinced by the teachers who had suggested that maybe they get an evaluation.
The other element is that people were online and they were researching. There were more and more articles on ADHD. You almost have to be asleep not to see at least some headline on ADHD in the media these days. So all of these things have come together. It’s a good thing that people who have not been identified are now getting treatment and relief. And it’s a bad thing when people are inaccurately diagnosed, and it’s a bad thing for this reason: If you give somebody — anybody — stimulant medication, they’re going to say their mood, their cognition, and their energy level is better. Does that mean they have ADHD? No, it means their brain chemistry was rearranged. And so the patient goes back to the physician and says, “Look, I’m so much better on this medicine, why don’t you keep writing it?” The physician scratches their head, wondering whether the patient really does have ADHD because their childhood and early adolescence didn’t seem to indicate any symptoms at all and the feedback from a collateral observer said, “No, we didn’t see any of these problems until he started complaining when he was 21 years old.”
How are your patients coping with this on average? Are they able to mostly get through with other medications?
In the fall, patients were saying it was an inconvenience — it could take two, three, four days to get the medicine. Now patients are saying it takes weeks to get medicine, and they have to call five, ten, 15 pharmacies before they can find one that has it in stock and will fill it. So the problem has just gotten worse. And given that ADHD individuals have low frustration tolerance, they just give up, and they’ll go without their medicine for weeks or even months, and they’ll get back in touch with me and we’ll see if we can find an alternative. But even finding alternatives now is a challenge.
And there’s another complication. If you’re seeking alternative medications to those which are in short supply, you have to do that within the formulary of the patient’s insurance. Well, those formularies are very restrictive. They’re so restrictive that you may not be able to come up with a substitute because there are so few alternatives.
So there’s no hopeful sign, no indication this is getting better.
Not a shred. I have patients in Florida who say you can’t get Adderall XR or Adderall in the state of Florida. It’s virtually impossible. And when it’s absent, it’s alarming. If we had a shortage of insulin like this, how fast do you think Congress and legislators would tolerate this for the general public?
This interview has been edited for length and clarity.