A brief review of primary care resources and toolkits for the stimulant shortage

A brief review of primary care resources and toolkits for the stimulant shortage | Image Credit: © Diomedes de jesus - stock.adobe.com.

Drug shortages have historically led to economic impacts, affecting labor costs and the expenses of alternative medications, as well as clinical impacts, such as increased medication errors and therapy delays. In October 2022, the FDA announced a shortage of the immediate-release formulation of amphetamine mixed salts, commonly known by the brand name Adderall, which is used to treat attention-deficit/hyperactivity disorder (ADHD) and narcolepsy. Both the extended-release and immediate-release forms of methylphenidate have been in shortage since December 2022, and July 2023, respectively. Similarly, the extended-release and immediate-release forms of amphetamine have faced a shortage since August 2022, and July 2022, respectively.¹

Several factors have contributed to the current shortage of stimulant medications. Adderall has been in short supply due to manufacturing issues at Teva Pharmaceuticals USA, Inc, the drug’s largest producer.² Furthermore, a letter from the US Drug Enforcement Administration (DEA) in November 2023 highlighted that manufacturers did not use their allotted quota amounts, which contributed to the lack of availability of stimulant medications.³ The initial shortage of generic Adderall prompted patients and providers to seek alternative medications, such as the generic and brand-name forms of methylphenidate, including Concerta, Ritalin, and Vyvanse. As a result, these alternatives have also become scarce. Max Wiznitzer, MD, a professor of pediatric neurology at Case Western Reserve University in Cleveland, Ohio, shared his experiences with Neurology Today in 2023 on frequently modifying prescriptions and receiving calls from patients unable to obtain their prescriptions at local pharmacies.⁴ Similarly, Jeffrey Steinberg, MD, a neurologist in Plantation, Florida, who treats many adult ADHD and narcolepsy patients, emphasized in that same article the urgency of the shortage, noting that switching medications is complicated because it carries risks of reduced treatment efficacy and often leads to insurance complications.⁴ Consequently, many patients have experienced disruptions in their quality of life, work performance, and relationships while trying to navigate these obstacles.⁴

The extended stimulant shortage has been further compounded by several factors, including the rise in stimulant prescribing due to improved telehealth access, temporary suspensions of the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (Ryan Haight Act), and the psychoeducational impact of the COVID-19 pandemic on patients.⁵ According to the DEA-commissioned report on stimulant prescription trends, the number of stimulant prescriptions dispensed increased by 60% from 2012 to 2023—from 50.4 million to 80.8 million.⁶ Since the onset of the COVID-19 pandemic, telemedicine has significantly increased, especially in specialties with chronic diseases such as psychiatry.⁷ In 2008, the US Department of Health and Human Services (HHS) implemented the Ryan Haight Act to regulate telehealth medication prescriptions.⁸ However, this act was temporarily suspended in January 2020 during the COVID-19 pandemic so that providers could prescribe DEA-controlled substances without requiring in-person patient exams.⁹ This suspension led to an increase in psychostimulant prescribing and a higher demand for Adderall, further contributing to the stimulant shortage.⁹ Recently, the DEA and the HHS extended these telemedicine flexibilities through December 31, 2025, to work on final telemedicine regulations.¹⁰

Another possible contributing factor to the rise in demand for stimulants is the increased recognition of ADHD symptoms during the COVID-19 pandemic, particularly among high-income families. The monthly stimulant dispensing rate increased by 11.8 per 100,000 individuals (95% CI, 10.0-13.6) after April 2020, with a higher rate of 15.5 per 100,000 individuals among children and youth living in the highest-income neighborhoods and a lower rate of 9.3 per 100,000 individuals living in the lowest-income neighborhoods. With increased parental recognition of student challenges in distance-learning environments at home, it is possible that families with higher incomes had more resources for virtual appointments, highlighting the importance of health equity in medically underserved communities.¹¹

Elevated demand for stimulants has also been affected by controversial clinical models. On June 13, 2024, the US Department of Justice announced that it had charged 2 individuals with health care fraud for facilitating access to Adderall and other stimulants with unclear justification.¹² Ruthia He, founder and CEO of Done Global Inc, and David Brody, clinical president of Done Health PC, allegedly utilized telemedicine to target and profit from patients with substance use disorders.¹² This redirection of the limited Adderall supply exacerbated the shortage and disrupted access to prescription stimulant medications.¹² A press release from the DEA noted another case in which Truepill, a retail pharmacy for telehealth companies such as Cerebral, unlawfully filled stimulant prescriptions.¹³

Despite the FDA’s announcement of the ADHD medication shortage in 2022, neither the FDA nor the DEA has provided a clear explanation or taken broader action. This shortage points to a larger issue within national drug prescription policy and medication supply control. The FDA and DEA are, however, collaborating with manufacturers, professional groups, and health care providers to develop a team-based solution. Their efforts aim to resolve the situation by redistributing allotments and supporting appropriate diagnosis and treatment of ADHD.¹⁴

Notably, there have been numerous reports of stimulant shortages internationally as well. For example, some companies, including Teva Canada, have reported shortages of extended-release amphetamine and extended-release methylphenidate due to “disruption of the manufacture of the drug.” These shortages each lasted for a few months at a time, which is considerably shorter than the shortage in the United States.¹⁵ In addition, the European Medicines Agency is experiencing an ongoing shortage of ADHD medicines such as atomoxetine, methylphenidate, and lisdexamfetamine due to manufacturing issues and an unexpected increase in demand for medicines used to treat ADHD.¹⁶ In Australia, there have been methylphenidate shortages since 2024 due to manufacturing issues.¹⁷ We attempted to search international literature relevant to this topic, but no other regions in the world were identified as affected.

This article aims to provide a commentary on the resources available in light of the stimulant shortage, with the purpose of efficiently providing a thorough tool kit of resources to providers.

Methods

We conducted a literature search in the PubMed database for articles related to the recent and ongoing shortage of amphetamine and methylphenidate. We used key phrases like stimulant shortage and FDA, DEA; methylphenidate availability; amphetamine availability; Ryan Haight Act; and prescription regulations. We also manually looked through the reference lists of relevant articles, and we selected the final articles based on the relevance of the abstracts and the credibility of the researchers. We recommend that a systematic review be conducted to determine the exact cause of the shortage.

The FDA Drug Shortages list¹ was last checked on March 27, 2025.

Summary of available resources

First-choice medications for ADHD treatment are methylphenidates for children and adolescents and amphetamines for adults. These 2 classes consist of numerous stimulant formulations and treatments, with several tools available to help choose a plan. Psychiatric Times™ published a dosing guide that explains and accounts for the factors of isomer formulation and duration of action,¹⁸ and the website www.adhdmedcalc.com simplifies the conversion of ADHD medications and provides information on starting and increasing dosages.¹⁹

The Nationwide Children’s Hospital and Partners For Kids developed a nuanced document with evidence-based clinical guidelines and expert opinions to help primary care practitioners and behavioral health providers treat children with ADHD.²⁰ This document covers screening, pharmacogenomic testing, preferred stimulants, and patient-centered considerations as well as providing a step-by-step guide on prescribing long-acting stimulant medications.²⁰ The American Association of Psychiatric Pharmacists’ Pharmacist Toolkit includes details on stimulant dose conversions and differences between stimulant classes.²¹ Additionally, an article previously published in Contemporary Pediatrics guides providers on available medications and approved treatment options amidst the stimulant shortage.²² Although the reporting of stimulant shortages may vary by source, the official FDA Drug Shortages website indicates that lisdexamfetamine remains in shortage.¹

The American Academy of Child and Adolescent Psychiatry (AACAP) also developed a practice parameter that outlines what to do and expect in various situations when treating children and adolescents with ADHD.²³ Considering the diverse factors and characteristics of patient conditions allows providers to make informed clinical decisions.

These resources are summarized in the Table.

Table

Nonstimulant medication considerations

Nonstimulant medications such as atomoxetine and viloxazine are second-line options for treating ADHD. The recent stimulant supply shortages in the US have not severely affected supplies of these nonstimulant medications. As a result, it is worth considering maximizing the dosage of generic atomoxetine up to 100 mg daily before considering augmentation with an available immediate-release stimulant (as outlined next).

Combination nonstimulant-stimulant medication considerations

Although not as frequently used as monotherapy, using a combination of more consistently available atomoxetine plus available immediate-release stimulants (eg, methylphenidate) to augment ADHD treatment can be an alternative to the unstable extended-release stimulant supply at local retail pharmacies.²⁴ The Figure shows a decision tree that incorporates alternative ADHD treatments.

Figure

Additional considerations

ADHD is a developmental disorder that manifests in childhood. Diagnosing adults is often more difficult because providers typically need to talk with patients’ families and teachers to determine whether prevalent signs of ADHD were present in early childhood. This complicates adult ADHD medication guidelines. Furthermore, ADHD is often comorbid with other psychiatric disorders such as oppositional defiant disorder, conduct disorder, substance abuse disorders, and anxiety, making diagnosis and medication management complex. The similarities between ADHD, generalized anxiety, posttraumatic stress disorder, and bipolar disorder further complicate diagnoses, necessitating careful differential diagnosis before prescribing any intervention. For example, prescribing stimulants for ADHD to patients with bipolar disorder can increase the severity and length of manic episodes. The parameter published by the AACAP provides additional detail on ADHD comorbidities.²³

Conclusion

This article compiled various resources from national organizations and websites that should be considered when diagnosing and treating patients with ADHD. Providers can decide how to best respond to short- and long-term stimulant shortages using the decision tree (Figure) and available resources (Table).

Although it is difficult to predict the effects of any policy changes with certainty, this situation should be closely monitored through collaboration between government regulators and representatives from organized medicine, industry, and patient advocacy groups. The AACAP and American Psychological Association released a joint letter to the DEA urging action on the ongoing stimulant shortage through collaborative efforts.²⁵ They encouraged medical providers and pharmacists to engage in discussions with government regulators to ensure safe accessibility to these medicationsas well as the establishment of effective partnerships between private and public entities (eg, DEA and FDA) to address current stimulant shortages and to prevent future ones from occurring.²⁵

Acknowledgments

We would like to thank Bernice Eads, a writing consultant at Case Western Reserve University Writing Resource Center, for reviewing the flow and structure of this paper.

References

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