America is beginning—far too late and far too slowly—to get some kind of a grip on deaths and harms involving illicit fentanyl and other opioids. At the same time, meth-involved deaths and harms are increasing. To exacerbate this, people who are prescribed controlled substances used to treat attention deficit and hyperactivity disorders (ADD/ADHD) are facing a crippling shortage of medication—and at least some are being driven to turn to riskier street drugs to fill the void.
Meth and closely related chemicals have many medical uses. Amphetamine salts, best known by the brand name Adderall, are used to treat mild-to-severe ADD or ADHD, as well as chronic fatigue and symptoms of Parkinson’s disease in some cases. Much of its popularity is also as an off-label “study enhancer,” used by many college students and young professionals to work longer hours.
When taken as prescribed, Adderall has a stabilizing effect on people with ADD that helps them focus and “avoid getting distracted by shiny objects”—as one friend used to describe my own tendency to move quickly from task to task, usually getting none of them done. I’ve taken Adderall for my ADD on-and-off for three years and have found it effective in small doses, with diminishing returns as dosages increase.
But for the past several months patients across the US who are prescribed the medication have found that filling their script has become an uphill battle. This is thanks to an industry-wide production shortage that has left most major pharmacies on backorder for the drug.
The shortage coincides with a sharp increase in the availability of street methamphetamine.
The Food And Drug Administration added the medication to its shortages list in September. And on November 25, ASPH, a pharmacy advocacy group, identified 13 different product strengths from three manufacturers as being in “backlog” status. According to ASPH a total of six companies have been making the drug. Of these, Mylan says it is on backorder until January. Sun Pharma has discontinued making the drug at all. And a third company, Aurobindo, refused to provide any information about the shortage of its drug or if/when it will return to the market.
The current shortage coincides with a sharp increase in the availability of street methamphetamine—an illicit stimulant that is extremely similar to Adderall but is ingested in unknown dosages and in riskier ways, and made in unregulated labs with unknown contaminants.
On the Ground in Philly
In Philadelphia where I live, diverted Adderall currently sells for $0.50 a milligram on the streets, which would scale up to $500 a gram. Meanwhile meth retails for as little as $40 a gram and the drug is sold in increments as low as $5.
He said he had never previously bought meth on the street in his life.
At one pharmacy, Filter spoke with a person, who requested anonymity, who had already begun replacing his Adderall with illicit methamphetamine. He said he had never previously bought meth on the street in his life.
“I’ve been trying to fill this for weeks,” he said, holding a paper script that had been folded and unfolded so many times it looked like it might disintegrate.
“Honestly, the meth I buy isn’t as ‘speedy’ as Adderall. From a purely therapeutic perspective, I would say it actually works better.”
To gauge the impact of the shortage Filter visited nearly 20 different pharmacies, including Rite Aid, Walgreens, and every CVS outlet in or immediately around Philadelphia’s city center. Every single one was on backorder. While several stores said they would be restocked within a week, in every case the resupply did not occur.
Pharmacists have little more insight into the workings of medicinal drug distribution than the customers they serve. “They tell us it’s coming and then the box arrives and there’s nothing there,” said one pharmacist, who had been fielding questions from frustrated patients all week.
Why the Shortage?
Adderall and its generic variants are Schedule II drugs and have production quotas set by the Drug Enforcement Administration. This is not the first time the ADD/ADHD community has struggled through a shortage of medicine. In 2012 a similar backlog causing widespread concern among patient advocates and doctors.
“I am very concerned about the future,” Ruth Hughes, chief executive of Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), told Reuters that year. “No one seems to have much inventory to get us through the months ahead.”
The reasons behind the present shortage, while complex and not made transparently clear, undoubtedly include stigma surrounding the drug and publicity around off-label use. Other reasons include increased demand for the drugs as more people like myself get diagnosed with ADD/ADHD later in life. There have also been reports of shortages of certain precursor chemicals.
Earlier this decade, as opioid-involved deaths continued to soar and law enforcement began targeting doctors, the DEA increased quotas for amphetamine salts significantly, from 17,000 kilograms in 2009 to 50,000 in 2016. Since then, the agency has pulled back.
The overdose crisis has spawned a regressive mindset about all mood-altering substances—including those provided legally.
But DEA quotas may not be the main problem. The overdose crisis has spawned a regressive mindset about all mood-altering substances—including those provided legally by a doctor. I regularly hear people in this field warn about the dangers of benzodiazepines—which, if taken as prescribed and not combined with other drugs, are pretty much limited to the possibility of dependency—without paying any attention to the quality of life of people who suffer from anxiety.
In my interactions with pharmacists, I’ve sometimes caught them inventing red flags on Pennsylvania’s Prescription Drugs Monitoring Program. Similarly, I still don’t know a single Suboxone patient who gets the five refills they are permitted under Schedule III guidelines. Again, their doctors often lay the blame on someone else, like the federal government’s supposed policy that Suboxone patients be drug tested once a month (the policy doesn’t exist; even in methadone clinics, only eight tests a year are required).
Our drug policies and the surrounding political rhetoric and media noise have trapped medical professionals in a constant state of fear, because no one knows whose door will get kicked in next.