I have a solo outpatient private practice focusing on psychiatric medication management and brief therapy for adults. Early on, I decided to accept insurance to help address the shortage of psychiatrists in this country. Because of the advances in telemedicine since the pandemic, I can see patients throughout the state where I am licensed. This should be the happiest time in my career. After several years of working as an employee for several hospitals, I can now practice medicine on my own terms. Given the abundance of out-of-network psychiatrists in my area, patients are often grateful to be seen despite the wait for an initial appointment.
However, one situation has been stressful for my patients and me: the current nationwide stimulant shortage.
Stimulants, such as Adderall, Ritalin, and Concerta, are first-line treatments for ADHD. Often considered a childhood condition, ADHD can persist into adulthood, especially with inattentive symptoms. Although not found in the DSM-5-TR criteria for ADHD, studies have shown that those with ADHD have a higher rate of debt.
Additionally, stimulants can be used to treat depression and narcolepsy.
Due to their risk of misuse, stimulants are classified as Schedule II controlled substances by the DEA. Before the declaration of a public health emergency due to COVID in January 2020, a federal law called the Ryan Haight Act mandated that an in-person medical evaluation be conducted before a controlled substance can be prescribed. However, with the public health emergency, the Ryan Haight Act has been waived, and the public health emergency was recently renewed for another 90 days on January 11, 2023.
On October 12, 2022, the FDA announced the nationwide shortage of Adderall. As psychiatrists were substituting other stimulants for Adderall, shortages of other stimulants soon followed, including Ritalin.
There are several reasons for the stimulant shortage. One, Teva, one of the largest manufacturers of Adderall, was experiencing production delays due to a worker shortage in October 2022. Additionally, the DEA imposes an annual maximum production of stimulants to avoid misuse. Lastly, there has been an increase in demand for stimulants, especially with the waiver of the Ryan Haight Act during the public health emergency and the subsequent ability to prescribe stimulants during telemedicine visits.
Sadly, the stimulant shortage is expected to last well into 2023.
How is the stimulant shortage affecting the patients in my practice? Some patients have resorted to taking their medications only on the weekdays, when they need them the most for work or school. Others call their pharmacy and are put on hold for as long as an hour, only to be told that information about stimulant supplies cannot be provided over the phone. A few have had success visiting several pharmacies in person. A couple of determined patients have traveled three hours to fill their prescriptions.
As an adult psychiatrist, I treat ADHD less frequently than my child and adolescent psychiatrist colleagues. As a result, I am less familiar with the newer, brand-name stimulants on the market. However, with the shortage, I find myself using these exact brand-name stimulants with the guidance of colleagues as well as reviewing continuing medical education material that address conversions of different stimulants. With this, I am spending more administrative time completing prior authorizations and obtaining manufacturer coupons from pharmaceutical companies. Once, I spent 90 minutes in a peer-to-peer review with an insurance company.
In the media, the opioid crisis has been at the forefront. However, I believe there is also a stimulant crisis occurring right now. There is a feeling of helplessness when I cannot provide the medications I prescribe for my patients. Although I am frustrated, it probably does not compare to how my patients are feeling. That said, the stimulant shortage has only added to the moral injury of psychiatrists throughout the country.
Christine Tran-Boynes is a psychiatrist.