LA GRANDE — Months after the U.S. government announced a shortage of the main drug used to treat ADHD, local pharmacists, providers and patients still are struggling to fill generic Adderall prescriptions.
Local pharmacies send lists of what’s in stock to providers at Grande Ronde Hospital every day, helping individuals find what they’re looking for — or reasonable alternatives — during the ongoing shortage.
However, the process is time-intensive, frustrating and, sometimes, unfruitful, leading Eastern Oregon pharmacists to ask lawmakers for help, and causing more families to consider putting their children with attention-deficit/hyperactivity disorder on a “drug holiday.”
The government first announced the shortage of the immediate release formulation of amphetamine mixed salts — commonly referred to by the brand name Adderall or Adderall IR, taken two to three times a day — in October 2022.
Although pharmacies and providers have tried to adjust to the ongoing crisis with daily communication, they say the system isn’t perfect and worry about the future.
“That would be a nightmare, if the problem doesn’t resolve itself soon,” said Red Cross Drug Store Pharmacist Darcy Blackman.
Blackman said a designated staff member checks their two manufacturers’ stock “at least twice a day” for available generic Adderall, celebrating when they’re able to place an order before it’s all sold out. She said the manufacturers allocate the drug to prevent one pharmacy from stockpiling it, and portion out what’s available based on the previous order volume from each location — in effect, in-store stock is limited for both immediate and long-release generic Adderall, as well as less-effective alternative medications.
“You’re basically getting (a prescription) order that you can’t fulfill, and then reaching out to the patient to find out if they would like us to try to change it to something else, and then reaching out to the doctor to get them to change it to something else,” Blackman said. “If (doctors) can’t turn it around and get it back to us in time, then by the time they do, we might be out of whatever we changed it to. … It’s so time-consuming.”
Ann Murray, co-owner along with her husband, John, of Murray’s Drug, with stores in Condon, Boardman and Heppner, said that it’s primarily generics that are in short supply.
"The brand name Adderall has been easier to get, but it’s way expensive,” she said.
Murray has noticed that it’s more difficult to order long-release generic Adderall that’s taken once a day than its immediate release counterpart, which is taken two-to-three times daily.
Blackman said it can be difficult to adjust to taking immediate release Adderall because patients go through more ups and downs throughout the day.
“It’s tough just because they’re not going to get as steady of a blood level,” she said.
Doctors may order Concerta, instead, for those unable to fill any type of Adderall prescription, but this comes with its own problems in that they’re not the same drug.
“Adderall is dextroamphetamine salts and Concerta is methylphenidate, which is Ritalin,” Murray said.
Even so, Ritalin can also be used to treat ADHD. But, since more people have turned to Concerta over the course of the Adderall shortage, high demand has caused a shortage for this drug, too.
Local adjustments
Every morning, Grande Ronde Hospital and Clinics Pharmacist Thomas Maslo said in July, contacts local pharmacies to get a pulse on what’s readily in stock, which is then sent out to GRH providers.
“We have an idea of where we can send prescriptions so that they get filled, and we notify the patient if it’s different from their normal pharmacy,” GRH family doctor Brooke Davis said.
Davis said sometimes providers can write multiple prescriptions for different doses so that the patient gets exactly what they need.
“For example, say, the person is on a 30 milligram dose, and they don’t have the 30 milligram tablets, you can get them a 20 and a 10 or two 15s,” Davis said.
Blackman said that although she appreciates GRH reaching out to local pharmacies each morning, the list of available stock at Red Cross Drug Store becomes “old data” fast — just hours after they inform providers of what medications they have, they may already be out.
“The best is when the provider is writing the order and they actually just contact us and say, ‘What should I write for?’” Blackman said. “It saves so many calls. But I understand from their perspective it’s hard, because it might take four or five minutes for them to actually be able to get through on the phone and talk to somebody, which is a lot of time.”
Maslo said Grande Ronde Hospital and Clinics combined write around 1,500 stimulant prescriptions — which include Adderall and Ritalin — every three months, and that this group of medications accounts for 10% of the total prescriptions GRH providers write.
Blackman said that she’s able to order three manufacturers’ stock bottles at a time when short or long release Adderall is available. Each manufacturer bottle comes with 100 pills.
Short release Adderall, which is easier to come by, is usually taken twice a day. However, the three manufactures’ bottles worth of short release pills that Blackman can order at a time will fill only five prescriptions that last a month.
For long release Adderall taken once a day, every three manufacturers’ bottles fills 10 prescriptions that last a month.
Maslo and Davis said the effort to streamline the process of getting patients their prescriptions is proving effective. But, the issue remains, and they are still contacted on a daily basis by individuals struggling to find or pay for medication.
“Pharmacy inventory is always challenging,” Maslo said. “Different pharmacies have different suppliers, so it changes who has it in stock. The second big challenge is the insurance.”
Insurance woes
Even if generic Adderall is in stock, the insurance copay might be too steep for many patients. “(Customers) might have been paying a $5 copay on generic and suddenly it’s $200, and they can’t afford it for that month,” Murray said.
Maslo calls insurance struggles a “hidden obstacle,” because, generally, pharmacies won’t know what insurance restrictions there are on the provider side of things.
“We sometimes don’t know either, until we send it and we get a message back from the insurance company,” Maslo said. “So for us, it’s just navigating the pharmacy inventory, and also the patient’s insurance to try to give them what they need.”
‘Drug holiday’ According to the Child Mind Institute, some parents of children who take Adderall or Ritalin to treat ADHD opt to put their kids on a “drug holiday” during the summer, since they don’t need to perform academically during this time.
Maslo advises easing off medication slowly.
“Less is more. If they could be on a drug holiday, and it doesn’t really affect their daily life too much, then I think that’s kind of a win,” Maslo said. “Probably what to tell the parents is, if you’re going to do that, don’t stop all in one day, because that’s when you will get withdrawal effects.”
The "drug holiday" idea is controversial and has less than unanimous support in the medical community - especially when done without the active participation of a doctor.
Davis said what she hears most from parents of children who have reacted negatively is the return of their symptoms — most often, it’s hyperactivity or inattentiveness.
Looking forward Murray, along with other pharmacists in Eastern Oregon, reached out to U.S. Sen. Ron Wyden’s Field Representative Kathleen Cathey, seeking support from his office.
In particular, pharmacists are concerned after allegedly hearing from manufacturers that the U.S. Drug Enforcement Agency quotas have stifled their production of Adderall.
The DEA categorizes Adderall as a Schedule II controlled substance, a group of substances that have “a high potential for abuse,” according to the DEA’s Drugs of Abuse 2020 resource guide. Such medicine are also effective in the treatment of medical conditions and are not illegal, but highly regulated.
Murray said that since Adderall is a Schedule II drug, there are many more restrictions on ordering or how the prescriber can get it to a patient.
For example, some doctors will write out the prescription only on paper. Recently, she’s had someone come into the Murray’s Drug in Heppner after driving for over an hour from Pendleton, because their doctor wasn’t able to send the prescription electronically.
As the Adderall shortage continues to frustrate patients and pharmacists, discussion of what has been driving it — a raw material shortage, DEA quotas or a mixture of both — has been discussed throughout the community.
“There may be some raw material shortages, but I don’t know why the brand name has been made and the generics aren’t,” Murray said. Maslo pointed to increased demand spurred by the COVID-19 pandemic and the supposed raw materials shortage.
Wyden met with Commissioner of Food and Drugs Robert Califf and the administrator of the DEA Anne Milgram on April 18 to discuss the shortage.
“Following our meeting, I anticipated robust and timely follow-up. That has not happened, and I am deeply disappointed on behalf of the Oregonians I represent,” Wyden wrote in a June 2 letter to Milgram.
“Specifically, I expected that the DEA and FDA would clarify the role and management of drug manufacturing quotas, as well as the conflicting reports from agencies, manufacturers and pharmacies, to help the public better understand the causes of these generic drug shortages” Wyden wrote.
Hank Stern, Wyden’s press secretary, in mid-July said the Wyden office hadn’t yet heard a response from Califf or Milgram after the senator sent them similar letters in early June. Maslo and Davis ask for continued patience from community members.
“We share their frustrations,” Davis said. “It’s just as frustrating for us to be trying to get a patient medications and not being able to do so.”
