Helping Patients Navigate the Stimulant Shortage and Other Challenges in Adult ADHD

Unprecedented demand, supply shortages, and production delays have resulted in an ongoing shortage of stimulant medications to treat adult attention-deficit/hyperactivity disorder (ADHD), placing both patients and providers in a frustrating situation.

Psych Congress Network sat down with Lenard A. Adler, MD, director of the Adult ADHD Program at NYU Langone Health, on site at the 2024 APA Annual Meeting to discuss the causes of the stimulant shortage and what strategies mental health clinicians have at their disposal to help patients navigate this barrier to care. Dr Adler also details some non-pharmacological approaches that can augment psychopharmacological treatment and help patients navigate daily life more smoothly.

Missed Part 1 of this interview? Find it here.

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Psych Congress Network: You mentioned the recent psychostimulant shortage and its impact on patients and providers. Can you elaborate on the implications of this shortage for clinical practice and share any insights or strategies for managing medication shortages while ensuring continuity of care for patients with ADHD?

Lenard A. Adler, MD: The impact of the stimulant shortage has been significant for patients, and it also has impacted providers but as I tell my patients it's my job to write the prescriptions and to rewrite them as many times until you get your medication.

But once a shortage is created in one area, it's sort of like when people are traveling on the highway and Google Maps picks up that there's an accident and diverts everyone else to another area, but then a backup is created on the second route that they've diverted them to because everyone's using Google Maps. So, the same thing happens with stimulant shortages.

Initial shortages were noted and for multifactorial reasons—in part because of the increased demand reasons that we've discussed but also because of supply shortages and production delays. Some of the companies in generic oral methylphenidate (Concerta) and also when lisdexamfetamine (Vyvanse) went generic there was a big conversion of people that were on branded Vyvanse by their pharmacy benefits manager who then switched them over to the generic—that created a shortage. There were also production shortages in some other amphetamine products.

So, all of this put together created quite a stew of different patients finding shortages in the medications they were on. The implications are that patients who are on certain medicines were unable to get their medications or had difficulty. The problem as a prescriber is, prescribers are unaware when they write a prescription to a pharmacy if the pharmacy has that medication or not, and there's no way they can know. The only way is to write the prescription, see if it's there, and if it's not there, cancel it and write another prescription.

Psych Congress Network: In your discussion of non-pharmacologic treatments for ADHD, could you highlight some evidence-based interventions that clinicians can integrate into their treatment plans? How do these non-pharmacologic approaches complement or potentially augment psychopharmacological treatments for ADHD?

Dr Adler: For all patients who have adult ADHD, using environmental modifications can be critical regardless of whether they're on pharmacologic treatment or not.

That means doing things like using their phones for reminders, reminders for taking their medication. Alarms can really ne quite helpful. They can use their phone as a scheduler. They can set up alarms for putting appointments in their calendars. Using techniques of doing things once rather than when something comes in, setting up a reminder—automatic bill pay is a tremendous advantage for my patients with adult ADHD. They can set that up so they don't have to wait to be reminded, or they could pick a day on which they pay all their bills. Trying to work in a relatively distraction-free environment can also be helpful. You just have to encourage them to find what works for them. Sometimes people like having some more, like having some music playing in the background that's not actually distracting more, or some white noise—whatever it may be, whatever works for them in terms of increasing their productivity, but those sorts of things can actually be quite helpful for any adult with ADHD.

In terms of more evidence-based therapies, cognitive behavioral therapies, either individually or group-wise have been shown to be quite helpful, either as augmentation strategies or as primary therapies. But for adults with ADHD, more often than not, they live with their symptoms throughout their lives and as compared to kids, medications tend to play a bit more of a primary role.

Psych Congress Network: Do you have any final thoughts you'd like to leave our audience with on the topic of Adult ADHD?

Dr Adler: Well, there a couple things I'd like to share.

One is that in the United States, we are lagging behind the rest of the world in terms of having diagnostic and treatment guidelines for adults with ADHD. There are Canadian guidelines, there are multiple European guidelines, there are Australian guidelines for adults with ADHD. At the American Professional Society of ADHD and Related Disorders, we’re in the process of developing them for adults with ADHD—they should be out by the end of the year for commentary. There will be a period of time for commentary from practitioners, so please keep your eyes and ears out for that. Our hope is that this will provide some guideposts for diagnosis and treatment for clinicians and help them in making diagnostic and treatment decisions.

Another thing I want to share with clinicians is when assessing individuals with ADHD: be comprehensive. There are no shortcuts here. Use a scale. All adults were once children—you have to go back and look at their childhood and what it was like, but also use rating scales whenever possible.

Finally, don't shy away from making these assessments. Adult ADHD is a disorder that can and should get better with good treatments.

Lenard A. Adler MD, completed his residency and chief residency in Psychiatry at the NYU Grossman School of Medicine, where he has remained on staff since 1986. Dr Adler is a professor of psychiatry and child and adolescent psychiatry. His research and clinical interests center on attention-deficit/hyperactivity disorder (ADHD) in adults, mainly focusing on new assessments and treatments. He serves as vice chair for education in the Department of Psychiatry and director of the Adult ADHD program.  He has published over 150 peer reviewed manuscripts and served previously as the President of American Professional Society of ADHD and Related Disorders.