State of the Art Pediatrics: Navigating a National Shortage of Stimulants

Column Author: Hannah Wolf, APRN, CPNP-PC

Jamie Neal Lewis, APRN, CPNP-PC, PMHNP-BC

Column Author: Amita R. Amonker, MD, FAAP | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Attention-deficit/hyperactivity disorder (ADHD) has become one of the most common neurodevelopmental disorders in childhood. Recent data from the National Institutes of Health (NIH) show an ADHD prevalence rate just over 10% among 4- to 17-year-olds from 2017 to 2022.³ The American Academy of Pediatrics (AAP) reports that of those children with ADHD, approximately half received behavioral treatment for their ADHD and almost two-thirds were taking ADHD-related medication.² Recently, prescriptions for stimulants increased overall by 14% from 2020 to 2022, especially for young adults and women, likely due to increased demand during the COVID-19 pandemic and the expansion of telehealth regulations to make care more accessible.⁴ 

For prescribers, selecting an ADHD medication for a child is no easy task. They must consider multiple factors, including the degree of impairment from ADHD symptoms at home and school, daily schedules and extracurricular activities, a child’s age and ability to swallow pills, comorbidities, current growth concerns, cardiac history, previous medications trialed by the patient or their close relatives, and insurance coverage, which may dictate certain preferred medications on their formulary or certain pharmacies that will provide coverage.²

One more thing that’s been important to consider over the last year and a half is medication availability. The Food and Drug Administration (FDA) first reported a shortage of Adderall in October 2022. Since then the list of medication shortages has expanded to include Focalin, Ritalin, Vyvanse, and others.¹ In August 2023, the Drug Enforcement Administration (DEA) and the FDA published a joint statement claiming that, in 2022, manufacturers were making and selling only 70% of their production quota as set by the DEA, amounting to nearly 1 billion doses fewer than they were allowed to produce.¹ This trend continued in 2023. While the FDA and DEA cannot require drug companies to make a drug or make more of that drug, they did ask manufacturers to confirm whether they are increasing production of these products to meet the quota and, if they are not, to relinquish their quota so it can be redistributed elsewhere. Nearly a year and a half later, we are still running into issues filling prescribed ADHD medications.

The specialists in the ADHD clinic at Children’s Mercy have recently used the following strategies to help patients, parents, pharmacies and insurance companies to work around medication availability issues to prevent treatment interruptions and promote better patient outcomes.

First, it is helpful to have parents call their preferred pharmacy to see if their child’s selected medication is in stock. If it is not, they can call around to other nearby pharmacies until they find it, and then relay that information to your office. This effort helps reduce some of the detective work for nurses or office staff, and helps avoid having to cancel a prescription to one pharmacy and resend it to another (and another, and another!). It is also useful to have clinical systems in place to quickly turn around the prescriptions on the same day (before that found medication then flies off the shelves). Consider having a daily “on-call” or “back up” prescriber who can order these prescriptions on the same day.

Second, depending on your clinic’s policies and procedures, consider writing a paper prescription so that if one pharmacy is out of medication, patients can quickly move on to a different pharmacy to fill it. Paper prescriptions can eliminate the delays caused by waiting for an online portal message to be seen or playing back-and-forth phone tag.

Third, many pharmacies have requested that prescribers send only a 30-day prescription without automatic refills, avoiding automatically filling a prescription for someone who may not need it quite yet, if, perhaps a child didn’t take their medication for a week or two because school was out for holiday break. The aim would be to avoid having prescriptions sitting on shelves unused when someone else might need it sooner. Patients could request a refill when they have about five days’ worth of medication left, or could set a calendar reminder to request medication on a certain day each month.

If patients are not able to find their selected medication nearby, they have effective ways to find a similar alternative. Attached below is a chart to compare medications, or you can always reference adhdmedicationguide.com/ for the popular chart by Cohen Children’s Medical Center. When it is necessary to switch medications due to unavailability:

1. Stay in the same class of medication (methylphenidates versus amphetamines).
2. Stick with a similar length of action (four to six hours, eight to nine hours, 10+ hours).
3. Use a similar dose range. If a patient is already at a middle to higher dose of one medication and tolerating it well, consider trying to find the equivalent dose of the backup medication, rather than re-starting at the lowest dose and having to spend time titrating up to an effective dose again. The website adhdmedcalc.com is helpful to switch between most medications and classes.
4. Consider switching from one extended-release medication to an equivalent dose of immediate-release medications given two or three times a day instead. (For example, an Adderall XR 20 mg could be switched to Adderall IR 10 mg twice daily.)
5. If a child is on a hard-to-find extended-release medication for school days, consider having them take a different immediate-release medication on the weekends (if home behaviors and extracurricular activities allow, of course). This way, they may be able to get by with about 20 pills per month of that extended-release if the pharmacy is short on that medication.
6. Consider asking the child’s insurance company if a brand name medication is covered temporarily.
7. As a last resort, if you are running out of medication alternatives, consider re-trialing a previously “failed” medication if it has been some time (e.g., over a year). This plan might be considered if a medication was stopped because it just wasn’t effective anymore, or if it caused a tolerable side effect such as decreased lunchtime appetite but didn’t greatly affect weight gain, or if adding an appetite stimulant such as cyproheptadine is an option.
8. If all else fails, don’t forget to consult your colleagues.² The ADHD clinic at Children’s Mercy is accepting referrals from affiliated primary care offices for assistance with medication management, psychology services, and parent-child interactive therapy (PCIT). You can also request a quick phone consultation by contacting 1 (800) GO MERCY.

Methylphenidate/dexmethylphenidate immediate release:

Methylphenidate/dexmethylphenidate extended release:

Amphetamine immediate release:

Amphetamine extended release:

References:

1. Ault A. No end in sight for national ADHD drug shortage. Medscape Medical News. March 12, 2024. https://www.medscape.com/viewarticle/no-end-sight-national-adhd-drug-shortage-2024a10004me?form=fpf
2. Wolraich ML, Hagan JF Jr, Allan C, et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528. doi:10.1542/peds.2019-2528
3. Li Y, Yan X, Li Q, et al. Prevalence and trends in diagnosed ADHD among US children and adolescents, 2017-2022. JAMA Netw Open. 2023;6(10):e2336872. doi:10.1001/jamanetworkopen.2023.36872
4. Chai G, Xu J, Goyal S, et al. Trends in incident prescriptions for behavioral health medications in the US, 2018-2022. JAMA Psychiatry. 2024;81(4):396-405. doi:10.1001/jamapsychiatry.2023.5045