21. 💊 Why is the Adderall Shortage happening in 2023?

Photo by Anna Shvets

An ADHD Horror Story.

The alarm clock goes off, and Sheila's eyelids slowly open. She shuffles over into the bathroom, lethargic. She's staring at the tube of toothpaste and toothbrush. Instead of picking anything up, she stayed her weight firmly palms-down on the cold surface of the sink. She splashes her face with water and blindly reaches for the towel to wipe her face. As she catches her reflection in the mirror, she thinks, "How is it only Tuesday?"

Finally, she flips on the light, but before brushing his teeth, she opens the medicine cabinet to retrieve a prescription bottle—15 mg of generic dextroamphetamine or Adderall. She unscrews the lid and shakes the bottle to peer inside—fresh refill. She takes one out and takes it with water.

Shower. Breakfast. Outfit. Out the door. Sheila's not walking to work; with a renewed pep in her gate, she heads to the coffee shop; it's part of her routine. She's a writer. It gets the day moving for Sheila to walk down her busy city street for coffee. On her walk back home and after a couple of sips of joe, her mind begins to transition into the neurotypical range. Suddenly she can't wait to get home and start the busy day.

At work, the days are intense; Long periods of staring at her screen, trying to ignore Instagram, but she does it well. Sitting at her desk focused and, by the end of the day, often excited to return to her assignments the next day. Thank god for that little capsule.

The alarm clock goes off; Sheila wakes up. She's groggy. She goes to the bathroom, splashes her face with water, turns on the light, and takes her medication, but this time she realizes she is about to take her last pill. No problem. She opens the app on her phone to request a refill from her doctor. She'd get the text when the prescription was ready for pickup, usually by the end of the day.

The following day she wakes up—still no text from the pharmacy. There was probably a problem with the app; it's happened before. The doctor's office isn't open until nine, so she'll start her day as usual, she decides. She turns the light on and continues to stare at the toothpaste. When she's finally dressed, she's running a little late to the coffee shop and realizes she's forgotten her wallet when it's time to pay. Luckily the barista was chill and gave her a pass.

The workday was hard; Sheila watched the minutes tick by at the bottom corner of her computer screen. She's not getting any work done anyways. She refrains from calling the doctor precisely at nine so as not to seem desperate but calls promptly at 9:07. She's surprised to be informed that the prescription is already with the pharmacy, as usual. Must be a problem with their text notification system; It's happened before.

She waits on hold for a long time, and when she finally gets an actual pharmacist on the line, she's stunned on the other end of the phone. There are no more Adderall or generic forms of the pill; there's a massive nationwide shortage. Sheila remembers seeing something about it months ago, but it never affected her routine trip to the drugstore.

Work was impossible. Nothing on the screen made sense, and she didn't know where to start. She still felt just as sleepy as when she got out of bed but couldn't slack off. She had deadlines to meet! Desperate times call for desperate measures.

She ran to the gas station and bought a couple of five-hour energy drinks, which made her a little anxious in her stomach, but she remained unfocused, and coffee didn't hit the same anymore. She only got a little done at work today because she was on hold with almost 20 pharmacies trying to track down her medication.

The next day was worse. Sheila could barely get out of bed, skipped her shower, and made coffee at home. She lay on her side, staring straight ahead at the illuminated screen of her laptop; the cursor blinks just ahead of where she left off in the middle of the first draft of an article due tomorrow. Around noon she finally called back and asked how long the Adderall shortage would last; the pharmacist replied, "Forever. For-ev-er. For-evvvvveurrrrrrrr.”

(Sort of) Based on a true story.

No, that didn't happen. But this story isn't a complete fabrication but a dramatization of an actual person's account that I read while researching this episode about the Adderall shortage. It resonated with me because it's my story in some ways.

Only a few days ago, I was affected by the Adderall shortage. I've heard about it but never had issues getting my meds. That changed days ago when I called to fill my prescription and was told there is none. I was suddenly hit with the reality that there's no absolute guarantee I can always get my hands on the stuff. My symptoms also hit me like a brick wall. I am not addicted to stimulants but am very clearly dependent on them, like millions of people.

Why is there an Adderall shortage? How long will it last? How do you cope if you run out of focus medication? And what is a possible darker underlying truth to America's relationship with stimulants?

History, with a dash of amphetamine.

Happy Accidents

The discovery of the decongestant properties of amphetamine was an accident in the 1920s. In 1927, a Romanian chemist named Lazăr Edeleanu synthesized amphetamine for the first time, but he did not recognize its stimulant properties. Instead, he used it to create a nasal decongestant called Benzedrine.

Edeleanu was looking for a synthetic substitute for ephedrine, a natural decongestant derived from the ephedra plant, which was in short supply then. He synthesized amphetamine by reacting phenylacetone with ammonia and reducing the resulting product with zinc and hydrochloric acid.

When Edeleanu tested Benzedrine on himself, he found it had a powerful decongestant effect, producing a sense of euphoria and increased energy. He was intrigued by these effects, but he needed to understand the compound's stimulant properties fully. Oh, he was more than intrigued. I don't know the bravery required to inhale the byproduct of a crude mixture of ammonia and hydrochloric acid without knowing the side effects, but it's a desperate move. This guy may have missed Ephedra himself.

In 1929, just two years later, pharmaceutical company Smith, Kline, and French introduced Benzedrine, the first amphetamine-based medication, as a nasal inhaler for treating nasal congestion due to colds, allergies, and other respiratory problems. Benzedrine quickly became popular due to its effectiveness as a decongestant and bronchodilator, and I'm sure that's why it was popular. People were shooting amphetamine up their noses.

The widespread use of amphetamines during this time also became fueled by the acknowledgment of other benefits, such as increasing energy, focus, and concentration. Now the use of amphetamine in a wide range of medical and non-medical contexts began, including as a treatment for depression, narcolepsy, and obesity, as well as a performance-enhancing drug for athletes and a recreational drug for party-goers.

This stuff is amazing!

During the 1930s and 1940s, amphetamines were prescribed by doctors and became a popular ingredient in many over-the-counter remedies. The military began using amphetamines to keep soldiers vigilant and diminish combat fatigue during World War II. After the war, amphetamines continued to be consumed, and recreationally more than before. In a previous episode, I talked about a video of Adolph Hitler on youtube, who allegedly enjoyed amphetamines, can be seen tweaking on some WWII-era stimulants at the Olympics. Look it up. I would attach the link again, but it feels weird to link to a video of Hitler twice.

Even Elvis Presley is known to have used amphetamines during his time in the army. He was first introduced to the drugs in the mid-1950s when he was touring extensively and trying to keep up with the demanding schedule. By the time he entered the army in 1958, he was already using amphetamines regularly to help him stay awake and alert.

During his time in the army, Elvis was given legal access to amphetamines, which I've already stated were provided to soldiers to help them stay awake and focused during long periods of duty. However, he quickly developed a dependence on the drugs, and by the time he returned to civilian life in 1960, he was using them to help him get through his busy recording and performing schedule.

Amphetamine abuse became a noticeable problem in the 1960s, particularly among college students and young adults. The drug was often used recreationally and associated with the emerging counterculture movement.

Party’s over.

The U.S. government classified amphetamine as a Schedule II controlled substance in 1971, making it illegal to possess or sell the drug without a prescription. Despite this, amphetamine abuse continued to be a problem, and the drug was often used in combination with other substances like cocaine and heroin.

In the 1980s, the world was still raw over the recent death of Elvis, in part due to amphetamine/general drug addiction. Meanwhile, the use of amphetamines as a treatment for attention deficit hyperactivity disorder (ADHD) began to increase. During the 1990s, amphetamine abuse continued to be a problem, particularly among young people. The drug was often used in combination with other substances like ecstasy and LSD. The combination of LSD and amphetamine is called whip-flipping, in case you were curious.

In the 2000s, prescription rates for amphetamine-based drugs like Adderall and Ritalin rose exponentially, particularly among college students and other young adults.

Amphetamine abuse remained a problem in the 2010s, as prescription rates for drugs like Adderall and Ritalin skyrocketed, The drugs were also increasingly being used by athletes and bodybuilders now.

According to a study published in JAMA Psychiatry in 2018, the number of adults who filled a prescription for an amphetamine medication (including both amphetamine and dextroamphetamine) increased from 3.3 million in 2006 to 5.6 million in 2015, which represents an increase of 67%. Additionally, the study found that primary care physicians, rather than psychiatrists, wrote most of those amphetamine prescriptions.

According to the U.S. census bureau, there's an estimated population of 332 million people in the United States. If 5.6 million of us use amphetamines, that's 1.6% of the population, which doesn't seem like much, and it's a drop in the bucket when you look at it as just one and a half percent, roughly. Regarding public health and drug use, 1.69% is damn-near a crisis because of the significant number of individuals who may be at risk for addiction, abuse, and other negative consequences of using stimulants.

There's a brief history of the creation of amphetamines and how their use became commonplace for treating ADHD in the first place.

Amphetamine use today

Why would anyone try that?

It baffles me that the use of amphetamines all started by accident, and it baffles me even more that someone was brave enough to risk their life inhaling the vapors of some shit he made with ammonia and hydrochloric acid. It made me wonder how big of a problem respiratory disorders were back in the 20s.

It turns out respiratory illnesses were indeed prevalent, particularly in urban areas with high pollution levels and exposure to infectious diseases. The leading causes of respiratory diseases at that time were tuberculosis, pneumonia, and influenza. In 1920, influenza swept across the United States and worldwide, killing an estimated 50 million people. So people were rightly paranoid about keeping their airways clear.

On the other hand, it made me wonder what makes people inhale the vapors of some stuff concocted in a sketchy apartment or trailer park laboratory; made out of cleaning products from under the sink and the charcoal-like dust from inside of double-a batteries?

A hundred years ago, working-class people labored in coal mines and industrial factories. They were also stay-at-home mothers with tons of chores and parenting to do. They were soldiers. I'm sure they used these meds to feel well enough to work through their malnutrition and poor working conditions. Whether it was to ease the TB symptoms enough to get back to the coal mine or to stay awake with the baby all day because you were already up all night, when the ephedra plant became scarce, people likely found it more challenging to perform their daily routines suddenly. That context fueled the birth of synthetic relief to the shortage of ephedra. That would make a guy inhale some unknown chemicals.

Are we different today? The industrial age has cooled since transitioning globally into the technological age. In one hundred years, we've traded coal dust for desktop computers in many occupations with the help of automation and computing power. Still, don't get it confused; we're working just as much as ever. Here is one subtle indicator. Look around at the future scape we live in, which all of our ancestors dreamed about while staring up from fields and clouds of factory exhaust. A dream that they dreamed in between shoveling with ungloved, blackened, and blistered hands. The dream was what they worked for. Their children and grandchildren wouldn't have to work like this. And most of us don't do we? Bye-bye, chemical-ridden plant, so long industrial mill, adios dangerous mine shafts. Take a look a the glory that was built in their places. Applebees, strip malls, modern medical facilities, and Walmarts full of Robotussin for cold and flu season, as far as the eye can see. *deep breath in and out* Take. It. In. Hey, but look at what's still here with us. Stimulants.

In 2023 now that we have workplace regulations and technology, the idea that we're also no longer sick and overworked is still far from the truth. We're just unwell and overworked in different ways. The corporate and service industries leave people mentally exhausted in a way that matches the levels of physical exhaustion from yesteryear. It's safe to say that stimulants are going nowhere. We need it to keep up with the demands of mundane jobs, the new neurotypical standard that is the lifeblood for men and women, and mothers and fathers everywhere. There's just one puzzling thing.

It seems the only reason we have focus drugs like Ritalin, Adderall, and Vyvanse (at all) is partly because of the availability of natural ingredients used to make stimulants in the past and how difficult it was to maintain and distribute naturally derived ingredients with finite lifespans and supplies. That's why it is odd to me that the problem of scarcity we aimed to eliminate in the first place has returned after creating synthetic alternatives that work even better.

Why is there an Adderall Shortage, then?

Shrouded in Suss-ness

Remember Sheila, the writer from the beginning of the episode? The real-life Sheila from the story eventually was able to refill her prescription but is scarred from the experience. Now, she keeps her remaining Adderall in a little glass vial beside her stove. I recommend not leaving it out in the open, especially if you're worried about losing it. She's been watching it dwindle day by day. She's a little concerned about what's going to happen when she starts calling pharmacies again.

It sounds like a major first-world problem, but here's what Sheila had to say:

"People don't really take Adderall seriously always, but try telling someone, 'You can't have your blood pressure medication for eight days,'" McClear said. "If you want to exist in the modern world, you have to be able to get stuff done. And that's what Adderall does. Otherwise, you're just not functioning."

The following parts are from an article dated March 26, 2023, on Slate.com, about the stimulant drought. Here's what Ike Swetlitz, a health journalist for Bloomberg News based in Boston, MA, said during an interview after hearing many stories like Shelia's as a part of his journalistic research: 

"I thought, well, that sounds a little strange. Maybe it's something going on with the pharmacy. So I started calling other patients' pharmacies, looking online for what people were saying about it, and stumbled upon a post on Reddit with a number of people who were writing about their difficulty filling Adderall prescriptions. And one of them said he had reached out to the FDA to see what was going on and that the FDA had shared with that person that there were some delays with Teva, which is the pharmaceutical company that makes most of the Adderall in the United States."

The FDA knew about this the entire time. Yet, in lieu of a public statement, people in desperate need of the drug have to find out about a medication shortage on Reddit. Suss. Suss as fuck. Suss flag numero uno. 

During the summer of 2022, the news broke via Reddit users, and the FDA finally issued an official statement months later, in October of 2022. 

"On October 12, 2022, FDA posted a shortage of the immediate release formulation of amphetamine mixed salts, commonly referred to by the brand name Adderall or Adderall IR. FDA is in frequent communication with all manufacturers of amphetamine mixed salts, and one of those companies, Teva, is experiencing intermittent manufacturing delays."

That's from the FDA website. It was; says: "Other manufacturers continue to produce amphetamine mixed salts, but there is insufficient supply to meet U.S. market demand through those producers."

When asked why they hadn't broken the news to the public sooner, their reply was, "They don't want to alarm the public when they're working on trying and preventing a shortage because then everyone's going to go try to stock up on it and make the situation worse." Suss. Suss flag two. How often does the FDA not announce things to the public because they are trying to protect us?

Why is it that Teva, one company out of the many companies that manufacture Adderall, is the reason why demands are slow? As a schedule two substance, there are rules that have to be followed. One company shouldn't even possess enough of the product itself to imbalance the entire industry for what they are blaming on "a labor shortage on the packaging line." *crickets* The Drug Enforcement Agency sets an industrywide cap—a "quota"—on the raw amphetamine needed to manufacture Adderall. Without DEA approval, no one is allowed to make any more.

The federal government will set the total quota for the total amount of raw ingredients that can be produced by everyone combined. And then within that, each of the manufacturers would apply to the government and say, "OK, we want to make this much." The government would evaluate those applications and divide up the total quota amongst all the manufacturers. Now, both the federal government and the manufacturers can request and make adjustments to those numbers throughout the year if they think that they really need more in order to meet the needs of people. Basically, the amount of product that can be made is on a sliding scale. 

Umm. What?!

It gets more confusing. They've said it just takes time to catch up. And while Teva's doing that, customers—the pharmacies and wholesalers buying the medications from the manufacturers and then giving them to their patients—would turn to other drug manufacturers to buy Adderall. And those drug manufacturers hadn't anticipated that increase in demand from those customers who had previously gotten it from Teva. So it spiraled throughout the market.

They said that there was a labor shortage on the packaging line. It's still a little bit unclear what the specifics of the labor shortage were. They've said that they were resolved by the summer, but that caused a backlog that led to the drought we saw in the months after.It doesn't help that in the past five years, Adderall prescriptions rose thirty percent. This is also a contributing factor to the shortage for Teva.

But wait..?

But wait, wasn't it about packaging line problems?! The entire narrative is difficult to understand. Regardless, during this interview, Ike was asked by host Mary Harris if Teva ever reached out to the DEA to request a quota increase for more raw materials to meet the increased demands and to make up for the "packaging line" problems. Teva never supplied an answer.

One other sizeable generic drugmaker said that they did request more from the feds. Some of that request was granted; some of it was denied. Neither Teva nor the DEA has elaborated on this, but the feds were willing to supply numbers based on reports from the companies they provide with the drug materials. The DEA claims that there was a lot of amphetamine raw material that the companies still had at the end of last year. What?

Drugmakers don't have enough raw material, and the DEA says they have excess. The DEA says, "See what had happened was, 'There are the companies that manufacture the active pharmaceutical ingredient in Adderall that makes it Adderall. And then there are the companies that manufacture the capsules you ingest, and we don't know where exactly that ingredient is and who has it.' " And therefore, the shortage we're seeing is not a shortage caused by the quotas.

I just wonder why go through all the steps to regulate it so heavily, but then say something like, "we don't know who has the raw ingredient." That's not part of the report somehow? Like, "we shipped the rest of the product last Tuesday to make capsules out of it, to so and so." I don't know. Obviously, it's easy for me to criticize because I have no idea how any of this works, but I think we can all agree its a little confusing.

Isn't part of the law, one entity can't even be in possession of a certain amount of the drug? So if someone has excess, isn't that considered the exact type of issue the DEA would be concerned with?

The short answer.

That's it. That's the answer to why the Adderall shortage is happening. It's he said, she said, its finger-pointing, blank stares, and pre-written press-release statements. When will the drought be over? Refer to the previous questions for the answer. Droughts like this have happened before, like back in 2011. At the time, those droughts were attributed to DEA quotas that needed adjusting, but covid made things harder with logistics in general. Teva said they cleared their packing issue, but there was just a delay, yet, here it is, April, and the problems seem to be spreading.

When there is a significant problem, the FDA, DEA, and drug manufacturers' policy is to do what's in the best interest of not upsetting us children. Enough of the politics; there are still things you can do to cope. Hasn't this been a long ass episode already, though? Much longer than usual, and I need a break, so we'll pick back up next time. We'll talk about how to cope with your delayed scripts, what you can do to feel emotionally grounded during withdrawals.

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