Are Medication Shortages Widespread? How Nurses Handle This Issue

The Origins of the Current Adderall Shortage

In October, the FDA announced a nationwide shortage of Adderall, a mixture of amphetamine salts used to treat ADHD. Teva, an Israeli pharmaceutical company and a major manufacturer of a generic formulation of the drug, cited worker shortages causing significant ongoing delays. While other companies have continued to make amphetamine salts, their total output is not nearly enough to match the demand. 

The number of Adderall prescriptions doubled between 2006 and 2016. Data suggests it’s grown even faster in the last two years, as regulations relaxed during the Covid-19 pandemic allowed the drug to be prescribed via telehealth visits. Startups advertising on TikTok and Instagram have been accused of grossly overprescribing the drug. 

Since Adderall is a controlled substance, the Drug Enforcement Administration (DEA) has strict rules on how the drug is produced (and in what quantities) to deter its abuse. That makes it difficult for pharmacies to increase their supplies quickly. Teva said in November that they believed shortages would continue for at least another 30 to 60 days; the FDA believes shortages could persist into 2023. 

“Every single year we go through a brief period in which there is a shortage,” Dr. Leahy says. “The DEA has to estimate how many patients might be on such substances, and then distribute the bioavailable ingredient to the manufacturers. If they estimate incorrectly, there might be a shortage.”

How Nurses Handle Medication Shortages

The sudden cessation of what’s been daily use of a powerful medication like Adderall can have significant side effects. 

Psychiatric-mental health nurse practitioners (PMHNPs) help their patients navigate those side effects and endure medication shortages safely. They consider alternative dosages, as shortages tend to occur in particular dosage levels first. However, that requires getting insurance companies to approve larger quantities of lower doses when they may have guidelines against doing so. It’s not paranoia: higher quantities have a greater chance of being diverted to different end users. 

“If a prescription was for 20 milligrams twice a day, for a quantity of 60 for a month’s supply, dispensing that prescription in five-milligram pills suddenly turns it into a quantity of 240,” Dr. Leahy says. “We don’t want 240 of those out on the street.”

For the current Adderall shortage, the FDA recommends switching some patients to an extended-release form of the drug. This requires careful negotiation, too. Brand-name drugs can be up to 20 percent stronger than generic ones, and insurance companies are less eager to reimburse for their higher price tag. Alternative medications are also an option, but they’re a drastic one. Other common ADHD medications work differently and have their own side effects. 

“I try to exhaust my resources within the bioavailable relative equivalent, if you will, of the same agent, as opposed to switching,” Dr. Leahy says. “Because methylphenidate (Ritalin) is not the same as a dextroamphetamine amphetamine salt (Adderall), and certainly neither of those are the same as an atomoxetine (Strattera).”

Switching medications isn’t an immediate process, either. Finding the right dosage takes time, as does adjusting to the medication’s side effects. The adjustment requires more one-on-one time between the patient and provider.

The Importance of Collaboration in Handling Medication Shortages

This cuts to the core of the broader issue: there is no easy solution to medication shortages, and NPs often need to spend more time with their patients for education, counseling, and alternative therapies to help them through. NPs will also need to collaborate with other healthcare professionals in shepherding patients safely through periods of shortage. 

“In terms of collaboration, it’s really prudent if you know the local pharmacies that your patients might be using,” Dr. Leahy says. “Go in and introduce yourself to the pharmacist. They’re going to know your prescribing habits, they’re going to know your patients.”

Collaboration is also important in managing side effects and overlapping conditions. Propranolol, for example, which is used off-label for anticipatory anxiety, is also an anti-hypertensive, a medication used for blood pressure; a PMHNP can work with a patient’s primary care provider or cardiologist to possibly cover two issues with one prescriptive intervention.  

“Something advanced practice nurses do extremely well is collaborate with other practitioners to help minimize the number of medications our patients are taking, and the frequency with which our patients are taking them,” Dr. Leahy says. “If we can get down to a once-a-day dosing as opposed to a three-times-a-day dosing, it helps with adherence, and it helps our patient stability across the board.”

Predicting and Handling Future Medication Shortages

Predicting medication shortages isn’t impossible. As Dr. Leahy points out, the traditional beginning of the school year tends to coincide with a noticeable increase in demand pressure on medications like Adderall.  

The most effective strategies an NP can employ to prepare for medication shortages are educating their patients and maintaining clear documentation regarding their prescriptive practice. 

But they can’t manufacture more medications themselves. Addressing shortages themselves would require a more compassionate or at least more accurate estimate by the DEA regarding the natural ebb and flow of demand for drugs like Adderall. Consulting with NPs and other healthcare providers could help the DEA see what providers like Dr. Leahy have seen for years. There’s a lot at stake. 

“My worry is that if patients aren’t going to be able to obtain their medications in the commercial market and the legal market, then they’re going to turn to the streets, just like they did in the opioid crisis,” Dr. Leahy says. “Street dealers never seem to have a supply shortage issue.”