American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, December 15, 2011

Is the adderall shortage a harbinger of future drug supply problems?

Today, most if not all doctor's offices are strained by the shortage of some prescription medication or vaccine. A month ago, President Obama signed his executive order directing the FDA to take steps to reduce drug shortages as the White House stated that drug shortages have nearly tripled over the past five years, reaching the stunning number of 178 in 2010. These shortages make regular news: Cancer patients without the chemotherapy needed to keep them alive, antibiotics unavailable to treat life-threatening infections, or intravenous nutrition to support the critically ill fighting to live while medical teams and families search for elusive remedies.

As this new reality plays out in hospitals and homes the media is provided a steady stream of drama for our morning paper or evening news. Meanwhile, time and focus is repeatedly stolen from physicians, patients, and parents in a myriad of ways. Currently, my medical practice in primary care internal medicine has been negatively affected by the shortage of Adderall, a medication used to treat attention deficit hyperactivity disorder (ADHD). What this medical condition may lack in dramatic news worthiness it more than makes up for in sheer numbers, with an estimated 4.5 million Americans living with this condition today.

I had my first inkling several months ago of the affect the Adderall shortage would have on my practice after one of my patients called frustrated that their pharmacy did not have their Adderall at the prescribed dosage. By calling several pharmacies I was able to find their medication at a smaller dose. Advising my patient to "double-up," I wrote another prescription and had to direct my patient to return to my office to pick up the rewritten prescription, a time-consuming process that doctors and patients can ill afford to repeat on a regular basis.

Unfortunately, this scenario, initially thought an exception, has now become the rule, monopolizing my own time while draining the daily resources of my staff, nurse and medical partner. Most ironically though, it forces a population of patients unable to concentrate without medication to focus on precisely the type of task that would challenge them the most in order to obtain their medication, a classic "Catch-22".

Last week, I had the opportunity to attend the Capitol Hill forum, "Is ADHD Ailing our Economy," in the Rayburn office building. From a panel of experts I heard evidence regarding the prevalence of ADHD in our country as well as the economic impact ADHD has on our nation's economy. I had previously thought in economic terms limited to drug costs alone, but during this forum I heard compelling evidence of the economic impact of untreated ADHD, such as the cost last year somewhere between $87 billion and $138 billion dollars in lost productivity or the expense of $3 billion dollars in burden to the judicial system in 2010 alone.

Against this backdrop of economic impact my curiosity as to the cause of the Adderall shortage was piqued. If the economic impact of untreated ADHD is so expensive, then how can we allow the shortage of Adderall to continue? I spoke with a representative for Shire pharmaceuticals, makers of Adderall XR, and was assured that the shortage did not extend to their product line, as the shortage was limited to the generic rapid release version of Adderall. He stated that the actual cause of the shortage was complicated, but Shire's quarterly report dated Mach 31, 2011 stated that "Shire's ability to supply this product is limited by quota restrictions that the U.S. DEA places on amphetamine use."

The FDA blames increased demand (legal and illegal), while the DEA has not released any official statement on the shortage, but does offer a "Drug Fact Sheet" comparing Adderall to cocaine and crack. Further confusing the reasons for this shortage are lawsuits filed over the last two years by Teva pharmaceuticals and Impax Laboratories, makers of generic Adderall, against Shire regarding shortages of the parent compounds in making Adderall as Shire is under contract to provide the parent compound to both of these companies.

While the specific reasons for the Adderall shortage remain elusive and the finger pointing continues, I fear this shortage will continue unchecked for many more months before a solution is found. Adderall is but one of many drugs now difficult to find and I am most worried that these shortages are a symptom of a growing dysfunction between government and the medical industry. Today's shortages may pale in comparison to tomorrow's deficiencies.

Dr. Simmons' travel and participation in the Capitol Hill briefing was made possible by sponsorship from Shire Pharmaceuticals.

This post by Steve Simmons, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Blogger junebug388 said...

we need a shortage of drugs like adderall that are irresponsibly written.

Please do not use this as an example of the serious problem of life saving and essential drugs that are increasingly unavailably

Linda Ray, M.D.

December 15, 2011 at 7:45 PM  
Blogger Frontrowseat said...

I have a 56 year old brother who suffers from a MEDICAL problem, not a psychiatric or addictive one! His inability to receive his medicine has ruined his quality of life. Let the Police find those who abuse prescription drugs ... and punish them. For heavens sake, don't make those who are now debilitated to an extreme, continue to suffer ... Walk a mile in my brother's shoes. Talk and stutter and stammer. Feel embarrassed because you can't think. Lose weight because you can no longer shop or cook. Then you can voice your BIASED opinion!

December 20, 2011 at 12:54 PM  
Anonymous Anonymous said...

Junebug388/Linda Ray MD:
Did you miss the part of the article stating "What this medical condition may lack in dramatic news worthiness it more than makes up for in sheer numbers?"
The impression I got was that the author acknowledged much more 'essential drugs' are in short supply, but chose to write about one PERSONALLY affecting them.

I agree that amphetamines are over prescribed, but in my opinion so are antibiotics, anti-depressants and tons of other medications. Unfortunately after 6 years of taking them nearly daily I can't function as well without them. I never planned to take them so long, in fact I came across this article because I intended on looking up adderall alternatives, but google suggested "adderall shortage in maryland" and I was interested because the shortage has been affecting me personally.

The last time I got my prescription filled I had to drive 30 minutes to a near by town to get it because none of the SIX pharmacies in my town had it in stock. Not a big deal, but pretty inconvenient.

December 25, 2011 at 11:58 PM  
Anonymous Anonymous said...

Is it just me, or does it seem like Shire may just be trying to turn a profit? By negating their contracts with Teva and Impax, refusing them the raw material to make adderall, Shire became the only pharmaceutical manufacturer of any type of amphetamine drug in the U.S. It seems to me that Shire is manipulating the market in order to have every ADHD patient in the U.S. taking their brand new drug Vyvanse, which they own exclusive patent rights to. Vyvanse is very expensive, and works better than Adderall, so I'm sure you can imagine the incentive for big bucks there. Sounds like a big pharma, "g-money game changer" type brainstorm to me. When the adderall shortage started, the price of adderall went from about $50 to around $90 over night. Lol, dosnt take a genius to figure out the amount of raw material Shire would need to limit to Teva & Impax, in order to make cost of adderall right around the same As the cost of Vyvanse. Well, for now anyway. See Vyvanse cost about $90 to $100 to those uninsured patients with ADHD which as I said is the same as adderall, but that's only with this "half off discount card" provided by Shire, that the prices are comparable. Long story short, Shire manipulates the market forcing everyone to take Vyvanse instead of adderall till adderall becomes obsolete and then stops handing out these half off cards and presto! Big bucks! You got insurance, no problem! You don't, too bad. Capitalism at it's worst. I'm sure they are breaking a few laws, I'm not a lawyer or anything but hey, wrong is wrong right?

March 13, 2012 at 5:46 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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