Janice Spinney: Drug Dike is Leaking

Today, I write to give an overview of the situation with prescription stimulants. Attention deficit disorder or attention deficit hyperactivity disorder (ADD or ADHD) is a behavioral disorder of attention or hyperactivity. Stimulant medications such as Adderall (mixed amphetamines), Ritalin, and Concerta (methylphenidate) are effective in helping individuals with the disorder focus and maintain attention. Stimulants work by blocking the reuptake of norepinephrine (adrenaline) and dopamine, leaving more of it to act at receptor sites.

Amphetamines have been around a long time, and they do not come without side effects. Each amphetamine used for ADD and ADHD comes with a “black box warning,” one of the highest adverse warnings a drug can carry. For amphetamines, the warning is specifically for sudden cardiac death, cardiac abnormalities, abuse, diversion, addiction, or dependency. Amphetamines are central nervous system stimulants, and they can overstimulate the heart.

The FDA has long-standing protocols for prescribing this class of medications to children and adolescents, but none as of 2024 for adults. During the few years of the COVID epidemic, from 2021 to 2022, the prescribing rate of stimulants rose by 10% to 14%. One reason for this is wider access to prescriptions through telehealth and the lifting of certain regulations for e-prescribing. COVID restrictions placed on people during the epidemic led to large numbers of people being prescribed stimulants. Many people were experiencing anxiety and a decline in behavioral health. The jury is still out on how and why stimulants became the drug of choice, but it did, similar to how prescribing opioids became the accepted treatment for pain.

Although there was a large spike in amphetamine prescribing during COVID, the trend of prescribing amphetamines for adults is still growing into mid-2024.

For anyone on this class of medication — or if you have a child on this class of medication — you are all too aware of the shortages and out-of-stock situations at many, if not all, pharmacies. There are many reasons for the shortages, but first and foremost is supply and demand.

As with the early years of the opioid epidemic, many important painkillers went out of stock due to supply and demand. As the FDA and DEA began to react to rising overdoses and deaths, quotas were placed on manufacturers, and raw materials were blocked or limited at import. This led to decreased production, manufacturing, and distribution of that class of drugs.

What was the fallout? First, many people with chronic pain were unable to obtain medication. Second, we saw one of the deadliest opioid and heroin epidemics, which lasted for 10 to 15 years. The third impact of the opioid epidemic is now a worldwide synthetic fentanyl use disorder, deadlier than any opioids or heroin.

For the stimulant class of medications, the FDA and DEA blame the manufacturers, and the manufacturers blame the feds. The feds say the manufacturers had allocations for an additional billion pills but did not manufacture them, while the manufacturers say they couldn’t get the raw materials to produce the product. So, there lies the problem.

Before another Sackler family (OxyContin is not addictive), distributor, or giant chain pharmacy gets sued and the epidemic of methamphetamine (an amphetamine similar to Adderall) rampages through the U.S., we must consider the prescribing, dispensing, and taking of amphetamines more cautiously. There seems to be an attempt at the top levels of government to slow down manufacturing and limit production of amphetamines. It’s also noteworthy that China is the major supplier of raw materials for prescription amphetamines, as well as supplying the world’s drug cartels with chemicals to manufacture illicit methamphetamine.

The street drug of choice here in the valley these days is methamphetamine, or crystal meth, sometimes laced with fentanyl. Ask any police officer, ambulance worker, emergency responder, or ER personnel what they are seeing, and you’ll learn how this drug is devastating our families.

Those with severe chronic pain and those with ADHD or ADD who need a prescription solution should never be denied appropriate therapy. The problem, however, is that there is too much in our community, leading to the abuse of prescriptions and similar chemical substances, in a clear parallel to the opioid epidemic from 15 years ago. The controlled substance that is prescribed and dispensed in large quantities in healthcare and pharmacy is abused on the street, meeting the supply and demand.

As healthcare providers, we make decisions every day on the appropriate prescribing of medication and maintain standards to protect the patient and the community from harm. It’s exceedingly challenging when the substance is chemically a "feel-good" drug, because as humans, we want to feel no pain, and we all strive to survive and succeed by any means. That is our nature.

There is always a solution for those who do not want to take a pill and for those who know there is a way to live in this world of motion and still maintain health and well-being. We must consider the pros and cons of taking these very potent chemicals and the global and local impact they have.

There are a number of medications on the market that can be used for ADD and ADHD that are not controlled substances, not habit-forming, and are not desirable for diversion.

There are also a number of behavioral health, holistic, or lifestyle modifications an adult can try in order to function and balance a busy mind and feelings of being overwhelmed. We must look at alternative ways to slow our brains down, focus, balance, center, and be attentive in this high-paced, overstimulating world. It’s not easy slowing down our brains or life in general in our current climate of technology, and it’s getting harder with every second that we speed toward singularity — hopefully not.

Years ago, it felt like the dike was leaking, and my one finger was not holding back the flow. It appears to be happening again. Pharmacists are the keepers of the drugs and must ensure the safety of their community.

Janice Spinney
Owner, Valley Independent Pharmacy
President, MWV Supports Recovery Coalition