When Amanda goes without her medication for attention-deficit hyperactivity disorder (ADHD), she struggles to function mentally and physically. Depression, anxiety and chronic pain stemming from fibromyalgia all become more prominent for the 46-year-old, which further exacerbate her ADHD symptoms, making everyday tasks like showering a challenge. Although she hasn’t faced any disruptions from this year’s Adderall shortage — which has now entered its second year — at one point she wasn’t able to get her medication filled at a single one of 16 pharmacies near her home in the Metro Detroit area.
Amanda, who asked to be referred to by her first name, has been on Suboxone since 2010 after two decades of using methamphetamine, cocaine and other drugs, including a few years of consistent heroin use. Once she decided to get treatment and stop using drugs, she continued to have to jump through hoops to get not only her Suboxone but also her Adderall prescription.
She said she was required to have monthly visits with her provider to get her prescription refilled and perform monthly urine screens, which both came with additional co-pays. There were other shortages, too, during which she had to go in person to multiple pharmacies and was sometimes turned away. Ultimately, she cycled through more than 10 different providers before finding one that was able to consistently fill both of them through Medicare, she said. But she's had friends who have been diagnosed with ADHD and haven't been able to connect to treatment.
“The whole system of just being able to acquire your ADHD medication is a huge problem and ordeal,” Amanda told Salon in a phone interview. “It's easier for a lot of people to just get it from the street.”
Amanda’s experience highlights a host of factors that have contributed to the rise in U.S. stimulant use in recent years: Many people who use drugs do so as a means to cope with undiagnosed mental, behavioral or neurological health conditions. Untreated ADHD is more common in people with stimulant use disorder than in the general population, and many patients get into using methamphetamine as a way to self-treat their condition, said Dr. Mark Willenbring, an addiction psychiatrist at the Expanse clinic in St. Paul, Minnesota.
“I have patients who used it in a controlled way for 30 years, as if they were self-treating ADHD,” Willenbring told Salon in a phone interview. “Their doctors wouldn't prescribe anything for them, so they were kind of stuck between a rock and a hard place.”
Last year, the Drug Enforcement Agency’s (DEA) quota for the amount of drugs like Adderall used to treat ADHD fell short of increasing demand, which contributed to the shortage. Just like the withdrawal of prescription opioids on the market is thought to have pushed people with addiction toward illicit opioids like heroin, restricting prescriptions for stimulants like Adderall could push people toward an illicit supply instead.
“I've had people say to me, ‘Why don't you just do a bump of meth and it’ll set you straight all day?’” Amanda said. “I don't want to have to do that. I have a prescription and I just want to be able to get my medication.”
Although stimulants are becoming increasingly involved in overdose deaths in what some are calling the “fourth wave” of the overdose crisis, treatments for this form of drug use are few and far between. Earlier this month, the Food and Drug Administration (FDA) called upon drug makers to develop new treatments that could be used to treat meth, cocaine or prescription stimulant addiction.
In a statement, Marta Sokolowska, the deputy director of the substance use unit within the FDA’s Center for Drug Evaluation and Research said: “Currently there is no FDA-approved medication for stimulant use disorder. When finalized, we hope that the guidance will support the development of novel therapies that are critically needed to address treatment gaps.”
One of the main challenges to finding treatment for stimulant use is that it can vary significantly depending on the person, the drug of choice and the route of administration. Cocaine, prescription stimulants and meth all work differently in the brain, have different effects on the body and are used in different ways, including being snorted, smoked or injected.
In its draft guidance for stimulant use treatment, the American Society of Addiction Medicine (ASAM) cites a handful of pharmacological medications that can be prescribed off-label to treat stimulant use disorder. Some studies show bupropion, an antidepressant used to treat tobacco addiction, can be effective for cocaine use disorder as well as amphetamine use disorder, particularly when paired with a drug used to treat opioid use disorder called naltrexone in the latter.
In addition to a few other off-label drugs that show some benefit in treating stimulant use disorder, one 2020 study published in Psychopharmacology showed stimulants used to treat ADHD can reduce cocaine use, including methylphenidate (also know as Ritalin) or mixtures of amphetamine salts like Adderall. Similarly, methylphenidate, which is FDA-approved to treat narcolepsy, can also reduce amphetamine use.
The idea to use meth or amphetamines to treat these conditions resembles the idea behind using opioid agonist treatments like buprenorphine and methadone to treat opioid use disorder. These two medications have been shown to be very effective in treating opioid use disorder because, being opioids themselves, they target the opioid receptors that cause cravings and withdrawal.
However, stimulant use activates not just one but many different receptors, and giving patients drugs like dextroamphetamine would not produce the same reductions in cravings or withdrawal for someone who used methamphetamine, said Dr. Brian Hurley, the medical director for the Bureau of Substance Abuse Prevention and Control for the Los Angeles County Department of Public Health. The why for using these drugs is also different: While people who use opioids tend to do so on a daily or more frequent basis to prevent withdrawal, people who use stimulants also differ in that they more frequently use in binges, Hurley said.
“Though the analogy [comparing] opioid agonists with opioid use disorder and psychostimulants for stimulant use disorder is logical, the combination of the mechanism of action of stimulants and the variability in the reasons people use stimulants outside of just kind of pure pharmacologic craving make the stimulant agonists less effective,” Hurley told Salon in a phone interview.
The ASAM recommends using psychostimulants to treat underlying ADHD in people who have both ADHD and stimulant use disorder, although their use remains “controversial” due to the potential for "misuse." However, there are some prodrugs of dextroamphetamine used to treat ADHD, such as Vyvanse, that have a slow onset and could be used for these patients, Willenbring said. Yet providers may be hesitant to prescribe any controlled substances that have shown promise in treating stimulant use off-label due to all of the additional regulations they are under through the DEA.
In lieu of not having any FDA-approved medications to treat stimulant use disorder, the ASAM also recommends turning to behavioral interventions instead, including contingency management, an evidence-based program in which people using stimulants are awarded small monetary rewards for not using.
California’s state health system has deployed contingency management across 24 counties. Essentially, when patients test negative on urine-drug screens, they receive gift cards, with a maximum reward capped at $599 over a six-month period. However, so far this is merely a pilot program and access is limited, said Chelsea Shover, Ph.D., an assistant professor-in-residence at the University of California, Los Angeles. Plus, contingency management in general tends to stop working for people once they stop attending, Willenbring said.
“It’s out there but in a pretty limited and scattered way,” Shover told Salon in a phone interview.
Why it hasn’t been more widely accepted traces back to the stigma that continues to constrain harm reduction efforts. Federal anti-kickback regulations that prohibit medical providers from rewarding patients to generate business may make healthcare providers nervous to offer services like contingency management, Hurley said. Although the Office of the Inspector General for the U.S. Health and Human Services Department released an advisory opinion that said such programs presented a "minimal risk" of being punished via anti-kickback statutes, a Montana clinic providing contingency management was investigated for fraud last year, illustrating the complexity of the issue.
Just like opioid agonist treatments are being used in addition to safe injection sites and needle exchange programs to mitigate the impacts of opioid use, any medications for stimulant use will need to be paired with behavioral and social interventions that meet people using these drugs where they are as well. Yet both pharmacologic and behavioral interventions are up against stigma that could prevent them from getting to patients even once they do prove to be effective.
"There are no molecules that I've seen in literature that have had a really robust response, but that doesn't mean that some can't help," Hurley said. "I'm glad [the FDA] is calling for additional research because we certainly need additional options."
For Amanda, the combination of Suboxone and Adderall to treat her substance use and ADHD has been "life-saving," she said. Not only does it help reduce cravings and attention problems, but also helps treat her fibromyalgia and depression that all once contributed to her substance use.
"That combination has allowed me to get my life stable again, control my pain and help with depression," she said. "It helps with so much, but people are reluctant to believe that. There's so much stigma around it."
