What Can Clinicians Do to Mitigate the ADHD Medication Shortage?

A nationwide shortage of medications used to treat attention-deficit/hyperactivity disorder (ADHD) has patients and parents of patients who rely on these medications scrambling to fill their prescriptions. While the shortage started with combination amphetamine and dextroamphetamine (Adderall), it has since moved to alternatives such as methylphenidate (Ritalin), and experts say there is no easy way to increase supply.

In this exclusive MedPage Today video, Adrian Jacques H. Ambrose, MD, MPH, a psychiatrist and senior medical director at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City, discusses what physicians can do to keep patients safe during this stressful and frustrating time.

Following is a transcript of his remarks:

In terms of what can physicians do to keep patients safe during this time — I have unfortunately three not-so-simple steps, and I’ll go into greater detail for each one of them.

First is really, I think this is an incredibly stressful and frustrating time for patients and families, so it’s really helpful to validate and empathize with all of the storms of the elicited emotions from the patients and families. Second is helping the families focus on what can be done right now, and radically accept what cannot be done right now. So from a non-psychopharmacologic perspective, what are some of the resources that we can engage to help the patients and families with their symptoms? And then third is from a medication — so from a psychopharmacologic perspective — I think this is where child psychiatrists can be really helpful in working with the family to consider different medication alternatives and different medication strategies to mitigate the symptoms.

So I think for the first part, is people always ask, Well, why is it helpful for me to talk about how frustrating it is? A lot of time when patients and families are coming to us, what they’re ultimately worried about, and the consistent message that I’ve heard from families, is that they’re so worried about the well-being of the patients and of their children. So when you have a treatment that works, and now you don’t have access to it anymore, it is so natural to worry about how the symptoms of ADHD, which is a medical condition, could potentially act up and impair their lives again. So I think coming from a space of empathy, allow patients and families to actually believe you when you say that, you know, there are certain things that you can do right now and there are other things you cannot do right now. So how can we better focus our energy on things that we can do?

Which leads into the second step, and allows that to be a little bit more successful. So small things can have really powerful impact. Like I mentioned before, it’s from a non-psychopharmacologic perspective, looking at things like increasing resources at school and work to mitigate the potential symptoms of ADHD, like distractibility or hyperactivity. By having more targeted breaks, having extra time on tests, talking with schools to create these healthier environments where if someone is struggling with ADHD, they can perform and be their better selves. Creating lists like: What should you put in your school backpack? What should you pack in your work briefcase? (If people are still using briefcases.) Looking at ways to have less disruptive strategies like having some kind of fidget toys that are less disruptive for others, but allow people to self-mitigate some of the symptoms, could be very helpful.

And in addition, I would be remiss if I don’t mention that we have combined treatments. This is where combined treatments can really shine. So collaborating with the therapists to augment with CBT, cognitive behavioral therapy, supportive therapy, interpersonal psychotherapy, depending on the core symptoms of ADHD that the patient or child is facing.

And then third, going back to the medication core, there’s also three different strategies. I’m a fan of threes. So one is looking at, are there different formulations of the same class of stimulants that you can use? So if you’re using methylphenidates or if you’re using amphetamine or mixed amphetamine, are there different formulation of the same class that you can try?

Second is trying different dosing schedules. So for example, if a patient was previously on an extended-release or prolonged release [form] of a medication, is it possible to try more frequent doses of shorter available acting formulations? Because the goal is trying to achieve the same equivalent therapeutic effects.

And then the third option is potentially exploring non-stimulant options if the family and patients have not tried that before, and looking at specifically medication that also target the adrenergic and dopaminergic receptors that can help mitigate some of the ADHD symptoms.