The ongoing Adderall shortage seems to have no end. Teva, the largest manufacturer of Adderall, is experiencing “ongoing intermittent manufacturing delays” due to increased demand. Every year, the DEA sets a quota — a limit on the amount of raw materials for many controlled substances, like Adderall. This is based in part on the Food and Drug Administration’s estimate of the need for the drug: For 2023, the FDA estimated just over 38,000 kilograms of amphetamine would be sufficient to meet the demand for Adderall and its generics – and the DEA set the quota at 42,400 kilograms, according to a DEA spokesman.

What is Adderall?

Adderall is a combination medication of Amphetamine/dextroamphetamine, used to treat attention deficit hyperactivity disorder – ADHD (attention deficit hyperactive disorder) and narcolepsy, a sleep disorder that makes one drowsy and unable to stay awake during the day.

Adderall is classified as schedule ll drug because its potential for abuse is high, due to its addictive nature. Other drugs that fall in this category are Vicodin, cocaine, fentanyl, oxycodone and Ritalin.

The Adderall shortage is affecting a large part of the U.S. population

According to the CDC:

CDC scientists found that, as of 2016, 6.1 million children aged 2-17 years living in the U.S. had been diagnosed with attention-deficit/hyperactivity disorder (ADHD), which is similar to previous estimates. Researchers also found that children living in rural areas were more likely to have been diagnosed with ADHD and less likely to receive behavioral treatment in the past year compared with children living in urban or suburban areas.

Among all children 2-17 years of age with ADHD, researchers also found:

• 6 out of 10 (62%) were taking medication for their ADHD, and represent 1 out of 20 of all U.S. children;
• Just under half (47%) received any behavioral treatment for their ADHD in the past year. Among the youngest children (2-5 years of age), the number increased to over half (60%);
• Nearly two-thirds (64%) also had another mental, emotional, or behavioral disorder, such as conduct disorder, anxiety, depression, autism, and Tourette syndrome.

During the pandemic, prescriptions for ADHD medications increased significantly

Relative annual percent change in percentage of persons aged 5–64 years with at least one stimulant prescription fill, by sex and age group — MarketScan commercial databases, United States, 2016–2021

How Adderall works

It is a stimulant that works by increasing the amounts of dopamine and norepinephrine in the brain. Dopamine is a neurotransmitter that plays a role in the “reward” center of the brain. It is released during pleasurable activities such as eating, sex, regular exercise and any activity that involves expectation of reward.

Norepinephrine affects how the brain responds to events, particularly how it pays attention and the speed with which it reacts to outside stimuli., belongs to a class of drugs known as stimulants. It can help increase your ability to pay attention, stay focused on an activity, and control behavior problems. High levels of norepinephrine activate the “fight or flight” part of the sympathetic nervous system, leading to fear and anger responses.

What non pharmaceutical interventions you can do to increase dopamine and norepinephrine

There are a wide variety of treatments available for ADHD, including medication, counseling and behavior therapy, and lifestyle changes.

• Eat tyrosine rich foods

Tyrosine is a non-essential amino acid, meaning the body can synthesize it, and is a precursor to norepinephrine and increases dopamine availability. Tyrosine rich foods include:

Beef, pork, fish chicke4n, firm tofu, milk, low fat ricotta cheese, large white beans, squash and pumpkin seeds and wild rice

• Regular exercise

Regular, consistent exercise has been proven to increase dopamine levels in the brain. In addition, regular exercise is widely known to improve mood.

• Balance gut health

Recent research is proving the important role your digestive system has in producing many neurotransmitters, including dopamine. Healthy microbiota in the gut leads to dopamine, serotonin and other neurotransmitters increase. Fermented foods which are rich in probiotics, kefir,yogurt with active cultures and fiber rich fruits and vegetables contribute to overall health.

• Get good quality sleep

Sleep allows the body to repair and rejuvenate. Sleep is one of the most important and underrated activities we engage in. When rested, your body is able to hand stressors and remain more alert and focused.

• Practice meditation or prayer

 According to a study “Increased dopamine tone during meditation-induced change of consciousness” two sets of participants were evaluated. One  set had eyes closed, and not instructed to do anything. The other set practiced focused meditation. The focused meditation group had a  65% increase in endogenous dopamine release. An increase in dopamine also occurred during a 7-day spiritual retreat.

You may have heard or been told by your care provider to never stop taking your antidepressant medication abruptly and wondered why. The side effects of suddenly stopping your antidepressant can be severe and last for months or even years.

What are antidepressants?

Antidepressants are prescription drugs used to treat clinical depression. They are one of the most commonly used medications on the market. 11% of Americans over the age of 12 take antidepressant medication.

They also are used to treat:

• Anxiety disorders
• Obsessive compulsive disorder (OCD)
• Panic disorders
• Serious phobias, such as agoraphobia and social anxiety (social phobia)
• Bulimia
• Post-traumatic stress disorder (PTSD)
• Help ease symptoms associated with nicotine or methamphetamine withdrawal

How antidepressants work

It’s thought that antidepressants work by increasing neurotransmitters. These are chemicals in the brain like serotonin and noradrenaline. They can improve mood and emotion, although this process isn’t fully understood.

Types of antidepressants

Selective serotonin reuptake inhibitors (SSRI)

SSRIs are the most widely prescribed antidepressant. SSRIs work by increasing serotonin levels in the brain. Serotonin is a neurotransmitter (a messenger chemical that carries signals between nerve cells in the brain). It’s thought to have a good influence on mood, emotion and sleep.

After carrying a message, serotonin is usually reabsorbed by the nerve cells (known as “reuptake”). SSRIs work by blocking (“inhibiting”) reuptake, meaning more serotonin is available to pass further messages between nearby nerve cells.

A few examples are:

• citalopram (Celexa)
• paroxetine (Paxil)
• sertraline (Zoloft)
• fluoxetine (Prozac)

Serotonin and norepinephrine reuptake inhibitors (SNRI)

SNRIs are similar to SSRIs. Evidence suggests that some people respond better to SSRIs, while others respond better to SNRIs. They are sometimes used to treat anxiety disorders and long-term (chronic) pain, especially nerve pain.

Examples of SNRIs include:

• duloxetine (Cymbalta)
• venlafaxine (Effexor)
• desvenlafaxine (Pristiq)

Tricyclic antidepressant (TCA)

TCAs are an older type of antidepressant. They’re no longer usually recommended as a first-line treatment for depression. This is because they can be more dangerous if an overdose is taken. They also cause more unpleasant side effects than SSRIs and SNRIs.

People with severe depression who fail to respond to other treatments may be prescribed TCAs. TCAs may also be recommended for other mental health conditions, like OCD and bipolar disorder.

Examples of TCAs include:

• amitriptyline
• imipramine
• nortriptyline
• Some types of TCAs, like amitriptyline, can also be used to treat chronic nerve pain.

Atypical antidepressants

Atypical antidepressants work in a manner different than other antidepressants. They change the levels of one or more neurotransmitters, such as dopamine, serotonin or norepinephrine.

Examples of atypical antidepressants include:

• Bupropion (Wellbutrin SR, Wellbutrin XL, others)
• Mirtazapine (Remeron)

What is half life?

A half-life is the time it takes for a drug in your body to reduce by half. Half-life does not change depending on the dosage a person is taking or the amount of time they have been on medication. Half-life can vary from person to person according to their overall health and other factors.

Every drug has its own unique half-life. For instance,

SSRIs

 Most SSRIs have a half life or a day or so, except Prozac

• Prozac (fluoxetine) has a longer half life than many other antidepressants. Depending on individual metabolism and health, it can take 1-4 days to reach half-life, and up to 30 days to be completely removed from the body.
• Sertraline(Zoloft)-22 to 36 hours
• Citalopram (Celexa)-36 hours
• Paroxetine (Paxil)-24 hours

SNRIs

• Duloxetine (Cymbalta)- 8 to 17 hours
• Venlafaxine (Effexor)-4 to 7 hours
• Desvenlafaxine (Pristiq)-about 11 hours

TCAs   

• Amitriptyline- 9-25 hours
• Imipramine- 19 hours
• Nortriptyline-36 hours

Atypical antidepressants

• Bupropion (Wellbutrin SR, Wellbutrin XL, others)- 33-37 hours
• Mirtazapine (Remeron)- 20-40 hours

Discontinuation syndrome

Never go off or change the dose of your antidepressant without the guidance of your care provider.

Discontinuation syndrome occurs when an antidepressant is stopped suddenly. Depending on the half life of the drug, the symptoms can be more severe and longer lasting. Withdrawal symptoms usually come on within a few days of stopping the medicine and can last from 1 week to several months or more. Some people have severe withdrawal symptoms that last for years.

Withdrawal symptoms

Neurotransmitters are not only active in the brain but the entire body. Abruptly stopping antidepressants causes changes to neurotransmitter levels that can be felt throughout the body.

There are many mental and physical symptoms when coming off /abruptly stopping antidepressants including:

• Mood swings, agitation, manic feelings, depression, irritability, confusion, paranoid, suicidal
• Irritable, anxious, confused
• Balance: dizziness, light-headedness, vertigo
• Unusual sensations: numbness, sound hypersensitivity, “brain-zap”, which is a feeling of an electric shock to the head
• Stomach cramps, loss of appetite, nausea, vomiting
• Insomnia, vivid dreams or nightmares
• Restless legs, uneven gait
• Slurred speech
• Heat sensitivity, sweating

Given the severity of symptoms from abruptly stopping antidepressants, be sure you have enough in case of supply chain disruption. Review your medications with your care provider and have a plan in place for enough medication in the event your medication is in short supply.