Where's My Ritalin? What The Stimulant Shortage Tells Us About Mental Health Care
In 2021 alone, there were over 40 million prescriptions for Adderall dispensed in the U.S., according to health research firm IQVIA.
Frequently used to treat ADHD, the demand for stimulants like Adderall and Ritalin has increased in recent years. Right now, there’s a shortage of stimulant medication in the U.S. Patients who need to access Ritalin, Adderall and other common prescriptions are scrambling for source pharmacies that have the medications or are using online communities like the ADHD Subreddit to find hacks.
My podcast guest Lindsay Scola called 70 pharmacies to source Adderall, which she uses to treat narcolepsy. She told me,
“I was grateful to find my medication today. I'm hoping that this pharmacy will be able to find it next month. Stimulants are already not a super easy process when they're in stock. You have to get a brand new prescription every month. I wasn't able to find out that my pharmacy didn't have the medication and hadn't been getting it until the very last minute. You're going into a panic situation of, ‘Oh my God, I'm not gonna have medication.’ I lost a week of my life, whether it was dialing pharmacies or napping more than I usually do, or just not being able to have my brain work in the way that I needed it to. Not everybody has the ability to do that with their jobs. And so this is a really dangerous situation that we're in.”
I am eternally shocked at how discombobulated our healthcare system is for mental health and mental illness. I'm someone with a lot of privilege and a lot of access and a good network. And still, when I’ve needed mental health care the amount of dialing and hoping that you have to do to find providers, medicines, and appointments is shocking in this day and age, when I can order something on Amazon in the time it takes for me to take a sip of coffee. I estimate I’ve been on about 25 different psychiatric medications in my life, trying to find the right alchemy. Some that I wanted to try cost as much as $1800 a month and insurance wouldn’t cover them.
How did we get here? Jeanne Pinder is a former New York Times reporter who is now founder and CEO of ClearHealthCosts.com. She’s an expert on the U.S health care system and how people get their medications.
The stimulant shortage is the result of two factors, says Jeanne. The first is an unforeseen result stemming from the FDA’s settlement in the opioid cases. New regulations aiming to lessen opioid addiction also placed restrictions on pharmacies to dispense controlled substances like Adderall and Ritalin, or drugs used for anxiety like Xanax. It’s much harder for pharmacies to dispense stimulants and sedatives now. The FDA is aware of the roadblocks and working to resolve them, but it may take months.
The second is an increase in demand. Jeanne explains that prescriptions for Adderall, for example, have increased up to 30% in the last five years. And the telemedicine boom means nearly 40% of all prescriptions for stimulants last year came via telemedicine, driving a huge increase in demand. Match that with supply chain limitations and you have less of the medicine in supply.
Underlying this all, Jeanne explains, is a broken system. “It’s a broken system [but] when I say that people who've been inside the system for longer than I have say ‘It's not broken. It's designed to work that way.’” She says access to mental health care is difficult because:
1) “Our healthcare system imposes this weird divide between physical health and mental health.” It was built into the system from a very long time ago, this sort of pre-industrial or agricultural era idea that if you're having struggles you should just pull up your socks and do it.
“The Mental Health Parity Act in 1996, further modified and bolstered by the Affordable Care Act, says that you shouldn't treat mental health and physical health as two completely separate things. However, our healthcare system still does treat them that way, even though there are laws in place that forbid that our healthcare system does that. And the end result of that is that it's very hard to get a psychiatrist appointment. Much of therapy turns out not to be covered by insurance policies or covered in name only. The insurer will say, ‘oh, of course we have therapists. We have one appointment in December, it's 300 miles away from you. Would you like that one?”
2) Insurance pays out less for mental and behavioral health and many people just pay out of pocket. “Therapists continually complain that they just don't get enough money from insurance companies to make it worth their while.” As a result of this, a lot of therapists do not take insurance. If you wanted to know what a visit to a primary care provider would cost you on insurance, you wouldn't be able to find that out. But you can find out how much most therapists charge if you go to Psychology Today. So essentially you have a system that's running on cash, which means that if you can afford it, you can get it. But if you can't, you don't.”
3) Psychiatric meds take trial and error, and lots of these meds are expensive and not covered by insurance. Lindsay Scola is on her 14th combination of medication to try and treat her narcolepsy. Many of us try lots of different kinds of meds ‘til we find the combo that works. And sometimes, insurance doesn’t cover the one that works. Although you can get generic Prozac for about $4 on many insurance plans, novel or newer psychiatric drugs can be expensive. I've had the experience of having to sort of fail on several meds or claim that certain drugs I’ve tried haven't worked, so we document that in order for my insurance company to pay for what I need.
Jeanne explains the term for this is step therapy. “It's supposed to make it sound innocuous. Like, you have to try this step and then that step and then the other step, essentially the insurance company doesn't wanna pay [so] they'll make you jump through hoops and the hoops might include try this one and fail it, try this one and fail it. It is awful. There's a certain amount of moral hazard attached to that because essentially the insurance company theoretically will be paying its part, the drug company is subsidizing your medication and writing it off on their taxes.”
If you’re finding challenges to access the medication you need, what can you do? Jeanne suggests checking patient assistance programs from the various drug companies. Search for “patient assistance program” and the name of the medication to see whether you can qualify for what is essentially a subsidy from the drug company.
I’d love to hear your stories…
Morra
PS: The coolest thing happened, which is that The Charles Hotel, right in the center of Harvard Square in Cambridge, MA (and one of my favorite Boston places) has asked to buy The Anxious Achiever book to give as a gift to guests staying at the hotel over Harvard’s commencement. I’m so honored and I love the idea that Harvard grads will be getting a copy, because the book is super helpful for high achievers in uncertain times. If you have a graduate in your life, The Anxious Achiever makes a great gift!