ADHD Medication Prescriptions Spiked Ahead of Adderall Shortage: New Report

January 17, 2024

Prescriptions for ADHD medications increased significantly during the COVID-19 pandemic, especially for women and for adults aged 20-39, according to a new study published in JAMA Psychiatry. The most significant increases were found among prescriptions for adults aged 20-39, up 81% for non-stimulants and 30% for stimulants; and for women, up 59% for non-stimulants and 25% for stimulants.¹ By contrast, researchers found a decrease or no change in rates of prescriptions during the pandemic for medications used to treat other behavioral health disorders, including anxiety, depression, and opioid use disorders.

The researchers, associated with the U.S. Food and Drug Administration (FDA), sought to explore how the pandemic altered patterns of behavioral health treatment within the U.S. by looking at trends in new prescriptions written between 2018 and 2020, and between 2020 and 2022 for five classes of medications: antidepressants and benzodiazepines (for anxiety and depression), stimulants and non-stimulants (for ADHD), and buprenorphine (for opioid use disorder).

Compared to the pre-pandemic period, new prescriptions during the pandemic period:

Increased for:

• Non-stimulants (atomoxetine and guanfacine extended release)
  • +32%, from 1 million to 1.3 million
• Stimulants (amphetamine-dextroamphetamine and methylphenidate)
  • +14%, from 5.2 million to 5.9 million
• Antidepressants (sertraline and escitalopram)
  • +10%, from 29 million to 32 million

Decreased for:

• Benzodiazepines (alprazolam and lorazepam)
  • −9%, from 15.1 million to 13.7 million)
• Buprenorphine MOUD
  • −2%, from 9.2k to 9.1k

While rates of new prescriptions for antidepressants increased by 10%, this growth was consistent with pre-pandemic trends for this class of medication, and thus did not indicate a significant change. By contrast, the pandemic increase in rates of new prescriptions for both stimulants and non-stimulants for ADHD marked a notable departure from previous patterns.

In their discussion of possible explanations for the change in prescribing trends, the authors of the study said, “increased awareness in underdiagnosed populations, increased needs due to COVID-19 pandemic-related stressors, and reduced barriers to access may have helped to uncover pre-existing unmet needs as well as potential overprescribing.” They stressed, however, that further research is necessary to untangle this knot of possible factors and to “differentiate increases due to unmet need vs. overprescribing,”

ADHD Medication Prescribing Patterns: A Closer Look

The greatest change in prescribing trends for ADHD medications was observed in two groups of patients: women, and people in their 20s and 30s.

The increase in treatment rates for women may indicate a slow but important narrowing of a long-standing, gender-based diagnosis gap. Many studies have demonstrated that ADHD in women is frequently overlooked and dismissed.^2,3,4 “The underdiagnosis of ADHD in adult women is an ongoing medical equity issue with serious consequences,” writes Kathleen Nadeau, Ph.D., in the ADDitude article, “The Fate of Females with ADHD Is Improving Too Slowly.” “Researchers in Scandinavia reported that undiagnosed females had much worse outcomes than did their undiagnosed male counterparts, with higher rates of suicide attempts and psychiatric hospitalizations.”

The Shift to Nurse Practitioners

The study found that, across all drug classes, nurse practitioners had the largest increases in pandemic-era prescriptions, which is generally consistent with a recent study that found the number of nurse practitioners treating patients for psychiatric and mental health conditions increased by 162% between 2011 and 2019. At the same time, the number of psychiatrists treating these patients decreased by 6%.⁵

According to the JAMA Psychiatry study, the number of stimulants prescribed by nurse practitioners increased by 57% during the pandemic, while prescriptions by psychiatrists fell by 1%. The authors of the study write that this data, “suggests an increasing contribution of nurse practitioners initiating medication treatment of behavioral health conditions compared with other health care practitioners.”

Joe Schatz, DNP, CRNP, PMHNP-BC, CARN-AP, director of University of Pennsylvania School of Nursing’s Psychiatric/Mental Health Nurse Practitioner Program has witnessed the increasing contribution of nurse practitioners first-hand and calls the trend, “a train that’s not stopping.” “There are fewer physicians entering the field of psychiatry and more psychiatric/mental health nurse practitioners (PMHNPs),” he says, noting that similar trends are happening in the broader primary care workforce. “It’s anticipated that primary care NPs will outnumber primary care physicians 2:1 by 2030. This unprecedented shift in workforce is likely contributing to the unprecedented shift in prescribing.”

This shift in care, Schatz says, highlights the need for more robust and standardized training in ADHD and other mental health disorders for all professionals.

Prescribing Trends and the Adderall Shortage

The spike in stimulant prescriptions during the pandemic, combined with manufacturing delays, contributed to the start of a stimulant shortage in October 2022. As the shortage drags on, impacting scores of children and adults, FDA commissioner Robert M. Califf, M.D., and others have placed the blame on over-prescribing practitioners, including telehealth providers.

However, others condemn the Drug Enforcement Administration’s (DEA) inflexible drug quotas, which have not been changed to meet heightened demand. According to the DEA and FDA, manufacturers sold only 70% of their allotted quota in 2022, leaving 1 billion doses that could have been made but which were not. It’s unclear whether this unused quota was associated with U.S. or international markets. In response to this gap between production capacity and prescription output, 20 members of Congress called upon the DEA last year to create new telemedicine and prescription rules, address supply chain issues, and respond to increases in demand when formulating production quotas. The DEA says it is instituting changes to increase transparency in the quota process, however it’s unclear whether these changes will positively impact the ongoing ADHD medication shortage.

What remains inarguable, says Schatz, is the fact that this persistent lack of access to appropriate medication has had devastating consequences. “I’ve seen romantic relationships end, businesses dissolve, premature resignations, and early retirements,” he says. “I’ve heard about car accidents, overdrawn accounts, late fees, and eviction.”

Looking forward, the authors of the study emphasized the need to investigate the impact of marketing on prescribing practices and the importance of prioritizing clinical ADHD guideline development, in particular guidelines for adult ADHD, in order to “define treatment appropriateness.” The American Professional Society of ADHD and Related Disorders recently convened a special committee for this express purpose, and the first adult ADHD guidelines in the U.S. are expected this year.

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