Explained | How Adderall abuse risks becoming another opioid crisis

By Ike Swetlitz

The fast rise of prescriptions for Adderall and other stimulants, along with rampant online treatment and advertising, suggest the start of another drug crisis like the opioid epidemic, a senior Drug Enforcement Administration official said Thursday.

The warning is the most urgent public message yet on these types of drugs by the agency.

“I’m not trying to be a doomsday-er here,” said Matthew Strait, deputy assistant administrator in the diversion control division said in an online seminar. But he compared the current situation with stimulants to the beginning of the opioid crisis and said “it makes me feel like we’re at the precipice of our next drug crisis in the United States.”

The DEA’s position on stimulants will have a direct effect on how many are manufactured, pharmacies’ access to them and how patients get prescriptions.

The agency is working on new regulations for online stimulant prescriptions, a practice that was made easier at the start of the Covid-19 pandemic. It is cracking down on businesses that violate the law, reviewing its methods for setting controlled-substance production limits and helping patients properly dispose of unneeded medications, a DEA spokesperson said.

The agency is responsible for ensuring that legitimate medicines only go to people who need them and stopping the flow of illegal drugs. The DEA failed to fully use these authorities to respond to the opioid crisis, a Department of Justice inspector general report found in 2019.

‘Controlled Substances’

Stimulant drugs are used to treat attention-deficit/hyperactivity disorder and narcolepsy. Because the drugs can be addictive and prone to abuse, they are “controlled substances,” which means the government limits their production, prescription and distribution. Similar rules apply to opioid painkillers, though experts chafe at comparing the drugs.

People who legitimately need prescription stimulants generally don’t get addicted to them, said David Goodman, a psychiatrist and assistant professor at the Johns Hopkins University School of Medicine. And if they stop using a prescription stimulant, they don’t go through withdrawal in the same way they would after stopping an opioid, he said.

At the same time, Goodman is concerned about people who don’t actually need stimulant prescriptions getting them anyway.

“The crisis, if you will, is not in the prescription of the medication,” Goodman said. “The crisis is in the accuracy of the diagnosis.”

There are no standard guidelines for the diagnosis and treatment of ADHD in adults, which is “most concerning” for the DEA, Strait said. Specialists in the field have been working on creating such standards over the past two years.

Stimulant drugs have also been in short supply since the summer of 2022. Many doses of generic Adderall, Concerta, and Vyvanse are still in shortage, according to the Food and Drug Administration.

Drugmakers have blamed some shortages in part on manufacturing limits the DEA sets. Some pharmacies have been unable to order sufficient quantities of the stimulants because of systems put in place after the opioid crisis. The DEA has previously provided data to show that the limits are not a problem in general, but has declined to provide company-specific information.

The DEA has been working with the Department of Health and Human Services to set up a “control tower” to make sure manufacturers that produce drugs in shortage can get buy enough materials, Strait said.

The opioid epidemic has killed more than 600,000 people, according to the Centers for Disease Control and Prevention. What started with inappropriate marketing by pharmaceutical companies and irresponsible prescribing by medical professionals now drives demand for heroin and fentanyl.

Three Similarities

Strait identified three similarities between the beginning of the opioid epidemic and the current situation: a public health concern, exploitation over the internet and an increased number of drugmakers manufacturing the drug.

The health concern that drove opioid use was the “fundamental belief” that pain is under-treated, Strait said. For stimulants, it could be the Covid-spurred “mental health crisis,” he said.

In both cases, unscrupulous people made use of the internet to fill the need, he said. For stimulants, Strait pointed to ads on social media sites like TikTok, as well as telehealth companies that “facilitate that prescribing function after short telemedicine encounters.”

Over two years ago, a Bloomberg News investigation revealed allegations that the telehealth company Cerebral Inc. was inappropriately pushing Adderall prescriptions. The company’s clinicians stopped prescribing controlled substances shortly after the article was published and faced federal investigations. The company has settled with some state and federal agencies and continues to cooperate with the Department of Justice, a spokesperson said.

Finally, Strait said, in both the opioid epidemic and the current situation, the country saw an increase in the number of drugmakers selling the pills, with the increased competition being “a hallmark of the epidemic,” Strait said.

Strait urged people looking for stimulants not to buy drugs on the internet.

“We see fake pills that look like Adderall that are being sold on the open net and the dark net,” he said. But they may not be Adderall at all, but rather fentanyl, or methamphetamine.