IN RECENT YEARS, many new stimulant medications have been approved by the US Food and Drug Administration (FDA) for treatment of ADHD. These new formulations vary in their duration of benefit, and many offer new ways that the medication is administered or “delivered.” Although this expanded range of stimulant medication options has been a significant benefit for many families and individuals, challenges arise when people are unable to get the specific medication that they think is best for themselves or their child.

Perseverance, flexibility, and creativity are key to success in dealing with the ongoing shortage of various ADHD stimulant medications. Here are some helpful tips and strategies.

Perseverance

If your preferred pharmacy does not have the medication that was recommended by your healthcare provider:

• Speak with the pharmacist (not a pharmacy tech) and ask what they recommend. Some chain pharmacies can check inventories at other locations, and they may also be able to advise you as to when they may get the desired medication from their distributor.
• Call other pharmacies that are not affiliated with your preferred pharmacy. In addition to calling other chain pharmacies, you should call non-chain pharmacies as well. As with your preferred pharmacy, ask the pharmacist what they recommend and when the desired medication will likely be available.
• If you call multiple pharmacies and cannot find the specific preferred medication, then wait a few days and repeat this same process of making multiple phone calls. This will be easiest if you keep a written list of pharmacies along with their phone number; you can also use this list to take written notes about what they advised you.
• Unfortunately, some pharmacies may not provide information over the phone if you call to check on the stimulant medications that they have available in stock. This is sometimes due to pharmacist concerns about drug-seeking behaviors. If a pharmacist does not want to disclose information about in-stock medication options over the phone, you can ask the pharmacist to look up your child’s name in a state “prescription monitoring program” to verify that this is not a drug-seeking behavior. You may have more success at getting this information from a pharmacist at a local, non-chain pharmacy—especially if you have been a longstanding customer of that pharmacy. In some instances, pharmacists may only share this information with a healthcare provider or their staff.
• Pharmacists may, in some instances, be more responsive to the needs of “regular” customers— families who have had many other prescriptions filled at their pharmacy in the recent past. Although it is impossible to know how all pharmacies will prioritize customers when they receive a limited supply of a specific stimulant medication, it is not unreasonable for a pharmacist to give priority to meeting the prescription needs of their longstanding customers. Thus, having a nice relationship with a local pharmacist may be helpful not just in terms of them possibly sharing information over the phone with you about inventory, but also possibly prioritizing your prescription needs for a specific stimulant medication when they have it available.
• Courtesy counts. Although it is understandable that you may get very frustrated and upset when they cannot obtain the stimulant medication that you need, you need to remember to not verbally assault the pharmacist since it is not their fault and they are generally very sympathetic to your situation. Kindness toward the pharmacist will increase the likelihood that your pharmacist will do everything possible to help you and your family.
• Lastly, you may wish to contact the manufacturer of the medication you are seeking. In some cases, the manufacturer’s website for the medication may be able to provide you with information about availability; if not, you can try calling the manufacturer directly for help in finding the medication.

Flexibility

If you are unable to get the medication that your healthcare provider has prescribed and you are not able to wait for it to become available:

• Speak with your healthcare provider about what stimulant medication alternatives exist and also speak with your pharmacist about what stimulant medications are in stock. Although no two stimulant formulations are exactly the same, there are many stimulant formulations that are extremely similar. And, although there are shortages of many different stimulant formulations, availability can vary day-to-day and can also vary brand versus generic, formulation, and even the strength.
• Generic stimulant medications are typically less expensive than their branded counterparts; for this reason, generic formulations of stimulants are more likely to be in short supply. Many of the newest stimulant formulations that are not available generically may be more available in pharmacies. And, although they are generally more expensive, their manufacturers often offer patient savings coupons to reduce a patient’s out-of-pocket costs.
• Consider your priorities when choosing the right alternative stimulant medication! If your preferred stimulant medication is not available, you may need to consider trying a different stimulant medication. In these instances, consideration should be given to what are the priorities in selecting an alternative stimulant formulation—is it the medication’s means of administration, its duration of action, or its costs? The accompanying charts show virtually all of the FDA-approved medications organized by means of administration and duration of benefit. Keep in mind that a combination of long-acting and short-acting medications is sometimes needed to achieve the desired duration of benefit or clinical response.
• If you are flexible and willing to try a similar stimulant medication—knowing that it may or may not as good, but it may even be better—then discuss this with your healthcare provider what stimulant medications may be a suitable alternative. It would be especially helpful if you can inform your healthcare provider what medications (name and strength) are presently available in stock.
• The accompanying charts, Stimulant Medications for Treatment of ADHD, show virtually all of the different FDA-approved stimulant medications for treatment of ADHD based on means of administration. Thus, for example, if a child has trouble swallowing a pill or capsule and needs a liquid formulation, then you can look at the different short-acting and long-acting liquid formulations as options.
• Since there are many long-acting formulations that differ in their general duration of benefit (eight vs. ten vs. twelve hours), recognize that a medication with a somewhat different duration of action may be an adequate (if not perfect) treatment choice.
• Since most individuals will respond well when treated with either methylphenidate or amphetamine, do not limit yourself to one active ingredient versus the other. The Stimulant Medications for Treatment of ADHD charts show you various possible options and alternatives.
• If once daily dosing with a stimulant for twelve hours of benefit is not an option, then consider using a combination of medications (if available) to cover that extended time period. For example, an eight-hour medication before school and a four-hour medication after school will approximate the benefit of the twelve-hour medication that may not be available.

Creativity

Speak with your healthcare provider about creative solutions with respect to prescribing based on availability. For example:

• If you use and/or your child uses a 15mg transdermal Daytrana patch but the pharmacy only has 30mg patches in stock, perhaps your physician can write a prescription for the 30mg patch and then guide you to cut the patch so that you only apply one-half of the 30mg patch. (The unused half can be saved and used the following day.)
• Similarly, if you are and/or your child is on a 20mg dose of Vyvanse and the pharmacy only has 40mg capsules in stock, discuss with your healthcare provider if they are willing to prescribe the higher dose and then have you dissolve a 40mg capsule in water but have you give only half the medication solution.

Please note that, although these strategies are safe and effective if properly implemented, the FDA does not recommend cutting transdermal patches in half or giving less than a complete Vyvanse capsule when mixed in water.

Some additional suggestions

Don’t wait until the last minute to request a refill. If you receive a thirty-day supply of medication, then mark your calendar as a reminder to when you should request a new prescription—which is typically twenty-five to twenty-eight days from when the last prescription was filled by the pharmacy (not when it was picked up by you).

If you do not, or your child does not take medication every day, you should still pursue a prescription refill at least three-and-a-half weeks after your most recent prescription was filled rather than wait until you only have a few pills or capsules left. You can even call your healthcare provider for a new prescription three weeks after the last prescription; although the pharmacist may not be able to fill the prescription after just twenty-one days, at least it will be on file and available for when a prescription renewal can be approved by your insurance company.

If you cannot find one or more acceptable stimulant medications, then speak with your healthcare provider about possibly using a nonstimulant medication (such as atomoxetine, viloxazine, or guanfacine) instead. Although these medications are not always as effective as stimulants, they are approved by the FDA for treatment of ADHD and can often play an important role when used alone or in conjunction with a stimulant for treatment of ADHD.

Andrew Adesman, MD, is chief of developmental and behavioral pediatrics at the Steven and Alexandra Cohen Children’s Medical Center of New York in New Hyde Park. Dr. Adesman is a professor of pediatrics at the Zucker School of Medicine at Hofstra/Northwell. He is a former member of CHADD's professional advisory board and Attention magazine's editorial advisory board.

Anna Krevskaya, MD, is a developmental pediatrician at the Steven and Alexandra Cohen Children’s Medical Center of New York, and she is an assistant professor of pediatrics at the Zucker School of Medicine at Hofstra/Northwell.