The Stimulant Medication Shortage Guide: Tips for ADHD Treatment & Medication Management in Philadelphia, Manhattan, Delaware & Nationally.
The ADHD medication shortage has been severely impacting patients in the areas that Rittenhouse Psychiatric Associates serves for several years now. This guide was put together, to help not only patients, but providers as well. We’re tired of seeing patients struggle with their ADHD symptoms, due to frequent disruptions in their care. We’re equally as frustrated seeing providers continuing to write patients for the same medications (like Adderall, Adderall XR, Vyvanse and Concerta), without discussing alternatives. Many patients AND PROVIDERS do not realize that there are multiple medications within the stimulant class, many of which are comprised of the same active ingredients as Adderall, Ritalin, Focalin etc, and have much better availability. When it comes to ADHD, routine is incredibly important. Part of that routine should include consistent treatment and ADHD medication management (if medically appropriate). We believe that if providers go a little bit out of their way to educate themselves on psychopharmacology, to spend a little more time with patients discussing options, to review promotions with pharmaceutical representatives, and to form relationships with specialty pharmacies – ADHD treatment and medication management can be very consistent and affordable for the individuals that we care for.
*Before we go on, this is NOT medical advice for anyone out there. It’s informative and meant to help professionals to understand that they can do more regarding helping appropriate patients struggling with their ADHD treatment, and to help patients to develop a better understanding of what to ask their medical professionals, when it comes to options. Do NOT change your medications without discussing with your medical professional. These medications have high risk for abuse, dependence, tolerance and withdrawal, and that’s not meant to be taken lightly. They also can have serious side effects, including (but not limited to) seizures, arrhythmias, elevated heart rate and blood pressure, and even death. With that said, they can be incredibly helpful and improve the quality of life, for the appropriate ADHD patient, and many tolerate them incredibly well.*
SCROLL DOWN For Medication “Substitutes” To Research and Discuss with Your Provider.
Background on the ADHD Medication Stimulant Shortage in Philadelphia, Manhattan, Delaware and throughout the US
Several factors have led to the Stimulant shortage throughout the US.
- DEA Annual Production Quotas of Controlled Medications: Each year the DEA (Drug Enforcement Agency) researches and decides on APQ (annual production quotas) of Schedule I and Schedule II Controlled Medications & Substances in the US. Medications such as Amphetamine (the active ingredient in Adderall), lisdexamfetamine (the main ingredient in Vyvanse) and Methylphenidate (the active ingredient in Ritalin), are Schedule II drugs, and we completely agree that as these medications have significant abuse potential, it’s incredibly important that the supply meets the demand, and does not significantly exceed it (of patients with ADHD, Narcolepsy or other legitimate medical reasons for taking these medications, at appropriate doses, under the care of a medical professional). This means, that there’s a limit with regards to how much Adderall, Vyvanse, Ritalin or other Stimulants are produced each year. Up until the last few years, demand was relatively consistent (albeit, the normalization of mental health treatment was producing an upward trend with regards to all mental health treatment). This resulted in a relatively consistent supply of medications, where the APQ’s, were appropriate to meet patient needs.
- The Opiate Epidemic and Shut Down Laboratories: Many do not realize, but the opiate epidemic has had a significant effect on the ADHD stimulant shortage in Philadelphia, Manhattan, and Nationally. As discussed above, there are annual production quotas that the DEA puts on the amount of Schedule I and Schedule II Controlled Medications that are produced each year. And as discussed above, that’s very important. As an appropriate response to the opiate epidemic, the DEA has been increasingly diligent about auditing laboratories and manufacturing companies that produce Adderall, Vyvanse, Ritalin, Concerta and similar medications (in additional to opiates). One of those laboratories (Ascent Pharmaceuticals), which produced approximately 12% of the generic supply Adderall, and large amounts of generic Ritalin, Concerta and Vyvnase, was shut down by the DEA in late 2022/ 2023, as there were concerns about their record keeping. When you do the math, we’re talking about 600 million less pills being produced – starting in 2023. For more information, click here.
- Failure to Meet the APQ quotas: In addition to laboratories and pharmaceutical companies having to halt or end the production of stimulants, the early 2020’s also saw supply chain issues with the Covid-19 epidemic and labor shortage issues. In 2022 and 2023, the DEA estimated (click here) that there was a one BILLION dose shortfall of produced stimulants in both 2022 and 2023 each! That means, that the US produced a billion fewer Adderall, Vyvanse, Ritalin and Concerta pills than they were allowed by DEA regulation, in BOTH 2022 and 2023.
- Covid – 19 Pandemic and ADHD Treatment: During the Covid-19 pandemic we saw an explosion of virtual Telehealth medicine, including in Psychiatry. From August 2019 to August 2020, there was a 3,552% increase in Telemedicine insurance claims alone. The increase in access of mental health treatment (especially to rural areas, where traditionally there has been a shortage of mental health providers) was a wonderful change in many respects. Patients should not have to live in a large city or wealthy community to have access to mental health services and ADHD treatment. Along with Telemedicine and increased access to mental health care, it only makes sense that there would be an increase in prescriptions written for ADHD medications and treatment – Prescriptions like Adderall, Vyvanse, Ritalin and Concerta, for legitimate ADHD patients.
- Big Business, Telehealth and ADHD Psychiatry: As you can see from #’s 1-4, in 2022/2023, things were pretty precarious regarding DEA quotas not being met, manufacturers of stimulants being shut down or on hold, supply chain issues, labor shortages, an increase in demand (due to the normalization of mental health and ADHD treatment), and increased access to mental health care throughout the country. Enter Big Business and ADHD online care: Around 2022, we saw a dramatic increase in large online mental health companies offering ADHD treatment, with extremely aggressive advertising campaigns on social media, and companies basically bragging about their short evaluations and subscription plans for ADHD medications. We’ve had patients call us, after using some of these companies, because they felt that providers were writing them for high doses of Adderall, without taking the time to understand their life story, personality, behaviors and other mental health difficulties (beyond possibly having ADHD). Our Opinion: If you had a bad day at work, a breakup with a significant other, are struggling financially, a family member is ill, you suffer with depression, had a recent trauma, are depressed, or have a substance use disorder – you likely will score pretty high on an ADHD survey. That does NOT mean that you have ADHD! That means that you need a provider to take the time to thoroughly review your history and symptoms, to make an accurate diagnosis and formulate a comprehensive treatment plan. Ok, I’ll get off my soap-box…. As we alluded to earlier, Adderall has high abuse potential, and with an explosion of prescriptions for this medication from some of these companies, we’ve also seen a significant increase in stimulant abuse and dependence (only worsening the shortage, harming patients with addiction struggles, and causing disruptions in care for legitimate ADHD patients, due to even a larger gap between supply and demand). The Adult population, targeted by a large number of these businesses is where we saw the largest growth; From 2012 – 2022 stimulant prescriptions for 31-40 year olds tripled per a report prepared by IQVIA for the DEA. And in case you’re wondering, we’re not the only ones concerned about the practices of some of these large online ADHD treatment companies. Click here and here and here.
How is Rittenhouse Psychiatric Associates different, and How do They Care for Patients with ADHD?
SCROLL DOWN For Medication “Substitutes” To Research and Discuss with Your Provider.
At Rittenhouse Psychiatric Associates, we pride ourselves in 60-90 minute initial evaluations, discussions about diet, exercise, meditation, and yoga, the offering of the non-pharmacologic treatment of ADHD (CBT Therapy for ADHD), a thorough understanding of a patient’s personality, behaviors, life-story and any history of trauma that could be affecting their symptoms, and when a medication is appropriate for the treatment of ADHD – discussing several options including non-controlled medications, and trade name controlled medications. Many of these medications are readily available through manufacturer programs, and contain the same active ingredients as medications such as Adderall, Ritalin, Concerta and Focalin. We also discuss the risks of stimulants (such as abuse, dependence, tolerance and withdrawal) and strive to use lower doses when appropriate, to minimize patient side effects and minimize the risk of addiction.
We are a practice of 25 psychiatrists, psychiatric nurse practitioners, therapists & psychologists who treat patients in Philadelphia, Manhattan New York, Pittsburgh, Delaware, Delray Florida and Southern New Jersey (Collingswood, NJ). We offer in-office and virtual Telehealth Psychiatric appointments – when allowed by law, for appropriate patients.
We will go the extra mile, to help patients struggling with the ADHD medication shortage. We study the pharmacology of the medications within the stimulant classes, we understand which medications are the most likely effective replacements for medications that are typically out of stock with pharmacies in Philadelphia and the areas that we serve, we educate ourselves on newer branded medications that are typically in-stock at specialty pharmacies, and stay up-to-date on manufacturer promotions – so that patients can consistently fill their medications, without disrupted care, for a reasonable cost.
Most of our providers trained at The University of Pennsylvania, The Johns Hopkins Hospital, and similar Academic Institutions and many teach, or have taught for their Departments of Psychiatry as well. We are an academic private practice, and driven by patient care, not volume or shareholder prices.
Finally, The ADHD Medication Guide, to Help Patients and Providers with the Stimulant Shortage in Philadelphia, Manhattan, Delaware and Nationally.
SCROLL DOWN For Medication “Substitutes” To Research and Discuss with Your Provider.
Overall ADHD Medication Substitution Tips: If a patient does well with either a medication in the amphetamine category, or the methylphenidate category, we generally try to stick with a replacement in the same category (as we find that patients often do better with one class vs. the other). If a patient does well with an immediate release, we’ll often recommend another immediate release. If they do well with an extended release, then we may try to use an extended release replacement. Finally, Patches can be very easy to fill, and may be a great option, particularly if their active ingredient is the same active ingredient as a patient’s typical medication. Patches may also be preferred, as individuals can wear them for only the amount of time that they need specific symptom management and many state that there are less “ups and down” from multiple dosing throughout the day.
Conversion Charts: Dosing is NOT the same for many ADHD medications, and providers should ALWAYS reference charts for proper dosage conversions, when making medication changes. Many of the providers within our practice at Rittenhouse Psychiatric Associates in Philadelphia, Manhattan New York, Pittsburgh, South Jersey and Delaware refer to The CHC Resource Library, and use the conversion charts found here. While it is common for a provider to prescribe a relative dose that’s slightly lower than a patient’s typical regimen (in case a patient is sensitive to the new medication) a dose several relative doses lower of a replacement medication, will likely inadequately treat a patient’s symptoms. This can be very frustrating for patients, especially if their ADHD treatment was well managed on their previous medication, and if they had to pay out of pocket for the new medication.
Prior Authorizations & How To Navigate Pharmacies: Providers within our practice at Rittenhouse Psychiatric Associates will complete a “Prior Authorization” for a new ADHD for a medication, within 24 business hours of notice that a prior authorization is required. Typically, this occurs after an Rx is sent in, and a pharmacy sends a “kickback” fax, stating that insurance didn’t go through. Many patients are surprised that the insurance company often will wait 48 or 72-business hours AFTER our PA is sent in, to decide on approval, and they will sometimes deny the approval (even if a patient cannot fill their normal prescription due to the ADHD medication shortage, and even if the provider provides all information that they request). This is very upsetting for both patients and provider alike, but the providers at Rittenhouse Psychiatric Associates will do what they can, to get the medication approved (within ethical & legal guidelines). Quick Tip: When a provider tells you that they sent in a prior auth… wait 48-72 hours, and ask the pharmacist to “re-run” the Rx (and tell them that a PA was sent in days earlier). It’s incredibly common for a medication to be approved, and the provider, patient, AND pharmacy to have no idea. The pharmacy has to “re-run” the Rx, to find out in these instances. This occurs whenever an insurance company approves a medication, but fails to send out a letter of approval (OR if they put said letter in snail mail – no joke)!
Paying out-of-pocket: There are times when a provider (through no fault of their own) cannot get a new medication approved. Insurance companies are “In Charge” when it comes to approvals, and have the final say. In these instances, patients are often surprised that paying out of pocket for some ADHD medications, can be [relatively] reasonable – albeit, not ideal. As an example, at the time that we wrote this article, using coupons easily found on GoodRx (scroll to bottom of page for link) withOUT insurance (“cash pay”), 30-day supplies of generic Dexedrine immediate release were 17 dollars at a local Rite Aid, Dexedrine Spansules 27 dollars at a local CVS, generic Mydayis was 92 dollars at a local Walgreens, Daytrana Generic patch 110 at a Rite Aid, and even generic Adderall 12 dollars at a local Rite Aid. These coupons are pharmacy specific (not just pharmacy company, but location). Some pharmacists are helpful with patients finding cost-savings like the above, but unfortunately others are not. We recommend that you review GoodRx for a couple substitute options (after meeting with your provider), as you may be surprised with what you find (prices for certain medications may be lower than your insurance’s medication copay – not kidding).
Using Manufacturer Coupons pertains to Trade Name ADHD Medications. Many individuals assume that a trade name medication will cost more than a generic, but this isn’t always the case. Pharmaceutical companies will often want patients to start (and continue on) one of their medications and therefore, will offer a month (or a year) with very low co-pays. A very common promotion is “first month free, and the following 6-12 months for 50 or 100 dollars a month.” Unfortunately, the promotions tend to be better for individuals with commercial insurance plans, but there are often promotions for individuals even without insurance. The logic for pharmaceutical companies is that if they have great medication that works well for ADHD treatment, a promotion may convince you to trial it, and you’ll likely want to continue with it. Even better, if the promotion lasts a year, that may give the insurance company time to get it on your insurance’s formulary. We’ve included links below to manufacturer coupons. This will help both patients and providers, with navigating the ADHD Stimulant Medication Shortage. THIS IS UPSETTING…. but some pharmacists will be more helpful with these coupons than others. We recommend asking your pharmacist directly if they can run the coupon through your insurance (even if your insurance doesn’t cover it, or they say you need a prior authorization), and if that’s turned down…. we recommend that you ask them to run these coupons as if you were paying in cash, outside of insurance. Some pharmacists will do all of this automatically, but others won’t. Unfortunately, we recommend you advocating for your care, and asking them to do so. Often you won’t know if the coupon works, until they run it through both insurance, and as “cash pay.” Of note, we at Rittenhouse Psychiatric Associates commend the pharmacies & pharmacists who take the time to help patients sort this out. It’s a lot of work, and they’re busier than ever with all of the pharmacy closures that have been happening in recent years. It’s not an easy job, Please thank them immensely!
Giving Trade Name a Try: If the medication that works to treat your ADHD is generic, and it really works for you, you could consider Trade Name. This could apply to patients taking Adderall, Adderall XR, Focalin & Focalin XR, Vyvanse, Ritalin, Concerta and others. For example, many do not realize but your provider can attempt a prior authorization to have your insurance pay for the original patented medication, from the original manufacturer. This typically involves the provider including in your prior authorization that you’ve failed multiple trials of other medications within the same class, and that there’s a reason for you not being able to fill the generic. Reasons could include that a patient has an allergy to one of the non-active ingredients in the generic (as long as it’s not also in the Trade Name medication), a side effect with the generic that they may not have with the Trade Name medication, or (in this case), that a patient has been unable to find the generic in many pharmacies, and they require the Trade Name medication to continue consistent care. We recommend that patients discuss with their pharmacy (and we always recommend Mom and Pop Pharmacies, as they tend to be very helpful), whether they can indeed get the Trade Name ADHD medication in, or if that’s also on a severe shortage.
*KEEP CALM AND BE NICE TO YOUR PROVIDER,” IF INDEED THEY ARE TRYING TO HELP – There are certainly providers out there who are not making the effort to discuss options with patients, fill out prior authorizations, and educate themselves on manufacturer promotions, specialty pharmacy availability, and the psychopharmacology of substitutes within the stimulant classes. However, please keep in mind, that this is a process. When a provider sends in a prior authorization (even with all requested information), insurance companies typically take up to 72 business hours to give a response. It’s not uncommon for them to deny to auth (say no), and then the provider needs to review their letter of denial, strategize a way to try to get an appeal approved, or re-review the chart, and try to sort out 2nd or 3rd line steps and/or options. Once the next step is sorted out, then the response from insurance to that appeal, or new prior auth. will take an additional 72 business hours or so (and they may so no again). Insurance companies also have “exclusion lists,” which means that no matter what you say, or do, they will not let a patient fill a specific medication. In our experience, it’s also not uncommon for “member services” of a person’s insurance company to tell patients that as soon as the prior auth is sent, they’ll let the patient fill the medication (giving a great deal of optimism to the patient), and then the actual decision makers within the insurance plan deny the medication, or put up road blocks for the provider. This makes the prescriber look like the “bad guy,” which is incredibly upsetting, especially if they’ve been working their tail off, trying to help.
Consider Non-Controlled Options for ADHD:
Non-Controlled Options for the treatment of ADHD can be surprisingly effective and well tolerated. These medications can be combined with stimulants (by the expert clinician), or can be used as mono-therapy. Medications such as Strattera (Atomoxetine) and Qelbree (Viloxazine) are taken daily, and their effects buildup in the system (with maximal effect typically occurring 8-12 weeks after initiation of ADHD Treatment). ADHD tends to affect individuals at work, at home and socially. Patients will often say that having support for their symptoms 24-7, is preferred to an “as needed” approach that many take with medications such as Adderall, Ritalin and Vyvanse. These medications do not have abuse potential, which is another clear benefit.
- Strattera (Atomoxetine) is a norepinephrine reuptake inhibitor, that is offered in generic and trade name versions. It is taken once daily, and maximum effect is typically 8-12 weeks after initiation of treatment (or at final dose). It provides support for a patient’s ADHD throughout the day (every day), which many patients prefer to an “as needed” approach. This medication is readily available, and not affected by the shortage. We’ve found that many adults “fail” a trial of this medication, due to dosing that is too low. Most adults w/ ADHD require 80 – 100 mg or so, for effective treatment. It does not have abuse potential.
- Qelbree (Viloxazine) is a norepinephrine reuptake inhibitor (similar to Strattera above). It is currently only offered in Trade Name, but the manufacturer offers an affordable promotion, found here. This medication is typically in stock, or relatively easy for pharmacies to order for patients. Full effect is 8-12 weeks after initiation of treatment (or at final dose), and it provides 24-7 ADHD support for patients (as opposed to an “as needed” approach.” We’ve found that it is generally well tolerated. It does not have abuse potential. Interestingly, if a patient’s insurance doesn’t cover Strattera, the manufacturer’s coupon may make Qelbree a more affordable option.
- Intuniv ER (Guanfacine ER) is a once daily medication that is available in Trade Name and Generic Versions. It is readily available, and treats both ADHD and elevated blood pressure. It is a centrally acting alpha 2 agonist (a different mechanism of action than most other ADHD medications, which explains its antihypertensive effects). With that said, it is generally well tolerated (even if someone has completely normal blood pressure). It takes several weeks of daily dosing to reach full effect. Patients will report improved ADHD symptoms all day, and many prefer this to an “as needed” approach.
- Clonidine (Kapvay) is a is a centrally acting alpha 2 agonist (similar to Intuniv above). It is used in the treatment of ADHD, elevated blood pressure, and some providers also utilize this medication for the treatment of anxiety and opiate withdrawal symptoms. The experienced clinician can often utilize this medication for a patient, even if they do not have hypertension. It is available in both Trade Name and generic versions. It is typically dosed twice daily (morning and night). It should not be stopped abruptly, as this can result in rebound (or withdrawal) elevated blood pressure. There are reports of this medication being abused (particularly by individuals with opiate use disorders), however, it is generally thought of as having very limited abuse potential, in relation to stimulants.
- Modafinil (Provigil) is sometimes used off label for the treatment of ADHD. It is more-commonly prescribed for fatigue in individuals with narcolepsy or shift work sleep disorder. With that said, it can be effective for some patients in treating ADHD symptoms. It is thought to work by binding to the dopamine transporter – inhibiting dopamine’s reuptake (making dopamine more available in several regions of the brain). Reports suggest less abuse potential than medications such as Adderall, Ritalin and similar ADHD treatments. Improved energy and cognitive performance can occur within 2 hours of first dose. This medication is either typically in-stock, or can be ordered at most pharmacies. However, it can be difficult to get insurance approval when used for ADHD, as it is not considered a first line treatment (and again, it is not FDA approved for ADHD).
- Armodafinil (Nuvigil) is sometimes used off label for the treatment of ADHD. It is the R-Enantiomer of Modafinil (translation, the two compounds are mirror images of each other). Thus, the information above for Modafinil, also applies to Armodafinil. For whatever reason, some patients do better, or tolerate one vs. the other.
ADHD Medications in The Amphetamine Category:
Immediate Release Amphetamine Medications:
- Adderall: Adderall is comprised of 75% Dextroamphetamine and 25% Levoamphetamine as its active ingredients (D and L-Amphetamine). It’s an immediate release medication, typically dosed twice daily, and providing about 4 hours of symptom relief per dose. Possible Substitutes:
- Evekeo is a generic medication comprised of 50% D-amphetamine and 50% L-amphetamine. It has the same active ingredients as Adderall, but a more balanced ratio of the active ingredients. Many patients state that there’s less anxiety, irritability, jitteriness and “crash” with Evekeo than Adderall, as D-amphetamine is more likely to cause those side effects per reports (than L-amphetamine). As it is available in generic, providers can typically get a PA approved, and it tends to be rather readily available at even large chain pharmacies, because neither patients or prescribers seem to know about it.
- See the medications under “Dexedrine” which are D-Amphetamine products – is the primary active ingredient in Adderall.
- Dexedrine is a generic medication, that is comprised of Dextroamphetamine (D-amphetamine). This is the primary active ingredient in Adderall (75% D and 25% L-amphetamine). Dexedrine is sometimes on shortage, but but LESS OFTEN than Adderall. It may be worth asking your pharmacist if they have this in stock, if you do well with Adderall.
- Zenzedi is a trade name medication, with its active ingredient being Dextroamphetamine (the primary active ingredient in Adderall and Adderall XR, and the only active ingredient in Dexedrine). Because it is a trade name medication, its manufacturer has co-pay promotions and this can typically be ordered by most pharmacies. Because many patients and prescribers do not think of this medication as an option, it tends to have better availability than Adderall. It’s short-acting, with a similar duration of action as Adderall Immediate Release. For the manufacturer’s promotion, click here.
- ProCentra’s active ingredient is D-amphetamine (the main active ingredient in Adderall [75%] and the only active ingredient of Dexedrine). It is an immediate release stimulant in solution (liquid) form. It is FDA approved in children, but can be used off label for ADHD in adults. As solutions are infrequently prescribed (particularly in adults) it tends to have better availability than many frequently prescribed tablets and capsules. We recommend that patients look at out-of-pocket prices using GoodRx (Scroll to bottom of page for link), or go to the manufacturer’s website for a coupon.
Extended Release Amphetamine Medications:
- Adderall XR: Adderall XR is comprised of immediate release Adderall (D and L-amphetamine) and beads that are coated so that after 4 hours or so, there’s a second delivery of these same ingredients, as they dissolve in gut. Thus, it typically provides about 8 hours of symptom relief for ADHD. Just like with immediate release adderall, it’s 75% D-amphetamine and 25% L-amphetamine.
- Adzenys XR-ODT is comprised of both D & L-amphetamine (the active ingredients in Adderall) and is formulated as an extended release dissolvable tablet. It is typically available at a large # of specialty pharmacies throughout the US, and they have a promotion making it reasonably affordable for many patients. Click here for participating pharmacies and coupon information. Many patients state that this medication has better tolerability than either Adderall or Adderall XR.
- Dynavel XR is an extended release combination of D-Amphetamine and L-amphetamine. Similar to Adderall XR, some of its beads are covered in coatings, but with a larger variation of thicknesses than in Adderall XR. Thus, patients will report very similar effects and tolerability as Adderall XR, but instead of it lasting 8-9 hours, its duration of effect is approximately 13. We think of this medication as “Extended- Extended Release Adderall” (see Mydayis below as well). Its manufacturer has a promotion making it relatively affordable for patients with many commercial insurance plans, and pharmacies can typically stock this medication within a couple of days of a prescription. The manufacturer coupon can be found here.
- Dexedrine ER caps / Spansules: Dexedrine ER is a generic medication, that is comprised of Dextroamphetamine (D-amphetamine). This is the primary active ingredient in Adderall (75% D and 25% L-amphetamine). Dexedrine is sometimes on shortage, but if Adderall XR is working well for a patient, and they a issues with filling due to the stimulant shortage, it may be worth asking your pharmacist if they can get it in stock. You may also consider asking your local specialty pharmacy if they can order it. If insurance doesn’t cover it, you may want to consider using a coupon from Good Rx (scroll to bottom for link) as this medication can be very affordable – possibly less than your typical copays.
- Xelstrym Patch is a patch delivering D-Amphetamine (the main active ingredient in Adderall and Adderall XR, and the only active ingredient in Dexedrine and Zenzedi). Patients can wear this patch for 8-9 hours, and will state that there’s a smooth activation of the medication into their system, and they do not have the “ups and down,” of taking an immediate release medication several times a day. Patients are recommended to alternate sites each day (for example, right shoulder one day, and left the next). The manufacturer has a promotion where patients with commercial insurance can fill this medication for a reasonable cost, and it is readily available (or it can be ordered within a couple days) at large number of pharmacies and specialty pharmacies throughout Philadelphia, Manhattan, Delaware and the US. The manufacturer promotion can be found here.
- Mydayis ER is an extended release combination of D-Amphetamine (the main active ingredient in Adderall and Adderall XR) and 3 Amphetamine salts. It is available in generic form, which makes it more affordable and available. Its active ingredients are coated in various thicknesses, so that it is absorbed into the body over a longer period of time than Adderall or Adderall XR. Reported ADHD symptom relief is approximately 16 hours. This can be very beneficial for patients who struggle with no only ADHD symptoms during the work day, but also difficulties with obligations into the evening. Similarly to Dynavel XR above, we consider this an “Extended-Extended Release Adderall” as well. Many pharmacies and specialty pharmacies are able to stock, or order this medication within a few days. Providers can attempt a prior authorization, but patients may also find that GoodRx (scroll to bottom for link) costs out-of-pocket to be reasonable.
- Vyvanse (Lisdexamfetamine) is a prodrug of Dextroamphetamine or D-Amphetamine. This means, that your body slowly turns it into Dextroamphetamine. It is available in both Trade Name and Generic formulations. Many think of Vyvanse as the “Gold Standard” of ADHD treatment for Adults, as it is once daily dosing, and often well-tolerated by individuals with ADHD. As its main ingredient is turned into its active ingredient, patients will often state that its effects are more gentle and “smoother” than multiple doses of immediate release medications (or even common XR medications). It also often lasts 12-14 hours. Unfortunately, all of this means that it is also frequently affected by the ADHD shortage in Philadelphia, Manhattan, Delaware and Nationally.
- Vyvanse is long-acting as mentioned above. Therefore, if someone does well with Vyvanse, but cannot fill it due to the Stimulant Shortage, we typically recommend a long-acting D-Amphetamine [Dexedrine ER or Xelstrym Patch] or D & L-Amphetamine medication [Dynavel XR or Mydayis ER]. If that’s not available, then we typically recommend a short acting D-Amphetamine medication [Dexedrine, Zenzedi or Procentra] or short acting D & L-Amphetamine medication [Evekeo]. See above for their information and manufacturer promotions.
- Vyvanse Chewable Tablets are available in doses from 10 to 60 mg. These tablets are a common-sense substitute for Vyvanse capsules (same exact medication, just a chewable pill). Patients are often surprised that many insurance companies will accept a patient being unable to fill their Vyvanse due to the shortage, as an acceptable reason to approve a prior authorization. Additionally, this may be a good option for individuals who have difficulty swallowing pills. We would recommend that patients ask their pharmacist if they have chewable Vyvanse in stock, and if their insurance requires a prior auth if so.
ADHD Medications in The Methylphenidate Category:
Immediate Release Methylphenidate Medications:
- Ritalin is comprised of a 50% ratio of D-Methylphenidate and L-Methylphenidate. It is typically dosed twice daily, as each dose typically provides about 4 hours of ADHD symptom relief (which is common among immediate release medications). Ritalin is very commonly prescribed for the treatment of ADHD in both children and adults, and therefore, is commonly affected by the Stimulant Medication Shortage in Philadelphia, Manhattan, Delaware and nationally.
- Methylin has the same active ingredients as Ritalin (D and L-Methylphenidate). It is in solution (liquid) form, and therefore, many patients and providers do not think about this medication as an option. Because of that, pharmacies often have it in stock, or at least can order it. It’s available in both Trade and Generic, and out-of-pocket expenses may be very reasonable on GoodRx (scroll to bottom for link).
- Focalin is comprised of Dexmethylphenidate (D-Methylphenidate – one of the two active ingredients in Ritalin)). For whatever reason, some patients do well with Ritalin (a 50% ratio of D and L-Methylphenidate) and some do best with only D-Methylphenidate (Focalin). Focalin has been significantly affected by the ADHD stimulant shortage in Philadelphia and nationally.
- See Azstarys below for an extended release D-Methylphenidate (and D-Methylphenidate Prodrug) product.
Extended Release Methylphenidate Medications:
- Ritalin LA is comprised of a 50% ratio of D-Methylphenidate and L-Methylphenidate. It is extended release, and typically dosed once daily. A dose is typically reported to last about 8- 9 hours. Unfortunately, this medication is often affected by the ADHD Stimulant Shortage in Philadelphia, Manhattan and Delaware.
- Cotempla XR-ODT is an extended release, dissolvable (grape flavored) D & L-Methylphenidate product. The manufacturer has promotions with specialty pharmacies and it is typically readily available. Click here. Many providers do not think about this medication as an option, which makes it easier to keep in stock.
- Jornay PM is an extended release D and L-Methylphenidate. It is taken AT NIGHT and its active ingredients begin to be slowly released, approximately upon awakening. It has a duration of action of approximately 10 hours (once taking effect). It is readily available at many pharmacies that are searchable on the manufacturer’s website, and there are typically promotions making it affordable for many patients – found here. Some providers believe that a once [nightly] medication for ADHD treatment, that doesn’t begin to take effect for 8+ hours after taking it, may decrease abuse potential significantly.
- Relexxii is a once daily extended release D & L-Methylphenidate ADHD product. It has a large # of dosage options (for tailing treatment) and has been FDA approved for patients from 6 to 65 years of age. It tends to be available through many pharmacies (as it’s less known than many other ADHD medications) and there are manufacturer promotions that can make it very affordable for many patients. Click here for promotions.
- Daytrana is a Patch containing both D and L-Methylphenidate. We think of this as Ritalin LA in patch form. This medication is available in both Trade and Generic versions, and therefore, providers can often get it approved through a patient’s insurance. It is often available at pharmacies, or they can typically order it within a few days.
- Quillivant XR is a solution (liquid) medication with the active ingredients of D and L-Methylphenidate. It is extended release, with approximately 12 hours of symptom control. As it is a solution, providers often do not think to prescribe it to adults, and therefore, it often is available at pharmacies (or they can order it within a few days). It is FDA approved in children, but can be used off-label in adults. For manufacturer promotion information click here.
- Concerta is an extended release D and L-Methylphenidate. It is very similar to Ritalin LA (above), but has a slower release pattern of its active ingredients (and therefore, patients often report a longer duration of symptom relief – up to 12 hours). Unfortunately, this medication is often affected by the ADHD medication shortage.
- See the possible replacement medications under Ritalin LA above, and Focalin XR below. Keep in mind, that Concerta is more closely related to the Ritalin LA replacements, than the Focalin XR replacements (as Concerta is a combination of D and L-Methylphenidate, and Focalin is D-Methylphenidate as the active ingredient only).
- Focalin XR is comprised of Dexmethylphenidate (D-Methylphenidate) as its active ingredient. It is dosed once daily, and patients often report an 8-9 hour duration of ADHD symptom relief. Unfortunately, this medication is often affected by the ADHD stimulant shortage.
- Azstarys is comprised of D-Methylphenidate (the active ingredient in Focalin and Focalin XR) and Serdexmethylphenidate. Serdexmethylphenidate is a “prodrug” of Dexmethylphenidate, meaning that the body turns it into Dexmethylphenidate. Because it has to break the prodrug down, this creates and extended release medication (breaking it down takes time). So, someone can think about Azstarys as an extended release Focalin, as the active ingredients are the same as the active ingredients in Focalin IR (once broken down). Azstarys is suprisingly available at most pharmacies (including large chains) and the manufacturer has a reasonable promotion, making it relatively affordable with most commercial insurance plans in the Philadelphia, Manhattan and Delaware areas. Click here.
Discontinued Medications in the US – in the Methylphenidate category include [added for completeness, we do not mean to frustrate anyone reading].
- Aptensio XR contains the active ingredients of D & L-Methylphenidate.
- Methylin ER (Ritalin SR): Solution forms of the active ingredients of Ritalin LA.
- Quillichew ER: A chewable and extended release D & L-Methylphenidate product.
- Metadate CD contains the active ingredients of D & L-Methylphenidate.
Link to GoodRx: For Out-of-Pocket costs for ADHD Medications, at your local pharmacies.
For More Information on non-pharmacological treatment of ADHD at Rittenhouse Psychiatric Associates, click here.
For More Information on ADHD (Definitions and General Information), click here.
To Schedule with Rittenhouse Psychiatric Associates:
Serving Philadelphia, Pittsburgh, Manhattan New York City, Wilmington, DE, Southern New Jersey, Delray Florida and Surrounding Communities.
