Dosage and Drug Shifts, Generics, and Caffeine Can Help Kids with ADHD in a Pinch

February 28, 2023 - By Jess Berthold - Without his medication, my son, who has ADHD, is a boat adrift on choppy seas. He bumps around, spilling drinks and food, unable to control his limbs and impulses. He can’t sit still; he won’t stop talking – loudly. His emotions run wild. Learning at school and engaging in many public activities are out of the question.

Adderall, my son’s medication, has been in short supply for months. This week, I spent five hours calling pharmacies and doctors to find 10 pills. Meanwhile, in online ADHD forums, parents are brokering medication swaps.

In October, the FDA announced a shortage of Adderall. Other ADHD drugs have followed, as patients switch to alternate medications such as Ritalin and Concerta.

What’s the cause of the shortage?

Rojas: It has to do with supply chain issues and a spike in demand from adults, especially during COVID-19 when ADHD symptoms got worse for many and the drug could be prescribed online for the first time. Meanwhile, the Drug Enforcement Agency, which controls the supply of Schedule II drugs, hasn’t increased manufacturing quotas.

What should parents do if their pharmacy is out of their child’s meds?

Rojas: First of all, let your child’s clinician know. They may be able to prescribe a brand-name version if your child normally takes a generic, or a different dosage level. Since these are controlled substances, the pharmacy needs a script for the precise drug and dosage. This can mean some back-and-forth between clinician and pharmacy. If your clinician is not offering to do these things for you – ask them to do it.

Romani: Parents can try calling around to different pharmacies because supply varies place by place. Be aware, though, that pharmacies may be reluctant to give out information about supply over the phone because these substances are prone to abuse. Also, the pharmacies themselves don’t know what their stock will be tomorrow for these drugs in shortage because manufacturers don’t tell them. So, you have to call them every day.

Should children switch to a different ADHD medication?

Rojas: If the child has taken a different medication in the past and tolerated it, it should be okay to switch. Otherwise, definitely talk to your clinician because ADHD drugs are not equivalent. There are few head-to-head studies, but we have a lot of clinical experience that, for example, shows Adderall is more potent than a methylphenidate like Ritalin, so you need to consider that with dosing. Also, dosing and medication fit are idiosyncratic with stimulants. I have 45-pound kids who run circles around us and need high doses, and 150-pound linebacker teens who feel faint on low doses. You must start low and build up, and not necessarily dose by weight.

Should parents ration pills? How?

Rojas: With the guidance of your prescribing physician, it’s reasonable to play around with lower doses and different schedules. I have patients who take lower or no doses of stimulants on weekends, saving them for school days. Some children will only take the pills on the days when they have their hardest classes. Parents of children with ADHD know very well what they can get away with – whether they can skip on Wednesday afternoon when there is math homework or Sunday when there is church. Older kids can tell us if, for example, they have finals coming up or some other important factor.

Is caffeine a good substitute or supplement for ADHD meds during the shortage?

Rojas: I’ve always called caffeine the poor man’s Ritalin. There is clear evidence that it helps with focus. The problem is that it’s more habit-forming than stimulants that are prescribed and taken appropriately. I’d suggest parents try tea with their children first, and on a weekend morning, to see how their child reacts. Be aware that caffeine can increase the heart rate, unmask arrhythmias and cause gut issues. You also need to be careful about combining higher-caffeine products with stimulants because that can increase side effects. Caffeine use should always be discussed with clinicians.

What can parents do to manage the side effects, like anxiety and depression, that might result from a shortage of medication?

Rojas: We know there is a lot of secondary anxiety for kids when ADHD symptoms are undertreated. It’s important for parents to keep a sharp eye on mental health and report any changes to their clinicians. Try to promote good sleep, exercise, healthy eating and social opportunities – always, but especially during a medication shortage.

MEET THE EXPERTS

Neal Rojas, MD, MPH
Developmental-behavioral pediatrician at UCSF Benioff Children’s Hospital San Francisco who specializes in ADHD.

Jamie Romani, RN
Pediatric nurse with UCSF Benioff Children’s Hospital

Source: UCSF  Image credit: FDA