Disrupted Access to Prescription Stimulant Medications Could Increase Risk of Injury and Overdose

Distributed via the CDC Health Alert Network
June 13, 2024, 1:00 PM ET
CDCHAN-00510

Summary
The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to inform public health officials, clinicians, and affected patients, their families, and caregivers about potential disrupted access to care among individuals taking prescription stimulant medications and possible increased risks for injury and overdose. On June 13, 2024, the U.S. Department of Justice announced a federal health care fraud indictment against a large subscription-based telehealth company that provides attention-deficit/hyperactivity disorder (ADHD) treatment to patients ages 18 years and older across the United States. Patients who rely on prescription stimulant medications to treat their ADHD and have been using this or other similar subscription-based telehealth platforms could experience a disruption to their treatment and disrupted access to care. A disruption involving this large telehealth company could impact as many as 30,000 to 50,000 patients ages 18 years and older across all 50 U.S. states.

This potential disruption coincides with an ongoing prescription drug shortage involving several stimulant medications commonly prescribed to treat ADHD, including immediate-release formulation of amphetamine mixed salts (brand name Adderall®). Patients whose care or access to prescription stimulant medications is disrupted, and who seek medication outside of the regulated healthcare system, might significantly increase their risk of overdose due to the prevalence of counterfeit pills in the illegal drug market that could contain unexpected substances, including fentanyl. Given the national drug overdose crisis and threats associated with the illegal drug market, individuals struggling to access prescription stimulant medications are urged to avoid using medication obtained from anyone other than a licensed clinician and licensed pharmacy.

In addition to concerns about using illegally acquired stimulant medications, untreated ADHD is associated with adverse outcomes, including social and emotional impairment, increased risk of drug or alcohol use disorder, unintentional injuries, such as motor vehicle crashes, and suicide. Health officials and healthcare providers may need to assist affected patients seeking treatment for ADHD and should communicate overdose risks associated with the current illegal drug market as well as provide overdose prevention education and mental health support.

Background
ADHD is a brain disorder that can make it difficult to concentrate or control impulsive behavior. ADHD affects an estimated 9.8% of children and 4.4% of adults in the United States. Clinicians commonly treat ADHD and narcolepsy with prescription stimulant medications. The percentage of children and adults receiving prescriptions for stimulants to treat ADHD increased from 2016–2021, particularly during 2020–2021. Telehealth policies implemented during the COVID-19 pandemic have allowed for greater access to ADHD treatment, including treatment with prescription stimulants, without the need for an in-person health care visit.

Although prescription stimulants are commonly used safely and appropriately, they can be misused (i.e., taken in a manner or dose other than prescribed, taking someone else’s medication, or taking a medication to get high or for another desired effect unrelated to a medical condition). Misuse of prescription stimulants, particularly among young adults, is a growing public health concern, with 14.5% of college students reporting misusing prescription stimulants. U.S. rates of overdose deaths involving stimulants, including cocaine and psychostimulants with abuse potential (e.g., methamphetamine and prescription stimulants), have increased steadily since 2014, both with and without co-involved opioids. The effect of stimulants on the human body and brain can vary by how frequently they are used, how strong they are, how they are consumed, and the amount consumed. People experiencing stimulant overdose are often awake and may be breathing quickly. They may need assistance in reducing overheating and overstimulation.

The impact of the indictment on the telehealth company’s patients is unknown at the time of this HAN’s release. However, some or all patients who have been accessing treatment or prescriptions for ADHD through the telehealth company might find they need to or want to find a new healthcare provider. They might also have difficulty filling a stimulant prescription. Some patients might try to seek medication outside the regulated healthcare system. Counterfeit pills that look like prescription stimulant medications, such as Adderall®, might contain illegally made fentanyl or other dangerous substances, thus increasing the risk of nonfatal and fatal overdose. Recently, the Drug Enforcement Administration (DEA) reported that laboratory testing indicates 7 out of every 10 pills seized from the illegal drug market contain a lethal dose of illegally made fentanyl, a synthetic opioid that is up to 50 times stronger than heroin and 100 times stronger than morphine.

Signs of an opioid overdose include—

• Unconsciousness or inability to awaken
• Slow or shallow breathing or difficulty breathing such as choking sounds or gurgling/snoring noise from a person who cannot be awakened
• Discolored skin (especially in nails or lips)
• Small, constricted “pinpoint pupils” that don’t react to light

A person who has been misusing prescription stimulants might seek out illegal drugs they believe can provide them with the same effects as the prescription. Transitioning to using illegal drug products is extremely dangerous. Unlike prescriptions, which have clearly labeled ingredients, quantities, and other safety information, illegal drug products are less predictable and might contain unexpected substances, unknown quantities, or potencies.

Recommendations for Public Health Professionals

• Communicate to partner organizations and agencies about this disruption and the potential associated overdose risk among affected patients.
• Support patients affected by a disruption in identifying new clinicians and legal sources of medications.
• Communicate risks of replacing prescription stimulant medications with drugs or pills obtained illegally, including pills received from family, friends, or acquaintances).
• Increase risk communication about the prevalence and danger of counterfeit pills that look like prescription medications. Communicate that 7 out of every 10 pills seized by DEA from the illegal drug market contain a lethal dose of fentanyl.
• Increase risk communication, harm reduction and other overdose prevention efforts (i.e., provision of naloxone) directed at adults primarily ages 18 through 50 years, as they represent the population most served by the indicted company and most at risk for overdose.
• Increase risk communication, harm reduction, and other overdose prevention efforts (i.e., provision of naloxone) directed at college students and at places where young adults study or work due to risks of stimulant misuse.
• Disseminate resources to help clinicians care for patients with ADHD or other health conditions treated with prescription stimulants.

Recommendations for Clinicians

• Help patients who have lost healthcare access to find new licensed clinicians and pharmacies.
• Avoid stigmatizing patients affected by a disruption in care.
• Educate all patients about the health risks of using drugs or medications obtained from sources other than licensed clinicians and pharmacies, including family, friends, and social media contacts. Communicate to patients that 7 out of every 10 pills seized by DEA from the illegal drug market contain a lethal dose of fentanyl.
• As a safety precaution, in case a patient obtains medication outside the regulated healthcare system, prescribe naloxone and overdose prevention education to any patient who has difficulty accessing their stimulant medication or tell patients where they, their caregivers, or families, can access naloxone. Naloxone, for example Narcan®, can reverse the effects of an opioid overdose and can be given to any person showing signs of an opioid overdose (e.g., unconscious or unable to be awakened; slow or shallow breathing or difficulty breathing).
• Ensure that patients requesting care continuity for ADHD receive appropriate assessments and best-practice treatments.
• Discuss with patients, their caregivers, and families the possibility of difficulty filling a prescription due to current drug shortages and work with them to ensure they are able to fill prescriptions.
• Offer other FDA-approved treatment options for ADHD if a prescribed medication is unavailable when needed or facilitate a rapid referral to a clinician who can provide such treatment.
• If you believe a patient might have a stimulant use disorder or needs immediate mental health support, provide referrals and information about how to access treatment services, including hotlines: #988 or 1-800-662-HELP (4357).
• Contact Poison Control (call 1-800-222-1222 or visit https://poisoncenters.org) for help with a poisoning emergency or for questions related to an unknown substance.

Recommendations for Pharmacists and Pharmacies

• Avoid stigmatizing patients affected by a disruption in care.
• Recognize that the indictment should not result in universal refusals to fill prescriptions from telehealth providers, and that telehealth provides access to needed care for many Americans.
• Recognize that Schedule II–V controlled substances can be prescribed via telehealth without an in-person visit until December 31, 2024, under current regulations.
• If your pharmacy does not have a particular prescription medication available to dispense, you may electronically transfer a Schedule II prescription according to federal regulations.
• Discuss with patients the possibility that they might have difficulty filling a prescription due to medication shortages, and share resources below on finding a provider to identify alternative treatment options if needed.
• Discuss with patients the risks associated with obtaining medications from anyone other than a licensed pharmacist due to the prevalence of counterfeit pills that look like their medication but could contain other dangerous substances. Recently, DEA reported that laboratory testing indicates 7 out of every 10 pills seized from the illegal drug market contain a lethal dose of fentanyl.
• If your state has a statewide standing order or protocol order for naloxone, dispense it, or let patients know where they can purchase it over the counter (i.e., without a prescription).

Recommendations for Affected Patients
For ADHD treatment

• If you are running low on your current prescription, schedule an appointment with your existing or new healthcare provider as soon as possible.
• Contact your primary care doctor if you can no longer access your previous healthcare provider for assistance obtaining ongoing prescriptions. If you do not have a primary care doctor, call the number on the back of your insurance card, and ask for assistance finding a healthcare provider near you. Resources like Find a Health Center (hrsa.gov) can identify federally funded health clinics in your area and the organization Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) can identify an ADHD specialist.
• Talk with your healthcare provider and pharmacist if you cannot find a pharmacy that has your medication.

To prevent overdose and other harms

• Only take medications prescribed to you by a licensed healthcare provider and dispensed by a licensed pharmacy.
• Never illegally purchase or obtain pills. Recently, DEA reported that laboratory testing indicates 7 out of every 10 pills seized from the illegal drug market contain a lethal dose of fentanyl. Pills obtained from family, friends, or social media contacts and not prescribed to you could contain deadly levels of illegally made fentanyl, and you wouldn’t be able to see it, smell it, or taste it.
• Never purchase or obtain illegal stimulants, such as cocaine, methamphetamine, or ecstasy. Substances might not be what they seem and could contain lethal doses of fentanyl or additional dangerous substances.
• Carry naloxone, a life-saving opioid overdose reversal drug. Naloxone should be given immediately in response to any unconscious person suspected of overdosing. Signs of an opioid overdose include—
  • Unconsciousness or inability to awaken
  • Slow or shallow breathing or difficulty breathing such as choking sounds or gurgling/snoring noise from a person who cannot be awakened
  • Discolored skin (especially in nails or lips)
  • Small, constricted “pinpoint pupils” that don’t react to light
• Never use illegally obtained pills or other substances.
• If someone is planning to use illegally obtained pills or other substances, test them first with fentanyl test strips, and make sure there is always someone else nearby who can help in case of emergency.
• In case of a poisoning emergency, call 911 and seek medical attention immediately.
• For questions about an unknown substance, contact Poison Control (call 1-800-222-1222 or visit https://poisoncenters.org).

For stimulant use disorder treatment

• Call or text #988 or 1-800-662-HELP (4357) if you believe you, a family member, or loved one might have a stimulant use disorder or are experiencing psychological distress.

For More Information
ADHD Symptoms, Diagnosis, and Treatment

• Attention-Deficit / Hyperactivity Disorder (ADHD) | CDC
• Improving the Lives of People Affected by ADHD | Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
• Adult ADHD Toolkit | American Academy of Family Physicians (AAFP)

Stimulants or Stimulant Use Disorders

• Stimulant Overdose | Overdose Prevention | CDC
• Treatment of Stimulant Use Disorders | Substance Abuse and Mental Health Services Administration (SAMHSA)

Counterfeit Pills

• Counterfeit Pills Factsheet | Department of Justice/Drug Enforcement Administration (DEA)
• Northern District of Iowa | United States Attorney and the Federal Bureau of Investigation Warn Iowans about the Dangers of Counterfeit Adderall Pills | U.S. Department of Justice
• Drug Overdose Deaths with Evidence of Counterfeit Pill Use — United States, July 2019–December 2021| CDC </a >

References

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3. Centers for Disease Control and Prevention. A Stimulant Guide: Answers to Emerging Questions about Stimulants in the Context of the Overdose Epidemic in the United States. 2022. https://www.cdc.gov/overdose-prevention/media/pdfs/2024/03/CDC-Stimulant-Guide.pdf
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