Back in 2019, I was diagnosed with ADHD at age 40, a process I described for the Guardian. The diagnosis came as a surprise to me, but not to anyone I knew: sure, I’d never been especially hyperactive (or even, y’know, active), but the chronic lateness, difficulty concentrating, lack of emotional self-regulation and decades-long struggle to locate my keys … these were all classic symptoms.
I was prescribed a medication called Vyvanse, which I’ve been taking daily since. It’s proven immensely helpful, allowing me to settle into a reasonably steady routine of writing and working. The days when I just can’t get anything done have been further and further separated by periods of unprecedented productivity.
In other words, everything has been going pretty damn well on the ADHD front. Or at least, it had until July this year, when I moved to the US.
I lived in New York City for most of the 2010s, returning to my native Australia in late 2017 when the company for which I was working went bust. My American partner joined me in Melbourne. We got married and applied for a green card. Then Covid happened, etc, etc, and it wasn’t until July 2023 that we packed our bags and moved back to New York.
Obviously, I made sure to bring as much Vyvanse as possible with me. “As much as possible” turned out to be two months’ worth, and the first month of our return was occupied exclusively with finding a place to live. Once that was sorted, though, my Vyvanse supply had started to wane, and with a two-week trip out of state on the horizon, I began looking into getting a new prescription.
Anyone who’s blessed enough not to have experienced the US’s, um, idiosyncratic approach to healthcare might think that this process should have been relatively straightforward. After all, I am a responsible adult, I’ve been happily taking the medication in question for five years without issues, I have a letter from my doctor attesting to that fact (along with medical records, etc), and I used my newfound freedom to choose an insurance plan to select one that specifically covered ADHD medications.
If so, let me gently disabuse you of that notion, because getting Vyvanse in the US in 2023 is a nightmare.
There are two reasons for this. The first is that there’s clearly been a reaction to the opioid fiasco of the 2010s, an era in which I walked away from a root canal with a no-questions-asked prescription for 60 Vicodin tablets. Sadly, that reaction hasn’t been anything as sensible as “let’s reform our outdated, pointlessly punitive drug laws and throw the Sacklers in prison until the heat death of the universe.” No, it’s been more along the lines of “let’s impose ever more insane restrictions on ‘controlled substances’ and treat anyone trying to obtain them with suspicion.”
The amount of damage this has done to anyone unfortunate enough to need prescription opiates to manage pain has been well documented, but there’s also been a huge overcorrection in regard to other “controlled substances”. Today, just finding a doctor who will prescribe ADHD medications is something of an ordeal: most general practitioners won’t even consult on ADHD, let alone prescribe medications. You might have more luck with a psychiatrist, except that my insurance plan requires a referral from a general practitioner to see a psychiatrist, which would be fine but for the fact that general practitioners won’t see you about ADHD, so … sigh.
The first general practitioner who agreed to actually speak to me insisted on trying to diagnose me with ADHD – a condition with which I have already been being treated for five years, remember – before she’d “even consider” prescribing anything. Thankfully, several weeks after my search began, I finally found a doctor who agreed to give me a prescription once she saw the letter from my doctor in Australia. She even offered to set me up with an innovative online pharmacy who’d deliver the medication to my door.
Hurrah! Now I just have to fill the script, and – oh dear Lord. Why does that say “$444.16”?
You may remember that my insurance plan specified explicitly that it covers ADHD medications. Well, it turns out that “we cover ADHD medications” actually means “we may in fact cover ADHD medications – but we may also choose not to, especially if we reckon we can put you on something cheaper.” Again, one might think this would be a question for a doctor, an idea to which the insurance industry’s collective response appears to be “lol”.
OK. Fine. It took a couple of days to sort prior authorization, and now all I had to do is get the innovative online pharmacy to schedule a delivery. Wednesday? That’s perfect, because I fly out on Thursday. I’m sure they’ll tell me well in advance if there are any problems. I mean, they wouldn’t do anything as obnoxious as wait until Wednesday night to tell me that they’re out of stock, right? Right?
Oh. And this leads to the second reason why this process has been so awful: there is a severe and ongoing shortage of ADHD medications in the US, one whose effects have extended to other countries around the globe. Given that amphetamines were first synthesized in the 1880s and the cartels seem to be pumping out vast quantities of methamphetamine happily enough, you might wonder why ADHD meds are so hard to find.
The intuitive answer is that because Vyvanse, Adderall and the like are controlled substances, the Food and Drug Administration (FDA) and Drug Enforcement Administration (DEA) put quotas on their production. However, while it’s hard to know exactly what’s going on, the answer doesn’t seem to be as simple as “the feds won’t let drug companies manufacture enough supply.”
A letter issued by the FDA in August 2023 noted that “based on DEA’s internal analysis of inventory, manufacturing, and sales data submitted by manufacturers of amphetamine products, manufacturers only sold approximately 70% of their allotted quota for the year, and there were approximately 1 bn more doses that they could have produced but did not make or ship,” and that “data for 2023 so far show a similar trend.”
Anyway, the reasons for the shortage don’t matter when you’re just trying to get your medication. And hoo boy, whether or not the controlled substance laws are behind the shortage, they make the process of trying to fill a script absurdly, needlessly difficult. Can I get an actual physical prescription and then ask around until I find a pharmacy? Nope. “Sorry, sir, this is a controlled substance.” Instead, I have to call the doctor and get them to send the prescription to a specific pharmacy. But how to know whether a given pharmacy has stock? Can I call around and ask? “I’m sorry, sir, we can’t tell you that. It’s a controlled substance.” You can’t … go and look in the supply cabinet? “No, sir, it’s a controlled substance.“
There’s something especially obnoxious about forcing people with an executive function disorder to negotiate a system so Byzantine it’d give Franz Kafka conniptions.
As I write this – and by God, has writing this ever been a trial – I’ve been unmedicated for over a week. I have weird episodes of something that’s not unlike narcolepsy, where out of nowhere, I suddenly get overwhelmingly sleepy. I have intermittent headaches – actual physical ones, in addition to the plentiful metaphorical ones that come from trying to deal with this nightmare. And the mental static to which I referred to in my original piece is back with a vengeance: concentration is slippery and ephemeral, and my attention wanders like a kitten constantly finding new things to play with.
The final irony is that if Vyvanse was any fun, I could probably have it illegally delivered to my door in half an hour, like any other illicitly recreational drug for which the US has an appetite. But the thing is that, as a prodrug, with its amphetamine component tied to an amino acid molecule, Vyvanse only has bioavailability if swallowed. Just like everything else about this hellish process, it is, in fact, no fun at all.