A 2022 KevinMD article raised concerns about generic formulations of ADHD medications. The author described what many patients and families had already discovered: Not all generics are created equal. For those of us who lived through the substitutions, the difference was not abstract. It was a roller coaster that intruded on daily life, even on vacation.

The generic in question was manufactured by Mallinckrodt. Unlike Concerta, which uses an osmotic-controlled release oral delivery system (OROS), Mallinckrodt’s version relied on a release profile closer to Ritalin LA. The distinction matters. Concerta’s osmotic pump delivers methylphenidate steadily throughout the day, minimizing peaks and troughs. Mallinckrodt’s round tablet, by contrast, produced bursts of medication followed by crashes. Patients who had relied on Concerta’s smooth arc suddenly found themselves riding waves of energy, focus, and irritability.

By contrast, Watson’s generic was not a true generic at all. It was an “authorized generic,” manufactured by Janssen (the maker of Concerta) and sent to Watson under agreement with it. It is impossible to tell them apart because the same factory made both products with the same imprint. Chemically and mechanically identical to the brand, Watson’s version preserved the osmotic release system. The only difference is the label on the large bottle of the medication sent to pharmacies. For patients, the difference between Mallinckrodt’s tablet and Watson’s authorized generic was the difference between stability and chaos.

My own family experienced this firsthand. On vacation, Kathy and Robert were subjected to the substitution. Instead of steady days, they endured unpredictable highs and lows. The medication roller coaster disrupted meals, outings, and even sleep. What should have been restorative time together became a lesson in how pharmacy substitutions can hijack family cadence. The problem was not ADHD itself; it was the formulation of the medication meant to treat it.

This is why the FDA’s role in bioequivalence ratings is so critical. In 2016 and 2017, after sustained advocacy from clinicians and patient advocates, the FDA downgraded the bioequivalence ratings of certain generics. Gina Pera and others documented the lived consequences of these substitutions, and the agency eventually acknowledged that the pharmacokinetic profiles were not equivalent. Pharmacies began to shift back to dispensing either brand Concerta or the Watson-authorized version. For many families, that change restored stability.

The FDA eventually confirmed what families had lived. Within six months, Mallinckrodt and Kudco were asked to prove bioequivalence or withdraw their products. When they failed, the agency downgraded their Orange Book rating from AB to BX. That bureaucratic shift was the official recognition that these tablets were not equivalent, and that the roller coaster was real.

And despite this action, Dr. Won was prescribed the BX generics rather than the AB rated generic in November 2019. Despite the FDA’s regulatory science initiative and the downgrade from AB to BX, patients like Dr. Won were still prescribed the BX generics in 2019. Why? Because the chain of care broke. Pharmacists either did not understand the designation or were pressured by insurers to ignore it. The FDA had done its job; the health care system had not.

But the lesson remains. “Generic” does not always mean “equivalent,” especially when the medication involves complex delivery systems. With simple molecules, substitution may be straightforward. With extended-release formulations, the mechanism of delivery is as important as the molecule itself. Patients deserve transparency about what they are receiving, and clinicians deserve clarity when prescribing.

The March 2022 article remains important because it captured a moment in time when families were still being subjected to ineffective substitutions. Seven months later, the landscape had begun to change, but the memory of those roller coasters lingers. For Kathy and Robert, the vacation disrupted by Mallinckrodt’s tablet is part of our family ledger. For me, it is a reminder that advocacy must extend beyond the clinic to the regulatory arena.

Responding to an article like this requires both validation and update. Validation, because the author’s lived experience was real and shared by many. Update, because the regulatory and pharmacy landscape has shifted since publication. Together, those elements create a narrative that honors the past while clarifying the present.

As a developmental pediatrician and psychopharmacology expert recognized by the FDA and the NIH, I have seen how medication formulation can shape not just clinical outcomes but daily life. As a historian, I recognize the importance of documenting these moments so they are not forgotten. And as a parent, I know the cost of a disrupted vacation. The roller coaster was not inevitable; it was imposed by a substitution that should never have been allowed.

The broader lesson is one of vigilance. Patients and families must be empowered to ask which generic they are receiving. Clinicians must be equipped to explain the difference between authorized generics and pharmacokinetic variations. Regulators must continue to scrutinize bioequivalence claims, especially for complex delivery systems. And platforms like KevinMD must continue to amplify these stories, because lived experience is the most powerful evidence of all.

Seven months after the article’s publication, the story remains relevant. It is not just about ADHD medication. It is about the meaning of “generic,” the importance of delivery systems, and the lived consequences of regulatory decisions. For Kathy, for Robert, and for countless families, the roller coaster was real. Our responsibility is to ensure it does not happen again.

Dr. Lindsay’s scholarship, profiled on ResearchGate and Doximity, extends across seventeen peer-reviewed articles, eleven book chapters, and forty-five invited lectures, as well as contributions to major academic publishers such as Oxford University Press and McGraw-Hill. His memoir-in-progress, The Quiet Architect, threads testimony, resistance, and civic duty into a reckoning with systems retreat.