16 May 2024

Should GPs be allowed to prescribe ADHD medication?

6:56 am on 16 May 2024
ADHD - Printed Diagnosis with Blurred Text. On Background of Medicaments Composition - Mint Green Pills, Injections and Syringe.

Photo: 123RF

Any moves to free up access to medication for Attention Deficit Hyperactivity Disorder (ADHD) must be balanced with ensuring patient safety and preventing drugs ending up on the black market, psychiatrists warn.

A recent University of Otago study showed a tenfold increase in the amount of ADHD medication dispensed for adults between 2006 and 2022.

However, only about one in five people with ADHD are currently receiving treatment for the condition, which is estimated to affect more than 250,000 New Zealanders.

Some-time actor, marketing executive, blogger, photographer and business owner Julie Legg said her ADHD diagnosis at the age of 52 has helped her make sense of her life.

Her restless mind, low boredom threshold and constant need for excitement caused "a few bumps in the road" for her career and relationships, she said.

"In a sink-or-swim environment, I learned to dog-paddle very quickly. But if there was a guide or some treatment or assistance along the way, that certainly would have helped me."

Julie Legg, ADHD advocate and author of The Missing Piece.

Julie Legg. Photo: Supplied

Clinical psychologists can diagnose ADHD, but only psychiatrists (or in the case of children, paediatricians) can endorse the use of stimulants to treat it.

Furthermore, patients are currently required to get reassessed by a psychiatrist every two years, which can cost more than $1000.

A hui this week at Parliament to discuss removing barriers to treatment for ADHD brought together health officials, Corrections, NZ Police and professional organisations for clinicians, as well as MPs from across the political spectrum.

Pharmac is considering removing or amending the two-year renewal criteria for ADHD treatments. Chief Medical Officer Dr David Hughes said the drug-funding agency hoped to have a proposal for public consultation in the second half of the year.

"There are ongoing supply issues with some ADHD medicines. We must carefully consider any potential changes, to make sure we don't make supply issues worse."

As for getting that diagnosis in the first place, there was support from health officials and professional bodies to make it easier.

Child psychiatrist Hiran Thabrew - the New Zealand chair of Tu Te Akaaka Roa, the Royal Australian and New Zealand College of Psychiatrists - said members were generally supportive of widening the prescriber base to allow vocationally trained GPs and nurse prescribers to treat ADHD.

"No one has a problem with increasing access - we don't want people suffering, we want them to be getting the care they need. But it's just a matter of balancing that with safety, especially for children and teenagers."

However, diagnosing ADHD could not be "shoehorned" into a 15-minute GP appointment, but required hours of careful and detailed assessment to rule out other physical or mental conditions with similar symptoms.

He cautioned against removing ongoing monitoring for children and teenagers, both because they were still growing and developing and because of the risk of abuse or "diversion" (ie patients giving or selling their medication to others).

"We know that diversion is highest in the young adult age group, up to 35 percent of high school students in the United States, according to some studies."

When he raised this risk with health officials at the hui this week, he was told there was unlikely to be a problem with diversion in New Zealand because police were not picking up anyone.

"I think that's a pretty high threshold in terms of adverse effects, if that's all they're counting as a problem - people coming to the attention of police or the criminal justice system."

Tauranga GP Luke Bradford, medical director for the Royal College of General Practitioners.

Tauranga GP Luke Bradford, medical director for the Royal College of General Practitioners. Photo: Supplied

Tauranga GP Luke Bradford, medical director for the Royal College of General Practitioners, was confident GPs with special training could diagnose and treat ADHD.

"We've got patients who are being treated for anxiety and depression, and using alcohol and cannabis to calm their brains down, when we know they very likely meet the criteria for ADHD and just need to trial medicine.

"There's the frustration of people saving up for months and months to see [a private psychiatrist], and you only need to have the car break down or for something else to happen for them to be back to square one, and this sense of hopelessness can creep in."

But Dr Bradford agreed it would not be possible to diagnose ADHD within a normal GP appointment.

"It's not like diagnosing a chest infection.

"We see it fitting into a specific interest type model in the same way as a lot of GPs will do skin cancer management, menopause clinics, travel medicine, so these are things that don't fit it into normal 15 minute appointments."

ADHD New Zealand chairperson Darrin Bull was heartened by the broad consensus that people should be able to get treatment in primary care.

ADHD New Zealand Chairman Darrin Bull says the community is in a state of crisis

Darrin Bull. Photo: Supplied

"It's going to make life [for people with ADHD] a lot easier, as well as free up a lot of time for psychiatrists."

A senior police officer at this week's hui told him they were "sick of arresting people just because they have ADHD and no one is helping them on the health side".

In Australia, the government has just approved standard clinical guidelines - the result of four years' work - to allow a broader range of clinicians to diagnose and treat ADHD.

In New Zealand, GPs were stripped of their authority to prescribe stimulants in 1999 due to concern they could be misused.

Dr Tony Hanne

Dr Tony Hanne Photo: Supplied

Auckland GP Tony Hanne, who had become a leading specialist in ADHD, continued treating thousands of patients over the next two decades under the supervision of psychiatrist Dr Allan Taylor. However, he struck trouble when Taylor retired and no one else was willing to take on the job.

Fearing his patients would be "cut adrift", he wrote to the Ministry of Health asking for help, but there was no response.

"So I simply said, 'Well, my duty is firstly a duty of care to my patients.' So I kept telling everyone what I was doing and why I was doing it, and that went on for six months, and then they took action against me."

Found guilty of professional misconduct by the Health Practitioners Disciplinary Tribunal last year, he was suspended by the Medical Council for a year from March this year, banned from prescribing restricted Class B ADHD drugs for three years and ordered to pay costs and fines of $175,000.

Hanne appealed to the High Court, and was hopeful the changes currently under consideration would make life easier for ADHD sufferers in future.

Meanwhile, several psychiatrists have stepped to take on his old patients.

"So that's fine as far as people in the past are concerned, but the question is still about new patients. When someone goes to a GP with symptoms of ADHD, how do they respond? How do they know it's ADHD, and how do they respond? And that's where I'm wanting to be involved."

Medication 'low-hanging fruit'

Thabrew said in some ways, the push for medication was "low-hanging fruit" - the bigger problem was the dire state of mental health support services.

"While all this focuses on drugs - dare I say this as a psychiatrist? - it's not all about medication when it comes to ADHD.

"There's no discussion from what I can see about psychological and non-medication support for people with ADHD, either children or adults, and we know we've got woeful shortages of psychologists to do that work."

Legg has written a book based on her own experience and interviews with other women diagnosed with ADHD, The Missing Piece: A Woman's Guide to Understanding and Living With ADHD.

She knew many people for whom the medication had been "brilliant and transformative", but she has chosen to explore behavioural strategies at this stage.

"It's probably the longer, harder journey, but I've taken it up myself as a bit of a goal to do.

"But never say never when it comes to medication for me. If my environment changes, and I know medication is available for me, I would be silly not to consider that as an option."

It was important to give people with ADHD credit for what their neurodiversity gave back to the world, especially in terms of innovation, she said.

"We're fun and we're great at problem solving and we're passionate. We're so many things - we're not just that list of traits. There's an upside too."

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