As diagnosing and prescribing medicines for ADHD expands to include GPs in most states and territories, a team of addiction medicine experts from Victoria are urging caution.

The context

The number of patients prescribed ADHD medicines jumped from 2 per 1000 in 2004-05 to 22 per 1000 in 2023-24, according to AIHW data – but recent analysis by University of New South Wales researchers for the ABC’s Four Corners suggests there is significant variability depending on where someone lives.

Over-emphasis on pharmacological interventions

In an editorial published in the Internal Medicine Journal this week, the authors argue that while expanding GP prescribing rights makes sense given the long wait times and high out of pocket costs to see a specialist, it could have unintended consequences due to differences in training across the country, as well as the increase in vertically integrated telehealth platforms  that “threaten to reduce ADHD care to a volume-based pharmacological service.”

Dr Pansy Lai, a mental health GP and psychotherapist, shares several of their concerns, particularly that current reform focuses disproportionately on stimulant prescribing over non-pharmacological interventions.

“I do believe that in the trainings there needs to be a shift where stimulants are understood to be only one part of the picture rather than the ‘magic wand’ or the only next step,” Dr Lai says.

Are the risks of stimulants being under-estimated?

The editorial authors, who include a GP, a psychiatrist, and academic clinicians who all specialise in addiction medicine, argue that the answer is yes.

Although short-term data on stimulants suggests there are common, manageable adverse events such as decreased appetite, insomnia and anxiety, longer-term population studies document an increase in hypertension, CVD, sudden cardiac death and stroke, as well as modestly increased risk of tic and new onset psychosis, they say.

However, Dr Alison Poulton, an ADHD specialist, academic paediatrician, and senior lecturer at the University of Sydney who is also a board advisor to ADHD Australia, believes the concerns raised aren’t specific to GP prescribing at all – and risks and benefits of a particular drug should be discussed on an individual basis.

“This is part of the ADHD horizon anyway,” Dr Poulton says.

“Always, with any medication, you have to think about what’s the long-term cardiovascular risk? What’s the psychiatric risk? And ultimately the prescribers need to have this conversation with each individual patient rather than legislating that ‘this should happen, that should happen.’”

“Rather than saying that we need to protect the community from these risks, they are risks that individuals can make their own informed decisions about,” Dr Poulton says.

While long-term cardiovascular risks of stimulants are important, you also have to consider the health risks of unmanaged ADHD – and the fact that those prescribed stimulants for ADHD will be monitored and have their blood pressure checked every six months, Dr Poulton adds.

“For example, we know that people with ADHD are at higher risk of smoking. Now, if you’re weighing up the risk of smoking against the risk of long-term stimulants in a medically supervised setting, there’s no question which is safer,” she says.

Is the system set up for GPs to manage ADHD?

The editorial authors also say current Medicare rebates don’t adequately compensate time-intensive assessments needed for a thorough ADHD evaluation — another point that resonates with Dr Lai.

“The current Medicare model indeed upholds rushed medicine over careful medicine, incentivising script dispensing as a response to patient pressure – as opposed to rapport building, detailed exploration of symptoms, neurodevelopmental history, trauma informed care, and time and expertise to provide psychoeducation and slow psychological medicine,” Dr Lai says.

GPs who provide mental health care “are constantly being undermined by the system,” which doesn’t adequately compensate long consultations she emphasises.

“ADHD treatment is complex. GPs do complex, whole person care and mental health care well and know when to refer – but they need to be supported by a system that is equitable and provides incentives for (instead of diminishing) provision of good, time intensive mental health care.”

Dr Poulton notes some advantages to managing ADHD in general practice.

“Management of ADHD actually fits really, really well with the GP model of care,” she says.

“People talk a lot about how long it takes to do a thorough assessment of someone with ADHD, getting all the comorbidities, but if you’re going to your own GP who knows you well, knows your background, they’ve already got a lot of the way towards getting this background information. Rather than a specialist who sees this patient for the first time and has to catch up on everything else, the GPs are really well placed to give this holistic care.”

Getting the balance right

Training for GPs to prescribe psychostimulants varies widely, from more extensive online training and peer support from specialists in some states to a couple of hours of ADHD-specific online modules in others, and no training at all in others.

This nationally inconsistent approach “may further exacerbate gaps in ADHD care and risk diagnostic overshadowing, while preventing consideration and treatment of important differentials,” the editorial authors say.

Moreover, they say we should be mindful of the commercial context behind the reforms – with medicinal cannabis ‘script mills’ serving as a warning. Vertically integrated telehealth services for ADHD are on the rise, often decoupling diagnosis from long-term management, they add.

“Expanding prescribing rights risks supercharging this model, encouraging clinics to incorporate GPs merely as logistical endpoints for stimulant delivery rather than partners in comprehensive care,” the authors write.

Still, Dr Poulton argues that as more GPs and practices take on ADHD management, they’ll build up their clinical skills, and within practices, some GPs will see more of these patients and support their colleagues where there are gaps.

That contrasts with specialised telehealth clinics where prescribers might not ever really get to know their patients, she adds.

“If you make it too difficult for GPs to train and get their prescribing rights, then you’re going to get the specialist clinics that are just trying to push people through, and could charge high prices because of the shortage of prescribers.”