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Is the soaring use of ADHD stimulants a cause for concern?

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Interest regarding ADHD in the media, GP and psychiatry clinics, on social media and via Google searches continues to grow.
 
According to new Australian guidelines, the condition affects about one million people nationwide, occurring in approximately 6–10% of children and adolescents, and 2–6% of adults.
 
But even that estimate may understate its prevalence, with Pharmaceutical Benefits Scheme (PBS) data compiled by the ABC suggesting that more than 1.5 million prescriptions for ADHD medication were issued in the 2020–21 financial year alone.
 
Current trends also indicate that figure will only increase in the coming years.
 
New analysis of PBS item reports conducted by newsGP has found prescriptions for some stimulant medications have exploded, coinciding with the arrival of the COVID-19 pandemic.
 
The most striking example is lisdexamfetamine: 60 mg doses have increased by 45x in the two years from 2019–20 to 21–22 (from 1274 to 57,946) while over the same period 40 mg dosage were 34x higher (3320 to 113,983) and 20 mg prescriptions increased were up more than 2300% (from 3843 to 88,609).
 
Other stimulants have also increased, albeit by lower amounts over a longer period:

• Methylphenidate 10 mg IR increased by 1.3x from 2018–19 to 21–22, from 126,656 to 168,450
• Methylphenidate 20 mg SR increased by 1.5x from 2018–19 to 21–22, from 66,031 to 103,132
• Dexamfetamine 5 mg increased by 1.3x from 2018–19 to 21–22, from 169,734 to 233,648

The figures suggest that ADHD is being diagnosed more frequently in Australia, as well as more reliance on the use of medication to treat and manage the condition.
 
However, while stimulants, particularly lisdexamfetamine, are being prescribed in higher numbers, Associate Professor John Kramer, Chair of RACGP Specific Interests ADHD, ASD and Neurodiversity, says there is more to the story than the numbers imply.
 
‘Prescribing data needs to be interpreted with caution, given the changes in PBS access to different stimulants in recent years. [Fox example], lisdexamfetamine came onto the PBS for adults in early 2021,’ he told newsGP.
 
‘The number of scripts written is [also] different to the number of patients treated. Even if the maximum number of repeats is provided on each prescription, for example six-month’s supply, two scripts will equate to one patient. If the number of repeats is changed to less than five, the maths changes again.’
 
Professor Kramer also pointed out how the different strengths of lisdexamfetamine may inflate their perceived use.
 
‘Patients are usually started on 20 mg daily, then the dose is worked upwards until the desired response is achieved,’ he said. ‘Thus, a patient might be issued progressively with 3–4 different scripts in the first six months of treatment.’
 
ADHD is a great and ongoing burden in Australia. Apart from the individual effect of symptoms, a 2019 Deloitte study estimated its associated social and economic costs to be $20.42 billion, equivalent to $25,071 per person with ADHD.
 
‘ADHD occurs in every population worldwide. It causes difficulties to differing extents depending on many factors,’ Professor Kramer said.
 
‘It can be seen as a neurodevelopmental condition. I think its best seen as a variant of normal human development, and in a world of neurotypicals, a person with ADHD is more likely to stand out.’
 
It is also often seen as a condition that needs to be managed, but Professor Kramer says ADHD may come with advantages, depending on the context.
 
‘Typically, [people with ADHD] do better in outdoors careers with lots of variety,’ he said. ‘If you’re a bushman in the Kalahari, you are probably better at it than non-ADHD people.
 
‘They also flourish in marketing, sales, as chefs, primary school teachers and in emergency departments. They will often thrive in a crisis.
 
‘My point is that it can confer survival advantages, which is why those characteristics continue in humans.’
 
Are stimulants being overprescribed and misused?
ADHD diagnoses have increased markedly over the past 30–40 years, leading some researchers to raise concerns related to overdiagnosis and misuse.
 
In the US, reports of Adderall addiction were already occurring as far back as 2016. More recently, COVID and lockdowns have also seen an increase in ADHD diagnoses, prescribing and addiction, reportedly fuelled by telehealth companies running short consultations specifically for ADHD.
 
The trend is not limited to the US. There has also been a 50% increase in stimulant prescriptions in the UK from 2015–21, where referrals for ADHD quadrupled between 2018–20 and 20–22.
 
Nonetheless, Dr Jacqueline Rakov, a clinical and forensic psychiatrist, told newsGP she sees ADHD as actually being underdiagnosed in some sectors.
 
‘One population where ADHD is underdiagnosed is in the prison population,’ she said.
 
‘Prescribing stimulants in custody has long been considered fraught because of the trading and standover culture, yet many of the individuals involved have been “self-medicating” with methamphetamine for some time.
 
‘This of course has its own implications, both psychoactively and serving to land them in the criminal justice system. This population also has next to no access to non-pharmacological interventions, significantly limiting their options and in turn, prospects at rehabilitation.’
 
But while she thinks some populations are neglected, Dr Rakov also harbours general concerns about increasing ADHD diagnoses and prescriptions.
 
‘It is a condition … that can be debilitating when untreated and life-changing when treated,’ she said.
 
‘However, it is becoming oversubscribed with many people presenting “seeking a diagnosis” of ADHD – especially because they saw an influencer on TikTok list a few vague symptoms which overlap with many other conditions such as anxiety, mania [or] personality disorder.
 
‘People will come and say, “I tried my friend’s Ritalin once and wow”. [This is] news to nobody, it’s a stimulant like caffeine, nicotine, speed or ice.’
 
Dr Rakov believes there is a reason people are self-administering stimulants in ‘varying degrees of problematic use’.
 
‘We are failing to address the “why” people aren’t concentrating,’ she said.
 
‘Are they anxious, with an overactive amygdala? Are they depressed, with impaired cognition? Have they not had adequate support for trauma?’
 
‘ADHD requires a nuanced understanding of many facets of the individual’s life beyond just “can’t concentrate”. There are a gamut of medications that are helpful in the different aspects of ADHD and they are not all stimulants.
 
‘If you are a hammer, everything looks like a nail. See pain presentations and the opioid crisis.’


Lockdowns have increased the number of adults, especially women, seeking a diagnosis, GP Dr John Kramer says.
 
Regulation regarding stimulant prescribing in the US is more relaxed than Australia, where they must be commenced by a paediatrician or psychiatrist before a GP can continue to prescribe.
 
However, concerns about overprescribing and possible harm have led Columbia University psychiatrist Professor Frances Levin to call for a new approach.
 
‘We don’t want a repeat of what happened with opioids,’ she told the Wall Street Journal.
 
‘There is a very important place for stimulant medication in the treatment of ADHD, and we have to be good guardians to know who is going to be best served by them.’
 
The same WSJ article reports that stimulants are among the most widely misused prescriptions drugs according to a US Government survey.
 
‘Due to its potential for abuse, Adderall is classified by the government as a Schedule II controlled substance, the same category as OxyContin,’ it adds.
 
And while the US healthcare system is obviously different to Australia, Dr Rakov has also seen a local rise in specific-ADHD clinics catering to diagnosis delivery.
 
‘Another frustrating exploitation of the public’s concern and vulnerability are these ADHD mono-clinics popping up,’ she said.
 
‘Sometimes, patients are seen as a once-off and not given any follow-up. The choice to charge $1200 for an “ADHD assessment” because it is “concern du jour” is underestimated in its ethical dubiousness.’
 
Overwhelming demand
The number of patients seeking ADHD diagnoses and treatment in Australia has prompted some psychiatrists to pre-emptively send a waiver to the referring GP asking that they take over the responsibility of the patient’s care and prescribing.
 
Meanwhile, in Melbourne, wait times for psychiatrists are routinely over six months and some patients now pursue one-off, interstate telehealth appointments with psychiatrists via item 291 in order to pursue an ADHD diagnosis that allows their local GP to continue prescribing.
 
It is an issue Dr Rakov is concerned about.
 
‘I have treated people after they have attended these clinics, [where they have] undergone skint history taking and paucity investigation, with no follow up,’ she said.
 
‘Some have developed worsening anxiety disorder – ie the condition that should have been treated in the first place – or others psychosis, sometimes warranting being detailed in hospital [and] which had not been explained as a risk.
 
‘How can these be done as a once-off when routine investigation for any first-presentation psychiatric condition would involve pathology testing?’
 
Side effects for stimulants can include headaches, appetite suppression, nervousness, tics and dry mouth, and the medication should be avoided for people with severe anxiety, Tourette’s, certain heart conditions or psychosis.
 
But even though some doctors are worried about the potential impact that the increased reliance on stimulants is having, Professor Kramer does not share the same concerns about misuse.
 
‘I see no valid comparison to the opioid [crisis],’ he said.
 
‘When you take opioids, you get the desired effect. People without ADHD, if they take stimulants, they won’t notice any significant effect. So it’s not addictive.
 
‘Certainly, there is a market for Ritalin in students, that’s undeniable, but the incidence of stimulant diversion is much less than opioid diversion because it doesn’t do what they want. Some may get a response which can help their exams, but I interpret the positive response largely as placebo.
 
‘One of my standard questions is to take a drug history, legal and illegal, and if they ever took speed. People without ADHD get the buzz, but [those] with ADHD won’t at all. This is virtually diagnostic.’
 
What is behind the increase?
There are many theories regarding the causes behind ADHD and what is fuelling the current increase.
 
In most cases, ADHD can be considered a multifactorial disorder where biological and environmental factors increase the risk of developing the condition. It is highly heritable, and the effectiveness of stimulants has led to the hypothesis that dopamine and noradrenaline are implicated.
 
For Associate Professor Kramer, part of the prescribing increase may be related to Australia catching up for lost time.
 
‘I think that historically ADHD has been more readily diagnosed in the US than Australia and the UK,’ he said.
 
‘Historically it has been generally underdiagnosed. Why is there more now? There’s been a lot more publicity, particularly online.
 
‘I [also] think COVID has played a significant role. For example, Melbourne having the longest lockdowns of any Australian city … has increased the number of adults, especially women, seeking a diagnosis.
 
‘I interpret this as possibly related to the breakdown of many folks’ adjustment strategies pushing them to the brink.
 
‘One way people with ADHD manage their condition is with regular exercise, so when they were closed down, people lost their coping strategies.’
 
Dr Rakov concurs that triggers for ADHD are multifactorial, but is worried that the focus of treatment tends to weigh towards pharmaceuticals.
 
‘Like many presentations we see, people are seemingly ignoring their own lifestyle contributors,’ she said.
 
‘The principal factors, well-addressed in Johann Hari’s book Stolen Focus, are the hidden mechanisms of social media and how they manipulate our attention.
 
‘Hari suggests individuals take back their autonomy over their “stolen” focus [by] practising pre-commitment, seeking out flow, taking time away from social media, allocating unbridled thinking time, sleep hygiene, and free play.
 
‘At the other side of the desk, like many treatments in psychiatry, there is a heavy focus on biological intervention. Even if someone does live with ADHD, they should not be handed a script and waved off for six months.
 
‘Most patients are not involved in cognitive remediation therapy, dialectical behavioural therapy or psychosocial treatment programs that optimise their life skills.’
 
The 2022 Australian ADHD guidelines detail pharmacological and non-pharmacological treatments, including for subgroups like people in the correctional system and those with co-occurring substance use disorders.
 
Professor Kramer hopes they will raise awareness and encourage GPs to screen at-risk groups.
 
‘It should also be a guide to parents, patients and teachers,’ he said.
 
As it stands, more voices are seemingly being heard in regards to their improved quality of life with ADHD diagnosis and treatment. But only time will tell if Australia’s guidelines and standards prevent similar harms to those being reported in the US.
 
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ADHD guidelines stimulants

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