ADHD, trauma and complex care

‘Doc, I heard that GPs can prescribe stimulants now … can you take over prescribing from my psychiatrist?’.
 
Paul*, whose family attends the practice, came to see me when he heard there were new changes to attention deficit hyperactivity disorder (ADHD) management and that GPs can now prescribe.
 
He asked if I could take over prescribing for lisdexamfetamine for his ADHD from his psychiatrist.
 
Paul works full time in administration, and lives with his wife and two children. He reported he has been stable on opioid dependence treatment for the past year. He takes no other medications and is otherwise well.      

ADHD is a neurodevelopmental condition, and symptoms are present from early childhood. It often affects multiple family members, and a parent can sometimes recognise their own diagnosis once the needs of their child come to attention.

It often occurs concurrently with other neurodevelopmental conditions including autism spectrum disorder or learning disabilities.  Psychostimulants are the most effective form of treatment for ADHD. In a person with an established diagnosis of ADHD who has been stable on medication, treatment can be life-altering, supporting function and planning, a great benefit for school or work.
 
GPs can already prescribe non-stimulant medication, give advice for ADHD, and prescribe psychostimulants under a co-prescribing arrangement with a paediatrician or psychiatrist.
 
Upcoming legislative changes in some states in Australia and New Zealand between now and 2026 will allow GPs to apply for the authority to independently prescribe psychostimulant medications (dexamfetamine, lisdexamfetamine or methyphenidate) for the treatment of ADHD.
 
The new legislative changes are highly positive and are much needed to address the gap there has been in access in prescribing for ADHD, a highly prevalent condition.
 
However, like any change, GPs are also navigating how they may see their role in care. It may seem that the new legislative changes mean that we no longer have the option to continue to work with people with multimorbidity, but a team approach can ensure those who have most to gain from treatment have access to it.
 
What if the presentation isn’t straightforward?
I am a GP with specific interest in complex care, mental health, abuse and violence and neurodiversity. Not every person with ADHD has multimorbidity, however many of my patients not only have ADHD, but also other co-occurring presentations, including alcohol and other drug (AOD) dependency, post-traumatic stress disorder (PTSD) or complex PTSD.
 
In the patients I see, a history of trauma can be psychological, sometimes unintentional. Someone like Paul who is diagnosed as an adult can describe living with internalised shame from when he was a child struggling to concentrate due to his distractibility. I call this the ‘trauma of identity’, where the individual has a tumultuous journey to understanding and acceptance of their self or identity. 
 
Paul may be struggling to come to terms with his own diagnosis, while also managing care of his children and wanting their needs better understood than his own experience. 
 
Co-morbid ADHD and trauma history increase the risk of developing risky, hazardous, harmful or dependent alcohol and other drug use. Having both AOD dependency and ADHD should not limit treatment for either condition. This group of patients can hugely benefit from ADHD treatment, however multimorbidity can make this more complex.  
 
For patients like Paul, having stigmatised health conditions like opioid dependency may compound the sense of shame and also prevent their ability to access care. 
 
It is important to assess the severity of a person’s AOD issues. For some patients with ADHD, AOD issues are stable, for example, Paul is stable in his opioid dependence treatment. People may have a history of past AOD issues in remission for years, or may use one substance without any issues. In these instances, I’ve found that co-management of both conditions is routine in the GP setting without significant specialist support.
 
Where the patient uses multiple substances, with evidence of risky, hazardous, harmful or dependent use, or where the periods of stability have been less predictable or prolonged, they will benefit from additional AOD specialist support.
 
The legislative changes that allow a GP to prescribe psychostimulants independently does not mean that we HAVE to practice independently, especially when care is complex.   
 
In general practice we care for patients with multimorbidity and across their lifespan. It means that we may see patients who may have relapse and remission in any of their presenting issues: how their ADHD impacts them, how drug dependency may impact them, how trauma may impact them. 
 
The decision of whether any of these presentations are stable enough to allow independent continuing prescribing, is the same decision that GPs face when deciding whether to independently manage cardiovascular disease, or diabetes with or without team-based care.
 
Sometimes it is our most vulnerable patients who may benefit the most from team-based care, but also have the greatest access difficulty. There is a lack of public services for ADHD with comorbidity, particularly substance disorder. As a profession, we should continue to advocate for the need for accessible specialist services that work alongside general practice.
 
Otherwise, GPs may be requested to step in and feel obligated to assist when they feel this gap.  Within the clinical setting, between doctor and patient, we should be clear about what our responsibility is as the GP.  This should be clearly communicated to the patient early when there is the decision to be involved in care, including if and when we feel team-based care is appropriate. 
 
All GPs will have some involvement in the care of patients with ADHD. For families like Paul, his children will now have the ability to access continuing care as they move into adulthood. Some individuals may even be diagnosed in the future by their local GP and be safely managed without other specialist support.
 
Alternatively, if Paul were to require care within a multidisciplinary team, then we as his GP may advocate to access specialist services within a multidisciplinary approach.
 
We need to ensure that patients with complex needs and multimorbidity are able to benefit from the new legislative changes together with all patients with ADHD.
 
I would also like to acknowledge the contributions of Associate Professor John Kramer, Chair of RACGP Specific Interests ADHD, ASD and Neurodiversity, and Dr Hester Wilson, Chair of RACGP Specific Interests Addiction Medicine for this article.
 
*Paul is a hypothetical patient
 
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ADHD alcohol and other drugs attention deficit hyperactivity disorder comorbidity PTSD trauma