It seems only yesterday that I held only one S8 prescribing permit for stimulants for ADHD.
In contrast, as 2024 came to an end, I seemed to be applying for one nearly every other week.
I was initially reluctant, as have many GPs, to dive under the wave, feeling it was outside my scope of practice.
However, many patients are now presenting and requesting referrals for ADHD assessments, with a good proportion describing the confirmation that they have ADHD and subsequent treatments as life-changing.
I am now of the view that ADHD, like other mental health conditions in non-complex adult patients, is a core part of general practice. There are many other conditions that we prescribe for after an initial assessment and recommendation from a non-GP specialist colleague, and I now see ADHD as no different.
ADHD – more than just the Tiktok phenomenon
The Australian Evidence Based Clinical Practice Guideline For Attention Deficit Hyperactivity Disorder (ADHD) was published in 2022 by the relevant peak body, the Australasian ADHD Professionals Association.
The guideline summarises the issues and the evidence pertaining to the condition. Looking at the prevalence helped me to contextualise this as a common general practice presentation.
From the guidelines:
- ADHD is the commonest neurodevelopmental disorder in children and adolescents.
- Prevalence in the Australian adult population is estimated to be as high as six per cent. This is similar to diabetes, an acknowledged common condition confidently managed in general practice.
- Persistence into adulthood of childhood or adolescent ADHD is probably between 60 and 80 per cent.
- Adults tend to have the inattentive variant of ADHD.
- The disorder is typically under-recognised in women.
- Common symptoms include lack of attention to detail, difficultly sustaining attention or (conversely) hyperfocus if in an area of high interest.
- Others include appearing not to listen or having difficulty following conversations, failure to finish tasks, task switching, difficulty organising tasks, avoiding tasks requiring sustained mental effort, constantly losing things, easily distracted, forgetful, mental restlessness, problems prioritising work, difficulty relaxing, and impulsivity.
- People with ADHD have poorer educational and employment outcomes.
- They also have poorer physical health, including higher rates of obesity and sleep problems as well as damaging outcomes from risk-taking behaviours.
Which populations have high prevalence of ADHD?
Adults:
- with any mental health disorder, including substance use disorders, borderline personality disorder, intermittent explosive disorder, internet addiction, psychotic disorders, binge eating disorder, and gambling disorder;
- who experience suicidal behaviour or ideation.
People of all ages:
- with neurodevelopmental conditions including autism spectrum disorder, intellectual disability, tic, language and specific learning disorders;
- who were born preterm;
- with a close family member diagnosed with ADHD;
- who were born with prenatal exposure to substances including alcohol and other drugs (resulting, for example, in up to 50 per cent prevalence in those with Foetal Alcohol Spectrum Disorder);
- with an acquired brain injury;
- who are imprisoned (prevalence in prison populations might be as high as 30 per cent);
- with low birth weight;
- with anxiety, depressive or bipolar and related disorder;
- with sleep disorders.
Women:
- ADHD is often under-recognised in girls and women so they are less likely to be referred for assessment, more likely to remain undiagnosed, and more likely to receive an incorrect diagnosis of another mental health or neurodevelopmental disorder.
An adult patient presents requesting referral or you suspect ADHD – what next?
I ask my patients what they are looking for from a diagnosis.
If they are solely looking for validation, or cannot afford a psychiatric assessment, I suggest doing some free online assessments such as the WHO Adult ADHD Self Report Scale (ASRS) (Part A), Conners’ Adult ADHD Rating Scale – short or Wender Utah Rating Scale (WURS) – short.
Validation can assist with understanding themselves and how they experience the world differently to their neurotypical peers. It can also help them engage in non-pharmacological strategies. Sometimes doing these scales and finding they might have ADHD can prompt them to seek a formal diagnosis.
The Australian guidelines outline the non-pharmacological approaches to ADHD.
All stimulant medications for ADHD are listed as schedule 8 drugs in Victoria. To access them, a patient must have a diagnosis and prescribing recommendations from a psychiatrist. The prescribing GP must have a valid schedule 8 permit. Permits remain valid for two years and require a psychiatrist review to renew.
Unfortunately, next steps can often depend on the patient’s financial ability to pay for the assessment. A patient of mine recently described getting a diagnosis of adult ADHD as “the personification of the inverse care law – with access to stimulants only for the financially privileged”.
Adults under 25 may be able to access assessment via a child and adolescent mental health services provider, such as Orygen.
In Victoria there are no public diagnostic services for adults over 25. There may be some bulk-billing private psychiatrists out there, but in general patients can expect to pay at least $1000 for their diagnostic assessment.
Some psychologists and neuropsychologists also provide a diagnostic service – but without the ability to authorise prescription of stimulants.
Schedule 8 permits for stimulants – what you need to know
American research shows that stimulant medication is effective in about 70 per cent of adults.
Although the guidelines recommend psychiatrists commencing medication, with the current demand on psychiatrists’ time and appointments, many are no longer either initiating prescribing or prescribing long term but doing a one-off “291” assessment then authorising GPs to prescribe. This includes initiation of medication.
Your patient gets their ADHD diagnosis from a psychiatrist, and you receive a letter authorising you to prescribe stimulants for them – what do you do next?
For stimulant medication you must apply for an S8 permit. It’s important to be aware that these permits are patient-specific. You must apply for one for every new patient requiring ADHD stimulant meds.
It’s useful to think about your workflow before taking this step. Do you want to see the patient and discuss options first, or apply for the permit then see the patient? You can apply for all the recommendations from a psychiatrist’s letter, even if you intend to only use one of them.
There are some exceptions to the permit rule. Paediatricians and psychiatrists are not required to hold a permit.
GPs can prescribe without a permit in circumstances where patients are confined and not personally managing their medications. Examples include incarcerated prisoners, aged care home residents, and patients receiving inpatient treatment in a hospital (including day procedure centres).
All applications for S8 permits are now done on safescript (there are some how-to videos here)
For general information on S8 permits in Victoria click here.
For more specific information on S8 permits for ADHD click here.
Multi-practitioner clinics
At multi-practitioner clinics, more than one medical practitioner might be involved in the management of some patients. However, as long as one practitioner holds a permit, colleagues can also prescribe, as long as this is consistent with and does not exceed the permit limits or conditions.
To ensure compliance, details of permits, including maximum dosage plus expiry or cancellation dates, should be prominently displayed within patient records.
Commencing stimulants – next steps
I ask my patients coming in to discuss commencing stimulants to book a 30-minute appointment.
I have an aide memoire to make sure I cover off necessary points, and take notes as appropriate. It looks like this:
- ADHD confirmed
- discussed
- keen to trial stimulants
- discussed non-Rx interventions
- discussed what success looks like
- discussed permit system
- discussed contract (we have a contract with all S8 permit patients to broach diversion risks)
- discussed FTF r/v needed for Rx and no short script or online script appointments
- discussed medications and side effects including dec appetite, weight loss, insomnia, rebound as Rx wears off, anxiety, tics, palpitations, elevated BP, elevated pulse rate
- discussed rare risks incl heart issues, seizures, mood disorders
- BP/pulse rate
- weight/height/BMI
- HS I+II+0 today
- ECG prior to starting
- travel
- once permit approved I will send prescriptions for XXXX to take for 2/52 and then if tolerating XXXX for 2/52 and then for review in 1 month
- handout given.
Medication options
The ADHD clinical practice handbook recommends methylphenidate, dexamfetamine or lisdexamfetamine as the first-line pharmacological treatment for people with ADHD, where symptoms are causing significant impairment – although the choice we have will be limited by the psychiatrist’s recommendations.
For more information see the ADHD in Adults section of HealthPathways Melbourne.
Contraindications
Contraindications to the use of psychostimulants include:
- glaucoma
- symptomatic cardiovascular disease
- hyperthyroidism
- hypertension
- certain psychiatric conditions, including psychosis and schizophrenia.
Who needs a cardiology opinion prior to commencing stimulants?
The guidelines recommend referral for a cardiology opinion before commencing stimulant medication for patients who have:
- a history of congenital heart disease or cardiac surgery
- a history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
- shortness of breath on exertion, compared with peers
- fainting on exertion
- palpitations that are rapid, regular and start and stop suddenly
- chest pain suggesting cardiac origin
- a heart murmur (not including innocent heart murmurs in children)
- hypertension.
When should you be more cautious with dose titrations?
The recommendation is that dose titration should be slower, and monitoring more frequent, if any of the following are present:
- other neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, intellectual disability)
- other mental health conditions such as anxiety disorders, schizophrenia or bipolar disorder, depression, personality disorders, eating disorders, post-traumatic stress disorder, substance misuse
- physical health disorders, such as cardiac disease, epilepsy or acquired brain injury.
Medication monitoring
It is good practice to record ADHD symptoms, impairment and adverse effects at baseline and at each dose change by the person with ADHD. Medication reduces symptoms but rarely does so completely. Therefore, it is important to have realistic expectations and ensure it is only one part of a person’s treatment and support plan.
I arrange monthly follow-ups while titrating ADHD stimulants, until we both feel medication is optimised and stabilised. After that, the frequency of follow-ups is mutually agreed, with the maximum allowed prescription for an S8 drug being six months. I insist on all follow-ups being face-to-face to allow for physical monitoring.
At monitoring appointments, I measure blood pressure, pulse and weight, then ask about:
- Side effects and how to manage them. Strategies include medication after food for reduced appetite, medication earlier in the day for reduced sleep, and assessing whether increased anxiety may be transient.
- Beneficial effects and managing expectations of outcomes.
- Strategies to reduce diversion. This includes advice to use only one pharmacy and that there will be no replacements for lost prescriptions. It is also recommended to perform occasional urine drug screens.
- Other stimulants can be tried if the initial one is not effective. Options are usually guided by the original psychiatrist letter.
What about other non-stimulant medications?
If stimulants are contraindicated, or are not effective, there are non-stimulant medication options.
These include:
- Atomoxetine
- Guanfacine
- Clonidine.
For detailed information about each, and other options see the Australian ADHD Clinical Practice Guidelines.
ADHD medication and travel
Many countries do not allow travellers to bring stimulant medications with them, or require either a permit to import or a letter from their treating doctor. It is up to each patient to ensure they are compliant before they set off.
For more information:
- Australian Evidence-Based Clinical Practice Guideline For Attention Deficit Hyperactivity Disorder (ADHD)
- WHO Adult ADHD Self Report Scale (ASRS) (part A)
- Conners’ Adult ADHD Rating Scale – short
- Wender Utah Rating Scale (WURS) – short
- Patient Schedule 8 treatment permits Victoria
- Stimulants for ADHD or narcolepsy – permit requirements – Victoria
- Safescript – How to apply for an S8 permit on safescript
- Health Direct – patient handout ADHD medications
- ADHD drug dose converter.
