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ADHD debate clouded by preconceptions and undisclosed conflicts of interest

Three separate contributors to recent editions (Levy, 2012; Paterson, 2012; Starling, 2012) were critical of my May 2012 Viewpoint ‘The rise and fall of ADHD child prescribing in Western Australia: Lessons and implications’ or my role in the National Health and Medical Research Council’s (NHMRC) decision not to approve the 2009 draft ADHD treatment guidelines. It may be instructive to identify points of both agreement and dissent. Dr Paterson rejects my claim that over the last decade there has been a ‘massive’ decline in ADHD child prescribing rates in Western Australia (WA), although he concedes, citing superseded data, that there was a 24% decrease in WA percapita child stimulant prescribing rates between 2004 and 2010. In October 2012, the WA Department of Health reviewed its past estimates and identified that between 2004 and 2010 the decrease in stimulant percapita prescribing rate for children was 32% (Department of Health, 2012). However, Common wealth Government Pharmaceutical Benefits Scheme (PBS) figures provided for me by the Department of Health and Ageing in April 2012 indicate that between 2002 and 2004 the number of children taking PBS-subsidised stimulants fell 16% despite WA’s population increasing 2%. When adjusted for confounding factors, such as the introduction of the non-stimulant Strattera, the WA per-capita child prescribing rate for all ADHD drugs fell approximately 50% between 2002 and 2010. Although this decline is less than the previous 70%+ decrease indicated by older WA Department of Health figures, the only data source available when I wrote my May 2012 piece, or my more conservative 60% estimate, it nonetheless validates my claim of a ‘massive decline’. Dr Paterson also rejects my assertion that tighter prescribing accountability measures were responsible for any decline. He cites significant retirements of prominent prescribers, rather than ‘bureaucratic changes’, as the reason. I agree that retirements contributed significantly but contend that these were ‘encouraged early retirements’ resulting from the pressure of ‘bureaucratic’ scrutiny. The first WA Stimulant Regulatory Report revealed a single paediatrician prescribed to 2077 children from August 2003 until December 2004. Following a significant ‘early retirement’ of a prominent ADHD advocate, this pattern of extreme prescribing to children moderated. This has not been the case for adults, with the WA Department of Health revealing that one psychiatrist prescribed to 1473 patients (including 1346 adults) in 2011 (Department of Health, 2012). Perhaps further ‘encouraged early retirements’ may reduce WA adult ADHD prescribing rates, which in 2011 were 3.3 times the national percapita rate. On a related issue, Professor Levy rejects my contention that heavy prescribers – such as Perth’s Dr 1473 – effectively facilitate the diversion of stimulants. She argues that: ‘dexamphetamine prescription rates have markedly decreased since the availability of slow release methylphenidate capsules, which are much more difficult to divert. Continuing reference to amphetamine diversion is thus out-dated’ (Levy, 2012). Although methylphenidate is now the most commonly prescribed ADHD stimulant in Australia (73% of all PBS scripts in 2010), this is not the case for WA adults (Department of Health and Ageing, 2010). In 2011, the vast majority (81.3%) of WA adults prescribed stimulants were taking dexamphetamine (only 22.3% for WA children) (Department of Health, 2012). This is entirely consistent with my contention that Perth’s high child prescribing rates in the 1990s and early 2000s created a dexamphetamine abuse culture amongst young WA adults, but, as a result of the decline in child prescribing, WA’s next generation has a brighter future. In 2005, detailed data about WA teenage prescription stimulant abuse became available, confirming anecdotal evidence of widespread abuse. Even though prescription rates had begun to drop, the 2005 Australian Secondary Students’ Alcohol and Drug Survey (ASSAD) estimated that 9492 (5.5%) of WA secondary school students had abused prescription ADHD amphetamines in the last year. It also found that amongst WA 12–17 year olds: