Case for caution in expanding attention deficit hyperactivity disorder prescribing

Abstract

Expanding psychostimulant prescribing to general practitioners (GPs) addresses Australia's attention deficit hyperactivity disorder (ADHD) access crisis, but risks significant unintended consequences. This article highlights the cumulative risks of long‐term stimulant use and the danger of fragmented care models. We argue that inconsistent training and the rise of vertically integrated telehealth platforms threaten to reduce ADHD care to a volume‐based pharmacological service. To protect public health, Australia requires a national framework prioritising mandatory education, shared care pathways and periodic reviews. Success must be measured by the quality of holistic care, not merely script volume.

The expansion of prescribing rights for psychostimulants to general practitioners (GPs) represents a landmark shift in Australian healthcare. Catalysed by the recent Senate inquiry into attention deficit hyperactivity disorder (ADHD) services, ¹ these reforms are a pragmatic and necessary response to a crisis of access, where patients endure unacceptably long wait times and face high out‐of‐pocket costs to see a specialist. The intention to improve timely, affordable and equitable care is laudable. However, in our haste to dismantle barriers, we must proceed with caution. This policy shift, while solving one problem, may have unintended consequences by underestimating the complexities of long‐term stimulant use, the necessity of multidisciplinary, holistic and longitudinal care and the risks of commercialised medicine. It is imperative that we, as a medical profession, look beyond the immediate benefits of access and consider the guardrails needed to ensure this new paradigm support safe, sustainable and high‐quality care. This perspective piece outlines key concerns and gaps in existing models, highlighting opportunities to shape policy that minimises harms and promotes public health.

Our current understanding of stimulant safety is largely shaped by short‐term data. A recent meta‐analysis of randomised controlled trials, with typical durations under 1 year, confirmed a profile of common, manageable adverse events like decreased appetite, insomnia and anxiety. ² Another study in older adults found that cardiovascular risk was highest during the first 30 days of initiation, before gradually attenuating. ³ These short‐term data are at odds with longer‐term population studies of stimulant use. Adverse effects from chronic use are well documented, with long‐term stimulant treatment associated with modest but significant increases in resting heart rate and blood pressure, alongside concerns about more catastrophic events, including an elevated risk of sudden cardiac death and stroke in adult users. ³ These documented risks directly challenge the minimal‐risk narrative, revealing that when considered across a patient's lifetime and at a population level, the potential for harm is far more significant. Swedish National cohort data suggest that long‐term stimulant use was associated with an increased risk of cardiovascular disease (CVD); notably, the risk increased by 4% for each additional year of use. ⁴ The risk was most pronounced for hypertension – which was 80% higher in those using medication for over 5 years. ⁴ In addition to the cardiovascular side effects, there are modest psychiatric risks, namely tic and new onset psychosis, with an incidence of up to 2.83 per 1000 people per year of treatment. ⁵ By expanding ADHD diagnosis and long‐term prescribing into primary care, we risk exposing a larger population to these cumulative harms without a clear framework to manage them.

The second major concern is the potential fragmentation of what should be integrated, multidisciplinary care. This concern is echoed by specialist bodies such as the Royal Australasian College of Physicians (RACP) ⁶ and the National Association of Practising Psychiatrists (NAPP) ⁷ who caution that ADHD symptoms frequently overlap with conditions such as personality disorder, anxiety, trauma, sleep disorders and substance use. The Royal Australian College of General Practitioners promotes comprehensive shared care for complex chronic conditions through key principles that include comorbidity assessment and management, care coordination and continuity. ⁸ Translating this guidance into an ADHD treatment model situates the GP as more than just a stimulant prescriber; shared coordinated complex care management requires knowledge, skills and expertise across the ADHD and co‐morbidity field. While GPs are slated to receive training in ADHD diagnosis, it is unclear, on a national level, how complete such training will be. With some states receiving online training and peer group support with specialists, others receive a couple of hours of online ADHD‐specific modules, and some states will receive no training at all. ⁹ , ¹⁰ , ¹¹ This nationally inconsistent approach to implementation may further exacerbate gaps in ADHD care and risk diagnostic overshadowing, while preventing consideration and treatment of important differentials.

The current desire for haste in upskilling GPs threatens to undermine the Senate inquiry's explicit recommendation for a National Framework for ADHD care. ¹ By rushing implementation, we risk establishing fragmented models that lack the structure necessary to support public and clinician confidence. As advocated by both the The Royal Australian and New Zealand College of Psychiatrists and the RACP, a consistent, tiered framework is essential. ⁶ , ¹² Such a model would clearly delineate the roles of GPs, paediatricians and psychiatrists, ensuring care would be escalated according to clinical complexity. This structured approach stands in stark contrast to the current proposals that grant prescribing rights with inconsistent support and training, often without established pathways to guide escalation for specialist support. Critically, this lack of structure risks reducing ADHD to a pharmacologically managed illness. The current reform narrative is overwhelmingly driven towards stimulant prescribing, overshadowing non‐pharmacological interventions – potentially encouraging single‐issue clinics to provide scripts without other evidence‐based supports. By providing the ability to diagnose and prescribe without providing training, funding or supported pathways to access non‐pharmacological interventions, patients may only receive partial treatment. ¹³ This outcome contrasts sharply with the goals of true integrated care. We must be vigilant that the pressure for rapid medication access does not overshadow non‐pharmacological interventions or supplant the comprehensive, collaborative care required to ensure patient safety.

The specialist‐led model, for all its accessibility issues, serves as a gateway to broader assessment. While GPs are experts in comprehensive care, their expertise is constrained by a primary care funding model currently unfit for ADHD diagnosis. Current Medicare rebates for GP consultations do not adequately compensate for the time‐intensive assessments a thorough ADHD evaluation requires, leaving substantial out‐of‐pocket costs for patients. ¹⁴ Granting prescribing rights without addressing this fundamental rebate shortfall means that access to a comprehensive and affordable assessment will remain elusive.

Finally, we cannot ignore the commercial context in which these reforms are occurring. The rapid commercialisation and prescribing seen in medical cannabis ‘script mills’ provides a stark warning. ¹⁵ With the emergence of clinics offering ‘risk‐free’ and complimentary, targeted product advertising driving patient demand, there is a powerful financial incentive to prescribe. ¹⁶ , ¹⁷ In the ADHD space, we are already witnessing the rise of vertically integrated telehealth platforms. These services often decouple diagnosis from long‐term management, using marketing to funnel patients into rapid, checklist‐based assessments. ¹⁸ 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. Without robust regulatory oversight, we risk fostering a market where the primary goal becomes volume and profit. This lowers diagnostic standards and increases the community‐wide volume of stimulants, heightening the risk of drug diversion and misuse. ¹⁹ The potential scale of this diversion is significant, with a recent meta‐analysis of studies indicating that 22.6% of participants misused prescribed stimulants in the previous year and 18.2% had diverted their medication and that non‐medical use of prescribed stimulants was a growing concern directly linked to increased accessibility. ²⁰ Indeed, a large cross‐sectional survey of 83 763 adults in America prescribed stimulants found 25.3% of participants reported misuse of their prescribed stimulants, with 9% meeting the criteria for a prescription stimulant use disorder. ²¹ Prescription stimulant misuse can result in a range of established and emerging harms. Studies have shown that prescription amphetamines are associated with increased odds of psychotic symptoms (OR = 1.61, 95% 1.26–2.06) ²² as well as emergent psychosis and mania (aOR = 2.68, 95% CI = 1.9–3.77). ²³ Poisoning due to prescription stimulants has been increasing in Australia and results in a range of harms, including hypertension, severe agitation and acute kidney injuries. ²⁴ The use of prescription stimulants has also been identified as a way to lose weight, ²⁵ as well as a cognitive enhancer, and, to promote wakefulness, ²⁶ was identified in 12% of respondents in a college‐based survey study. ²⁵ Lastly, one cannot ignore that with the current commercial prescribing model for medicinal cannabis and relative lack of regulatory oversight, medicinal cannabis will be prescribed to patients who are vulnerable to harms from these medications and medications will be prescribed despite contraindications. ²⁷ Similar concerns could exist for ADHD prescribing without thorough oversight, and the concerns over prescribing stimulant medications despite contraindication and over off‐label indications is a real one.

The expansion of ADHD assessment and management to primary care practitioners can meaningfully contribute to holistic long‐term care and, as such, is timely and much needed. However, there is a need for a more cautious and deliberate implementation with robust structures to ensure standards of care are consistent across prescribers. However, as the RACP warns, a piecemeal, state‐by‐state approach is not in the best interest of patients. ⁶ For a safe implementation, we need to build a consistent national framework with clear guardrails, not just open the gates. This framework should include a focus on both prescriber‐related policy changes and broader system reform to promote safer care:

• Mandatory training for all ADHD prescribers that extends beyond pharmacology to cover complex differential diagnoses, non‐pharmacological interventions and the principles of multimodal care.

• Formalised shared care pathways to ensure a minimum of consistency and consideration for complexity across GP, paediatric and psychiatric care.

• Funded pathways and clear guidelines for GPs to integrate easily with psychologists and other allied health professionals.

• Structured referral pathways and templates inclusive of comprehensive prior medical and psychiatric diagnoses and prescription histories with the requirement for certain key information, such as medical, psychiatric and substance use history, to be submitted before the issuing of stimulant treatment.

• A mandated framework for periodic review of the diagnosis and the continued need for medication to avoid therapeutic inertia and monitor for cumulative harm.

• Stronger regulation of the advertising and business models of prescribing services to prevent the commercialisation that has plagued other areas of medicine and to identify vertical‐prescribing models that are resulting in harm.

• Ongoing research and evaluation around the changes to ADHD prescribing to shape evidence‐based policy better and to detect signals of unintended consequences, including stimulant prescribing patterns and data linkage to monitor for hospital presentations, poisonings and psychiatric admissions linked to prescription stimulants and indicators of diversion.

Solving the access crisis is a vital goal, but its success cannot be measured by the number of scripts written. True success will be a system that provides timely, comprehensive, high‐quality and safe care for the long term.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.