Pharmacists can act as an ‘early warning’ monitor of over-prescribing and diversion, writes Dr Des Corrigan
I am guilty of too frequently quoting the Spanish-American philosopher George Santayana, who observed that “those who cannot remember the past are condemned to repeat it”. Although clichéd, it does have a particular resonance given all that is happening in our world at the moment. But what, you may wonder, has it got to do with ADHD? Well, the quotation popped into my head as a result of all the publicity around ADHD in the print, online and visual media over recent months.
We have seen a deluge of ‘celebs’ and ‘influencers’ rushing to share their delayed diagnoses and far more worryingly, anguished parents lamenting the lack of services for their newly- diagnosed young children. Santayana’s observation comes into play because, as is well-known, the standard pharmacotherapy for ADHD is an amphetamine-type stimulant (ATS) such as methylphenidate, or amphetamine itself or a pro-drug thereof.
In February, The Irish Times, using HSE data obtained under the Freedom of Information Act, reported an 87 per cent increase in ADHD-related prescriptions, rising from 72,769 in 2020, to 135,818 in 2024. A report in the August issue of Irish Pharmacist linked this to a 30 per cent rise in expenditure on such medication, at €9.2 million in 2024.
This increased availability of ATS brings with it the inevitable risk of their misuse and diversion. We have previous form in this country where ATS are concerned, hence my worry. In the late 1960s, ATS misuse was one of our major drug issues, which may surprise those who think that our drugs problems have involved only heroin or cocaine or benzo misuse.
One 1969 study of boys in a Dublin remand home indicated that over 11 per cent of them had used ATS. My memory of this is particularly vivid because the late CS O’Connor and I actually did the analysis of the urine samples out in Shrewsbury Road. As a result of these and other findings, the Dept of Health in 1970 introduced the Medical Preparations (Control of Amphetamines) Regulations that restricted prescribing of ATS to such an extent that the level of misuse in that remand home reduced to 0.6 per cent in just six months.
Now, I am most definitely not calling for a restriction on the supply of ADHD medications, because it is abundantly clear that the outcomes for untreated ADHD sufferers are far worse compared to those treated with ATS. The BMJ in August reported a Swedish study of over 84,000 individuals with ADHD who started treatment promptly with methylphenidate and compared them with 64,000 whose treatment was delayed after diagnosis. Treatment was associated with reduced risk of suicidal behaviour, substance misuse, transport accidents and criminality, but not accidental injuries, while stimulants were associated with lower rates compared to non-stimulant medication.
Although Cochrane Reviews in 2016 and 2023 state that methylphenidate and amphetamines seem efficacious in improving ADHD symptoms, an article in Drugs and Therapeutics Bulletin earlier this year noted that NICE recommended a treatment approach that addresses psychological, behavioural and educational/occupational needs with medication prescribed where there is significant impairment.
It went on to note that psychotherapy, including CBT, may be useful, but that medication is more effective in reducing symptoms, as is a balanced diet, regular exercise and in adults, moderation of alcohol intake. The DTB article refers to conflicting evidence that omega-3 supplements, vitamin D, magnesium and excluding artificial food additives are of benefit.
For far too many distressed parents of ADHD children, it is the lack of access to those psychological services that is hard to understand and accept and reading The Irish Times article about ‘pauses’ in HSE-provided ADHD services appalled me and is shameful in a highly-developed country. While pharmacists are only involved in the provision of medication, there is nothing to stop them individually or collectively from advocating for adequate provision of essential comprehensive services.
From a supply-side perspective, pharmacists can provide effective early warning of over-prescription of stimulant medications and of diversion and non-medical use (NMU). Not surprisingly, given our lack of information about most pharmacy issues, we know next to nothing about the existing situation in Ireland. In the US, misuse and diversion are highly prevalent, with between 1.4 and 2 million reporting non-medical use of ATS that they obtained mainly from family or friends (especially college peers), according to a 2020 systematic review in the Journal of the American Academy of Child and Adolescent Psychiatry.
Not surprisingly, given our lack of information about most pharmacy issues, we know next to nothing about the existing situation in Ireland
Others fake the symptoms from DSM-V in order to fraudulently obtain prescriptions. While most misuse is by the oral route, there are reports of powdered product being snorted, smoked or injected. Most of this misuse is among those who are non-ADHD, in order to improve academic performance by increasing concentration, helping to stay up longer studying. As a result, these products are referred to as ‘cognition enhancers’, ‘neuroenhancers’ or ‘smart drugs’.
Among US pharmacy students, a 2003 study included in a 2012 overview of the misuse of prescription stimulants in Brain and Behaviour noted a prevalence of NMU of 7 per cent, mostly in those who were white, older and “low academic achievers”. Prevalence was also high in medical and dental students. The evidence suggests that they were basically wasting their time attempting to improve performance, as there is little evidence of a positive outcome in those who do not have ADHD and in those who had been diagnosed, there was only a modest impact on grades and college attendance. In fact, a recent (2023) research study in Scientific Advances found that while methylphenidate and dexamphetamine increased motivation, productivity was actually decreased while completing a complex everyday task. In addition, a number of US universities prohibit the NMU of prescribed stimulants by adding it to their definition of cheating.
Given the side-effects of NMU, such as sleep problems, decreased appetite, abdominal pain, headache and anxiety, and more rarely dependence, psychosis, cardiovascular issues and sometimes sudden death, pharmacists have an opportunity to educate patients and parents about the risks of diversion
and how to cope with pressure to ‘share’ their medication. They can also act as an ‘early warning’ monitor of over-prescribing and diversion, as they have done in the past with Diconal and Temgesic, for example.
Dr Des Corrigan, Best Contribution in Pharmacy Award (winner), GSK Medical Media Awards 2014, is an Adjunct Associate Professor at the School of Pharmacy and Pharmaceutical Sciences at TCD where he was previously Director and won the Lifetime Achievement Award at the 2009 Pharmacist Awards. He was chair of the Government’s National Advisory Committee on Drugs from 2000 to 2011, having previously chaired the Scientific and Risk Assessment Committees at the EU’s Drugs Agency in Lisbon. He chaired the Advisory Subcommittee on Herbal Medicines and was a member of the Advisory Committee on Human Medicines at the HPRA from 2007 to 2024. He has been a National Expert on Committee 13B (Phytochemistry) at the European Pharmacopoeia in Strasbourg and served on the editorial boards of a number of scientific journals on herbal medicine.
