Why the recent Pharmac changes don’t fix access barriers to ADHD medication

We all dream of a world where no one needs to pay for – or repetitively prove – their disability or chronic medical condition. And from December 1, this will no longer be the case for some who are medicated for ADHD. However, access to the gold standard treatment for ADHD will still be impossible for tens of thousands in Aotearoa.

Last Tuesday, Pharmac announced two changes affecting people wanting access to medication for ADHD and narcolepsy: scrapping the requirement to renew your prescription every two years and funding lisdexamfetamine, a very useful and highly anticipated addition to the pool of currently funded ADHD medication. 

These are major wins for those who already have something called Special Authority: the agreement from a psychiatrist or a paediatrician to be prescribed a particular medication. So if you can see a psychiatrist privately, costing upwards of $500 to be assessed for Special Authority, or if you’re a paediatric patient, lucky you! Here are the changes, explained:

Removal of renewal criteria

From 1st of December, Pharmac will remove the renewal criteria for some medicines used to treat ADHD and narcolepsy, such as: methylphenidate (Ritalin, Concerta, Rubifen), dexamfetamine (or dexamphetamine) and modafinil (Modavigil). This follows a public consultation which proposed these exact changes. (Side note: modafinil can be used to treat ADHD, but is only funded in the treatment for narcolepsy.)

About 65,500 people used these medicines in the last year and this number is increasing. Currently, adults need to renew their Special Authority every two years and only from a psychiatrist. 

But from December onwards, once you get Special Authority, a doctor or nurse practitioner can continue to prescribe it. This means that people using these medicines can access repeat prescriptions through their GP. 

Funding lisdexamfetamine 

Lisdexamfetamine, which otherwise costs over $100 a month, is part of a class of medications called ‘amphetamines’ known to be most effective and tolerable in treating ADHD in adults. In some countries it's the top recommended medication for ADHD. 

Currently Pharmac funds three types of ADHD medication: atomoxetine, methylphenidate (Ritalin, Concerta, Rubifen) and dexamfetamine.

But from 1st of December, Lisdexamfetamine (Vyvanse) will also be funded, costing $5 for three months. Pharmac estimates that over 6000 people will benefit in the first 12 months of funding. 

But the reality is different for tens of thousands of adults with ADHD

Firstly, accessing medication or even getting a diagnosis or referral is not solely a financial issue. Inequity and culture play a large part. For example, Māori are more likely to be under-prescribed ADHD medication, making up only 10% of people receiving pharmacological treatment, despite being 17% of the total New Zealand population.

Māori parents are also less likely than Pākeha to initiate a diagnosis of ADHD for their children. This could be for several reasons, such as parents not considering their child’s behaviour as warranting investigation, or due to a lack of culturally safe practices. What this could mean is more undiagnosed Māori adults with ADHD. And when you add on barriers in the referral process, those inequities are amplified. So given that, this is what’s happening: 

For any ADHD patients relying on funded public health care, it’s unlikely that you’ll be able to access stimulants like lisdexamfetamine (Vyvanse), methylphenidate (Ritalin, Concerta, Rubifen), and dexamfetamine (or dexamphetamine). As mentioned, stimulants are the gold standard for treating ADHD but can only be accessed from a psychiatrist or paediatrician.

Instead, you’ll be limited to what your GP can prescribe: second-line medications such as atomoxetine and bupropion (Zyban, Wellbutrin) and recommended lifestyle adjustments, which are not as effective as stimulants, according to University of Waikato academic GP Steven Lillis.

Lillis says this is because there is a close to 0% chance that ADHD patients will be seen by a psychiatrist in public mental health services.

“I can refer to secondary care, but… they have told us as GPs they will not see people with ADHD, they will categorically decline referrals for ADHD and that is true up and down the country… I don’t know of any public health mental health service that is accepting ADHD referrals, ie. for the primary purpose of popping somebody onto a stimulant.”

Lillis says between 30,000 to 40,000 in Aotearoa have ADHD that they would like treated with the most effective medications, but cannot access them. 

“I have seen so many tertiary students drop out of university when they go from a fairly structured environment of a school to the unstructured environment of a university. We know that untreated ADHD gets people into trouble with the law. We know that their chances of doing well at work are reduced. We know that their interpersonal relationships suffer as a consequence. For 30 to 40 thousand people to have to endure that because they are simply denied access to the most useful medication is simply wrong.” 

Lillis says in his research:  “ADHD is also an outlier in our medical system. For almost all other chronic diseases, uncomplicated cases are managed entirely in primary care, with secondary care referral only for more complex cases… When all cases of ADHD, including those that are uncomplicated, require specialist psychiatry or paediatric evaluation, efficiency and accessibility is lost.”

While these recent changes are a step in the right direction, the next step, Lillis says is for the government and the Royal New Zealand College of General Practitioners to enable more health practitioners at primary care level to prescribe first line medications and decide on what’s required from these prescribers to ensure safe prescribing. For some, there is a concern of over-diagnosing and over-prescribing for ADHD.

“I think it’s promising that there has been some movement,” says Lillis. “We just need to take one more step.” 

Subscribe to our weekly newsletter, The D*List Delivered!