Development of the NursePrescriber role, Adult ADHD

A Workshop

Lisa Riches, ADHD Nurse Specialist/Prescriber

Workshop

‘an opportunity for interactive group discussionand learning’

Please join in….

Non-Medical Prescribing 2006:

...designed to improve patients’ access tomedicines, develop workforce capability, utilizeskills more effectively and ensure provision of

more accessible and effective patient care

Non-medical prescribing by 2010:

A well-integrated and established means of managing apatient’s condition and giving him/her access tomedicines

Operating safely and prescribing is clinically appropriate

Patients are satisfied with their experience

Evaluation of nurse and pharmacist independent prescribing, DOH Policy and ResearchProgramme Project 2010

Recent patient views:

The Experiences of Adults with ADHD regarding Impairment, Accessing Services and Treatment ManagementMatheson et al 2012

‘There was very little follow-up really and very littlehelp in working with the medication, which ultimately I

gave up on because…I didn’t have anybody who wasknowledgeable to actually work with me on it, on

tweaking it, or trying different things’

‘There was very little follow-up really and very littlehelp in working with the medication, which ultimately I

gave up on because…I didn’t have anybody who wasknowledgeable to actually work with me on it, on

tweaking it, or trying different things’

Key messages influencing practice:• Psychosocial burden: ADHD-related impairment had an overwhelmingly

chaotic impact on every aspect of patient’s lives and many felt ill equippedto cope. A chronic sense of failure and missed potential from living withthe impact of ADHD impairment had led to an accumulated psychosocialburden, particularly in those diagnosed in later life

• Multi-modal treatment: Medication as a standalone treatment for ADHDwas perceived as having limited effectiveness at alleviating impairment.Therefore, additional support alongside medication in the form ofpsychological therapies or psycho-education was strongly desired

• Specialist support: In some, medication use was often inadequatelymonitored with little or no follow-up by healthcare professionals, leadingto poor adherence and a sense of abandonment by the healthcare system

• Matheson et al BMC Health Service Res 2013

A ‘partnership’‘Since the decision about whether to take a medicine

or not ultimately lies with the patient, it is crucialthat health professionals and patients engage

in ‘shared decision-making’ about medicines usage.

Shared decision-making, (similar to the concept‘concordance’), requires health professionals to

engage with patients as partners, taking into accounttheir beliefs and concerns.’

GMC 2013

How effective?

‘We now know that ADHD medications cannormalize the behaviour of 50-60% of those

with ADHD and result in substantialimprovements…in another 20-30% of people

with the disorder.’

Russell Barkley

Consider…

co-morbidityco-morbidity

choice vs. safetychoice vs. safety

placeboeffect

placeboeffect

expect theunexpectedexpect the

unexpectedmanaging

expectationmanaging

expectation

substancemisuse or

dependency

substancemisuse or

dependency

costcost

optimizingeffect

optimizingeffect

evaluatingefficacy

evaluatingefficacy

physicalhealth

physicalhealth

Managing Expectations

‘Drugs are not a panacea; they won’t magicallymake you a different person, nor will they undoyears of ingrained behaviour….They won’tchange your IQ. They won’t necessarily improveyour social skills, organisational abilities, timemanagement skills, and self-confidence’

From: ‘Succeeding with Adult ADHD’ Levrini/Prevatt

Medication for ADHD provides:

a window ofopportunitya window ofopportunity

an environmentan environment

aplatform

aplatform

How can we optimize effect?

• Psycho-education

• Lifestyle management

• Emotion and mood

Optimizing effect…..• Educate about the disorder and its

management• Adjustment to diagnosis; support the

individual (and those close to them) throughthe diagnostic process and its aftermath• Address mood and self-esteem• Optimise engagement and adherence• Support family members

Lifestyle management• Sleep• Exercise• Emotional regulation techniques (including

mindfulness)• Work/education guidance• Communication & relationships• Addressing addictions• Networks and ‘integration’• Dietary changes• Outside help: Counselling/ Coaching/ Therapy• Time management, organisation & structure

What should I prescribe?

• NICE guidance: NICE technology appraisal (2006); NICE clinicalguideline 72 (2009); NICE quality standard 39 (2013)

• Manufacturer’s recommendations• BNF• Trust policy• BAP (British Association of Psychopharmocology)

Medication Choices

Short-acting methylphenidate HCLConcerta XL – modified release licensed where treatmentstarted in adolescence

Equasym XL; Medikinet XLStrattera (atomoxetine HCL) licensed for adult use

Elvanse (lisdexamfetamine dimesylate) – long-acting licensed where treatment started in adolescence

Dexamfetamine sulfate

Consider differential responses tostimulant medication:

‘individuals may respond verydifferently to different stimulants and non-responseor intolerable side-effects with one stimulant does

not preclude a good response to another’

Arnold: Journal of Attention Disorder 2000

Useful publications

Evidence-based guidelines for the pharmacological management ofattention deficit hyperactivity disorder: Update on recommendations fromthe British Association for Psychopharmacologyhttp://www.ncbi.nlm.nih.gov/pubmed/24526134

‘Good practice in prescribing and managing medicines and devices’GMC Jan 2013

Handbook for attention deficit hyperactivity disorder in adultsUK Adult ADHD Network (UKANN)

Case study 1Mr A, age 21, diagnosis as child age 11 and prescribed medication for ADHD for 1 year and not compliant.Reassessed and diagnosed as adult. Lives with girlfriend and baby. Dad Jamaican, did not know him. Close toMum – he thinks she has ADHD. From age 2-8 brought up by maternal aunt; uncle physically abused him.Brought up in care from age 13 when house burned down. Did not finish schooling although predicted highgrades. Moved around a lot. Difficulties with temper as child. No employment history. On benefits; difficultiesmanaging money.Suspended sentence for 2 years with probation for supplying Class A drugs.Smokes tobacco roll-ups. Currently no recreational drugs, no alcohol, no coffee, no energy drinks.Came with friend, older, also has ADHD, acts as ‘mentor’ in supporting him. Presentation - well kempt, fidgetyand had difficulty following conversation in clinic. Describes difficulties including losing focus, procrastination,frustrated at not being able to carry activities he wants to. No mood disorder, no co-morbid mental healthproblems. Motivated to seek help, though admits to not trusting professionals.GP had started Concerta XL at 18mg and titrated to 54mg; this was not helpful and Mr A self-medicated up to108mg with no benefit. Told GP who suggested he continue at 54mg.No physical health contraindication to treatment. No other medication.Impatient for help with medication.

What issues are there to consider? What concerns do you have? What might you prescribe?How might you optimize medication?

Case study 2Mr B, age 53, diagnosed as adult. Lives with long-term girlfriend and their 2 children. One sonbeing assessed for ADHD. Remembers his mother describing him as ‘strange’. Says he alwaysknew there was ‘something wrong’ with him. Struggled to work at school, often caned formisbehaviour. Bullied. Preferred being alone, ‘lost in his own thoughts’. Sought solace in playingmusic.Had clerical job in Civil Service; described being in a mess but able to improvise and get awaywith it. Struggled with deadlines. Past 20 years worked as singer/songwriter. Lifestyle involvestravelling, highs and lows.Describes difficulties with temper, compulsive spending, sex addiction (sought help for this),hoarding, problems with managing paperwork, organising and planning, procrastination.Significant relationship difficulties.Drinks alcohol every day. No recreational drugs. Several espresso’s a day.Speeding tickets but no other involvement with the law.Reports low mood. No suicidal thoughts or self-harm.Father died of heart attack. Mr B has history of hypertension and high cholesterol. No othermedication.Impatient to start medication. Concerned that he will only want medication for specific tasks andworried that it may interfere with his musical creativity.What are the issues to consider? What concerns do you have? What might you prescribe?How might you optimize medication?