When experts discuss the rates of medication for ADD/ADHD most do so with a resigned air, as they believe that these rates will simply continue to rise indefinitely. This may seem, at first glance, like a defeatist attitude that there is no denying that the trend is upward and has been so for a long time. It need not be the case however! There is an excellent example, on the other side of the world, of a jurisdiction that effectively engineered a massive turnaround in ADHD prescription rates.
The state of Western Australia covers the entire Western third of the Australian continent, yet contains only about 10% of the Australian population. Its capital, Perth, could at one stage stake a credible claim as the ‘Ritalin capital of the world’ with prescription rates much higher than the US average. It is estimated that by 2003 about 20,000 West Australian children (out of a population of 2.2 million) were taking stimulants to ‘treat’ ADHD. A recent report by the West Australian Health Department puts the figure for 2008 at 5666! This means that the prescription rate was brought down by almost three quarters in the space of five years.
The West Australian experience proves that prescription rates need not be a one-way street, but that they can indeed be turned around leading to better outcomes for children and for society at large. (For example, the reduction in stimulant prescription rates coincided with a significant reduction in amphetamine abuse!) So what can we learn from Western Australia when it comes to tackling the sky-high prescription rates in most North American jurisdictions?
Here are a few factors that contributed significantly to the turnaround:
Citizen activism: The West Australian population is fairly small (only about 2.2 million people). Perth is also a very isolated city, about four hours flying time from the other major Australian population centres. The drugging of 20,000 children in such a relatively small and isolated population attracted widespread attention. The drug companies tried their usual tactics in trying to reassure people that their products were perfectly safe, but there were many people who refused to stop asking questions. The main question that they kept asking was why Western Australia had perhaps the highest stimulant prescription rate in the Western world. This led in 2004 to a full parliamentary enquiry into the issue. This enquiry conducted by the West Australian Parliament was the beginning of the end of high prescription rates in the state. The lesson is clear: In a democracy we have the privilege of bringing issues to the attention of our political leaders and doing so thoughtfully and persistently can sometimes result in radical changes.
Tightening up prescription rules: The enquiry by the West Australian Parliament yielded some surprising and disturbing results. It seemed that only a handful of paediatricians were behind the massive spike in prescription rates. These paediatricians wrote prescriptions under a system called ‘Block Authorisations’ under which: “…a practitioner was able to apply to the (West Australian) Department of Health and be granted blanket approval to treat any number of patients with stimulant medication, without further notifying of changes to individual patient details or dosage.” The rationale behind the system was that people who often worked with a specific kind of medication would be more familiar with it and that it would therefore not be necessary to check the reasons for every prescription. The unintended consequence was that it handed certain doctors (whom the state thought could be trusted) a blank check to write as many stimulant prescriptions as they wanted without being accountable for them. The enquiry made it clear that this trust placed on doctors was abused on a massive scale by some of them. One of the major recommendations of the enquiry was that physicians should be able to account for every single stimulant prescription that they write. Paediatricians would in future have to: “…apply to the (West Australian) Department of Health and obtain a unique Stimulant Prescriber Number (SPN) to initiate stimulant treatment in any patient. The practitioner must provide individual patient details, including age, gender and dose required, thus enabling the collection of data for future analysis of stimulant use in Western Australia.”
Emphasis on a multi-disciplinary approach: The Parliamentary enquiry was very critical of the way in which ADHD was diagnosed and treated. It pointed out that many paediatricians did not bother to look for other possible causes or at alternative methods of treatment. In many cases diagnoses were rushed, leading to only one possible outcome: Medication. As a result of the enquiry physicians will now have to be able to indicate how they went about eliminating other possible causes of inattention before deciding on an ADHD diagnosis. The state is also in the process of setting up two multidisciplinary centres for the treatment of ADHD where alternative treatment methods will be used under the direction of people from several different health-related disciplines. The purpose of the centres will be to reduce the rate of medication even further by first exhausting alternative treatment options before medication is recommended.
The West Australian example clearly shows that rising medication rates need not be a one-way street but that it can be successfully turned around where there is sufficient popular concern and resultant political will. It is true that Western Australia is a unique place with a relatively small and isolated population, but there is no reason why these stunning results cannot be replicated on a larger scale in other jurisdictions.
Click here for more information about the way in which medication rates in Western Australia was lowered.