Western Australian Stimulant Regulatory Scheme...Suggested citation Department of Health, (2007),...

Pharmaceutical Services Branch Health Protection Group

Western Australian Stimulant Regulatory Scheme 2006 Annual Report

Suggested citation Department of Health, (2007), Western Australian Stimulant Regulatory Scheme 2006 Annual Report, Pharmaceutical Services Branch, Health Protection Group, Department of Health, Western Australia

I

Table of Contents List of Tables..................................................................................................................I List of Figures............................................................................................................... III Executive Summary .........................................................................................................V Glossary of Terms .........................................................................................................VIII Overview...................................................................................................................... 1 2006 Results.................................................................................................................. 4

Overview .................................................................................................................. 4 Authorised stimulant prescribers................................................................................... 4 Stimulant Notifications Received During 2006 ................................................................... 4 Patients with a Notification and/or Dispensed Medication .................................................... 5 Patients with a Terminated Notification of Treatment Using Stimulant Medication ...................... 6

The ADHD Cohort......................................................................................................... 7 Children (≥2 to <18 years) .............................................................................................. 9

Authorised stimulant prescribers treating children ............................................................. 9 Children with a nominated co-prescriber........................................................................10 Number of children per co-prescriber............................................................................10 Patients by Age and Gender .......................................................................................10 Children in the ADHD cohort by location of residence.........................................................12 Children in the ADHD cohort by medicine notified.............................................................15 Average daily notified dose ........................................................................................16 Dexamphetamine only ..............................................................................................18 Methylphenidate only ...............................................................................................19 Methylphenidate LA only ...........................................................................................20 Patients on combination treatment ..............................................................................21 Comparison of average daily notified doses.....................................................................22 Children in the ADHD cohort treated with other psychotropic medicines ..................................23

Adults (≥18 years).......................................................................................................24 Authorised stimulant prescribers treating adults...............................................................24 Adults in the ADHD cohort with a nominated co-prescriber ..................................................25 Number of adult patients per co-prescriber.....................................................................25 Patients by Age and Gender .......................................................................................25 Age at first Notification for adults in the cohort ...............................................................27 Adults in the ADHD cohort by location of residence ...........................................................28 Adults in the ADHD cohort by medicine notified ...............................................................30 Average daily notified dose ........................................................................................31

Dexamphetamine only ..............................................................................................33 Methylphenidate only ...............................................................................................34 Methylphenidate LA only ...........................................................................................35 Patients on combination treatment ..............................................................................36 Comparison of average daily notified doses.....................................................................37 Adults in the ADHD cohort treated with other psychotropic medicines ....................................37

Naïve Patients in 2006.....................................................................................................39 Comparisons with 2004 & 2005 Data ....................................................................................42 Appendices ..................................................................................................................46

Appendix 1: Stimulant Regulatory Guidelines...................................................................46 Appendix 2: Stimulant Notification Form ........................................................................50 Appendix 3: Queries used in the data extraction from the MODDS database ..............................51 Appendix 4: Estimated Population by Project Specific Age-Groups .........................................53 Appendix 5: Projected populations per Health District for children and adults in 2006 .................54 Appendix 6: Health Districts by Postcode........................................................................55

I

List of Tables

Table 1. Number and type of notifications processed for 2006 ................................................... 5

Table 2. Patients with a current notification and dispensed stimulant prescription by diagnosis on Notification form. ............................................................................................. 7

Table 3. Patients in the ADHD cohort by age group and gender .................................................. 7

Table 4. Authorised stimulant prescribers by number of patients notified ..................................... 8

Table 5. Authorised stimulant prescribers by number of patients notified - children......................... 9

Table 6. Children in the ADHD cohort with a nominated co-prescriber by professional category of co-prescriber ......................................................................................................10

Table 7: Stimulant co-prescribers by number of patients notified ..............................................10

Table 8. Children in the ADHD cohort by age group and gender.................................................11

Table 9. Number, percentage and rate per 1,000 population of children in the ADHD cohort by Health District..........................................................................................................14

Table 10. Average daily notified dose in dex equivalents for children in the ADHD cohort by age group and gender.....................................................................................................17

Table 11. Average daily notified dose in dex equivalents for children in the ADHD cohort by number of medicines prescribed (single/combination) ..............................................................17

Table 12. Notification statistics for children in the ADHD cohort treated with dexamphetamine only.....18

Table 13. Notification statistics for children in the ADHD cohort treated with methylphenidate only .....19

Table 14. Notification statistics for children in the ADHD cohort treated with methylphenidate long-acting only ...............................................................................................20

Table 15. Notification statistics for children in the ADHD cohort treated with a combination of stimulant medicines (doses presented in dex equivalents) ............................................21

Table 16. Average notified daily dose of stimulant medicine(s) for children in the ADHD cohort by medicine(s) notified (doses presented in dex equivalents) ............................................22

Table 17. Number of children in the ADHD cohort prescribed other psychotropic medicines................23

Table 18. Number of stimulant prescribers by number of adult patients notified .............................24

Table 19. Number of adults in the ADHD cohort with a nominated co-prescriber by professional category of co-prescriber. ..................................................................................25

Table 20. Stimulant co-prescriber by number of adults notified..................................................25

Table 21. Adults in the ADHD cohort by age and gender ...........................................................26

Table 22. Age at first Notification for adults in the ADHD cohort.................................................27

Table 23. Number, percentage and rate per 1,000 population of adults in the ADHD cohort by Health District..........................................................................................................29

Table 24. Average daily notified dose in dex equivalents for adults in the ADHD cohort by age group and gender.....................................................................................................32

Table 25. Average daily notified dose in dex equivalents for adults in the ADHD cohort by number of medicines prescribed (single/combination) ..............................................................32

Table 26. Notification statistics for adults in the ADHD cohort treated with dexamphetamine only .......33

Table 27. Notification statistics for adults in the ADHD cohort treated with methylphenidate only........34

Table 28. Notification statistics for adults in the ADHD cohort treated with methylphenidate long-acting only ...............................................................................................35

Table 29. Notification statistics for adults in the ADHD cohort treated with a combination of stimulant medicines (doses presented in dex equivalents) ........................................................36

Table 30. Average notified daily dose (in dex equivalents) of stimulant medicine(s) for adults in the ADHD cohort by medicine(s) notified......................................................................37

Table 31. Number of adults in the ADHD cohort prescribed other psychotropic medicines ..................38

Table 32. Naïve patients in the ADHD cohort by age and gender .................................................39

Table 33. Average daily notified dose (expressed in dex equivalents) for patients in the ADHD cohort (naive and total) ..............................................................................................41

Table 34. Number and type of stimulant Notifications processed 2004-2006 ...................................42

Table 35. Patients with notification and/or dispensed medication 2004-2006 .................................43

Table 36. Diagnosis of notified patients with stimulant prescriptions dispensed 2004-2006 .................43

Table 37. Number of patients in the ADHD Cohort by age and gender (2004-2006)............................43

Table 38. Number and proportion of patients in the ADHD cohort with a nominated co-prescriber (2004-2006) ....................................................................................................44

Table 39. Average daily notified dose in dex equivalents for patients in the ADHD cohort by age group and gender 2004-2006 .......................................................................................45

III

List of Figures Figure 1. Number and proportion of authorised stimulant prescribers by professional category ............ 4 Figure 2. Patients notified or dispensed stimulant medicines during 2006 ...................................... 5 Figure 3. Number and proportion of patients with a terminated stimulant notification by reasons for

treatment termination........................................................................................ 6 Figure 4. Number and proportion of children in the ADHD cohort by professional category of notified

stimulant prescriber........................................................................................... 9 Figure 5. Children in the ADHD cohort by gender ...................................................................11 Figure 6. Number of patients (≥2 and <18 years) per 1,000 population in the ADHD cohort.................12 Figure 7. Number of children per 1,000 population, in the ADHD cohort by Area Health Service ..........12 Figure 8. Children in the ADHD cohort by medicine(s) notified...................................................16 Figure 9. Other psychotropic medicines prescribed to children in the ADHD cohort..........................23 Figure 10. Number and proportion of adults in the ADHD cohort by professional category of authorised

stimulant prescriber..........................................................................................24 Figure 11. Number and proportion of adults in the ADHD cohort by gender .....................................26 Figure 12. Number of adult patients per 1,000 population in the ADHD cohort .................................27 Figure 13. Number of adults per 1,000 population, in the ADHD cohort, by Area Health Service ............28 Figure 14. Adults in the ADHD cohort by medicine(s) notified......................................................31 Figure 15. Other psychotropic medicines prescribed to adults in the ADHD cohort.............................38 Figure 16. Number of stimulant naïve patients per 1,000 population in the ADHD cohort by age group and gender.....................................................................................................40 Figure 17. Proportion of patients in the ADHD cohort (stimulant naïve and total) by medicine notified....41 Figure 19. Number of patients per 1,000 population in the ADHD cohort 2004-2006 ...........................44

IV

V

Executive Summary The Stimulant Regulatory Scheme sets the policy for the prescribing and dispensing of stimulant medicines (dexamphetamine and methylphenidate) in Western Australia. This is a report of the data collected through the Scheme for 2006. As at 31 December 2006 there were 229 authorised prescribers of stimulant medicines in Western Australia. Approximately one half of all authorised prescribers were psychiatrists (n=115, 50.2%) and one third were paediatricians (n=76, 33.2%). Authorised prescribers submitted 7,207 Notification forms during 2006. As at 31 December 2006, there had been Notifications submitted for 21,458 patients since the commencement of the Scheme in 2003. Of these Notifications, 20,649 (96.2%) were current and 809 (3.8%) were terminated as at 31 December 2006. There were 30 patients (3.7% of terminations) whose treatment was ceased because of substance abuse, diversion or non-adherence to stimulant treatment. Patients with a current Notification, a primary diagnosis of ADHD and at least one dispensed stimulant prescription written in 2006 were eligible for inclusion into the 2006 ADHD cohort. There were 14,425 patients who met the criteria for inclusion in the 2006 ADHD cohort who had 113,076 dispensed stimulant prescriptions written in 2006. There were 159 authorised prescribers who had submitted Notifications for patients included in the 2006 ADHD cohort. The total number of patients in the cohort per authorised prescriber ranged from 1 to 1,127. There were approximately equal proportions of children (n=7,283, 50.5%) and adults (n=7,142, 49.5%) in the cohort. Further analysis was conducted on children and adults separately. The mean age of children in the cohort was 12.4 years. There was a male to female ratio of 4.1 to 1 for children in the ADHD cohort. Children in the cohort were treated by 105 authorised stimulant prescribers. There was a mean of 69 and a median of 21 patients per authorised stimulant prescriber who treated children in 2006. The number of children per prescriber ranged from 1 to 854. Paediatricians treated over 90% of the children in the cohort (n=6,568, 90.2%). There were 2,078 children in the 2006 ADHD cohort (28.5% of the cohort) with a nominated co-prescriber. The number of children per co-prescriber ranged from 1 to 226. There were 16.6 children per 1,000 population in Western Australia included in the cohort. Boys had higher rates of notification than girls at each age group. There were 2,765 children in the ADHD cohort (38.0% of the cohort) who resided in the North Metropolitan Area Health Service (NMAHS) and 2,883 (39.6%) who resided in the South Metropolitan Area Health Service (SMAHS). A smaller number (n=1,621, 22.3%) resided in the WA Country Health Service (WACHS). Fourteen children had interstate or overseas postcodes and were coded as “Other”. The notification rate for children in the ADHD cohort per Health District ranged from 4.1 to 28.9 per 1,000 population. There were 10 Health Districts with more than 20 children per 1,000 population in the cohort and there were 5 Health Districts with less than 10 children per 1,000 population in the cohort.

VI

The average daily notified dose (in dex equivalents) for girls in the ADHD cohort was 16.5 mg per day (0.4 mg/kg/day) and for boys was 17.0 mg per day (0.4 mg/kg/day). Doses ranged from 1.5 to 75 mg per day. On a milligram per kilogram basis doses ranged from <0.1 to 2.1 mg/kg/day. There were 3,982 children (54.7% of children in the cohort) notified as being prescribed dexamphetamine only. The average daily notified dose of dexamphetamine for these patients was 0.4 mg/kg/day and 17.4 mg/day. Doses ranged from 0.1 to 1.7 mg/kg/day and 2.5 to 60.0 mg per day. There were 979 children (13.4% of children in the cohort) treated with methylphenidate only. The average daily notified dose for these patients was 0.9 mg/kg/day and 28.5 mg/day. Daily notified doses ranged from 0.1 to 2.3 mg/kg/day and from 5.0 to 120 mg per day. There were 1,738 children (23.9% of children in the cohort) notified as being prescribed methylphenidate long-acting only. The average daily notified dose for these patients was 0.9 mg/kg/day and 32.5 mg/day. Daily notified doses ranged from 0.2 to 2.4 mg/kg/day and 10.0 to 120.0 mg per day. There were 584 children (8.0% of children in the cohort) notified as being treated with a combination of stimulant medicines. To present summary statistics for this group, the notified doses were converted to their dex equivalents so that they could be displayed as one unit. The average daily notified dose, expressed in dex equivalents, for these patients was 0.6 mg/kg/day and 24.9 mg/day. Doses ranged from 0.2 to 2.2 mg/kg/day or 7.5 to 80 mg per day. Approximately one in ten children in the ADHD cohort were notified as being prescribed other psychotropic medicines in conjunction with stimulant treatment (n=720, 9.9%). Anti-depressants were the most common medicine specified (n=238, 34.5%) but the most common medicines prescribed fell into the “Other psychotropic medicines” category (n=299, 43.4%). There were 7,142 adult patients in the ADHD cohort in 2006 (49.5% of the total cohort). The mean age of adults in the cohort was 31.4 years. There were 4,500 men and 2,642 women in the ADHD cohort giving a ratio of men to women of 1.7 to 1. The age of men in the cohort ranged from 18 to 78 years and women ranged from 18 to 81 years. There were 737 adults in the cohort (10.3% of adults in the cohort) who were at least 50 years of age. Adults in the cohort were treated by 127 authorised stimulant prescribers. Child and adolescent psychiatrists (psychiatrists with additional qualifications in child and adolescent psychiatry) treated approximately half the adults in the cohort (n=3,517, 49.3%). The number of adult patients per authorised stimulant prescriber ranged from 1 to 851. There was a mean of 56 and a median of 7 adult patients per prescriber. There were 2,627 adult patients (36.8% of adults in the cohort) with a nominated co-prescriber. The number of adult patients per co-prescriber ranged from 1 to 368. There was a mean of 2 and a median of 1 patient per prescriber. There were 3,374 adult patients (47.2% of adults in the cohort) who resided in the NMAHS and 2,925 (41.0%) who resided in the SMAHS. A smaller number (n=806, 11.3%) resided in the WACHS. Thiry-seven adults had interstate or overseas postcodes and were coded as “Other”. The number of adult patients in the cohort per Health District ranged from 0.6 to 8.9 per 1,000 population. Daily notified doses for adults in the ADHD cohort ranged from 2.5 to 80 mg per day. Men had higher average daily notified doses (in dex equivalents) in each age group but the over all average daily notified dose was the same for men and women (33.2 mg/day). Men aged 18 and 19 years had the highest rate of notification (24.5 per 1,000 population). The rate of notification decreased with age in both men and women. There were 6,340 adults (88.8% of adults in the cohort) notified as being prescribed dexamphetamine only. The average notified dose for these patients was 31.6 mg dexamphetamine per day. Notified doses ranged from 2.5 to 80 mg per day.

VII

There were 390 adults (5.5% of adults in the cohort) that were notified as being prescribed methylphenidate only. The average notified dose for these patients was 54.4 mg methylphenidate per day. Notified doses ranged from 5 to 120 mg per day. There were 242 adults (3.4% of adults in the cohort) notified as being prescribed methylphenidate long acting only. The average notified dose for these patients was 44.9 mg methylphenidate long-acting per day. Notified doses ranged from 10 to 120 mg per day. There were 170 adults (2.4% of adults in the cohort) notified as being treated with a combination of stimulant medicines. To present summary statistics for this group, the notified doses were converted to their dex equivalents so that they could be displayed as one unit. The average daily notified dose, expressed in dex equivalents, for these patients was 33.8 mg per day. Doses ranged from 9.5 to 60.0 mg per day. There were 1,977 adults (27.7% of adults in the cohort) who were notified as being prescribed other psychotropic medicines in conjunction with stimulant treatment. Anti-depressants were the most common medicine prescribed (n=1,630, 71.3%), followed by mood stabilising agents (n=326, 14.3%). There were 1,906 patients (13.2% of the cohort) who were notified as being treated with stimulant medication for the first time in 2006- 980 children and 926 adults. The age of patients notified for the first time in 2006 ranged from 4 years to 78 years. The rate of females notified for the first time in 2006 peaked in the 18 to 19 year age group (1.4 per 1,000 population) and the rate of males peaked in the 4 to 9 year age group (4.5 per 1,000 population). Patients who were notified for the first time in 2005 made up 14.8% (n=2,196) of the cohort whilst in 2006 this decreased to 13.2% of the cohort (n=1,906). Average daily notified doses (milligrams per day) for children and adults who were notified for the first time in 2006 were lower than the cohort overall, however on a milligram per kilogram basis for children the doses remained the same. Patients are required to be commenced on a low dose that is titrated according to patient response. Patients who commenced treatment in 2006 may not have yet reached a stable, final dose which may account for this difference. The number of patients included in the ADHD cohort decreased approximately 5% between 2004 and 2006 (from 15,163 to 14,425). The number of children in the cohort decreased each year whilst the number of adults increased. The average daily notified dose of stimulant medicines decreased between 2004 and 2006 for both children and adults. There was a small increase in dose on a milligram per kilogram basis for children in 2006 (2005=0.44 mg/kg/day, 2006=0.45mg/kg/day).

VIII

Glossary of Terms

Term Definition

ADHD cohort Population of people diagnosed with ADHD and prescribed stimulant medicines for treatment. The ADHD cohort for this report consisted of all patients with a current Notification with a diagnosis of ADHD and a dispensed prescription for dexamphetamine and/or methylphenidate (immediate release or long acting) written during 2006.

Authorisation Written approval from the Chief Executive Officer of Health required prior to prescribing a stimulant medicine outside criteria set out in the Stimulant Regulatory Guidelines in Western Australia.

Authorised Prescriber Medical practitioner who is authorised to initiate treatment with a stimulant medicine in Western Australia. Must be registered with the Medical Board of Western Australia with specialist qualifications in paediatrics, psychiatry, neurology or other qualification approved by the Chief Executive Officer of Health.

Children Refers to patients ≥ 2 and <18 years. Population dominators have been calculated on this basis.

Co-prescriber Medical practitioner, notified to the Department of Health by the Authorised Prescriber, who may also prescribe stimulant medication for a specified patient according to the drug, drug form and dose nominated on the Notification Form.

‘Dex’ equivalents Methylphenidate (immediate release or long acting) expressed in same terms as dexamphetamine. Methylphenidate dex equivalents = (methylphenidate in mg)/2

Dispensed Medication Table A table in the Monitoring of Drugs of Dependence System (MODDS) which contains records of dispensed stimulant medications from reports submitted each month by every pharmacy in Western Australia.

Notification Form Notification of Treatment Using Stimulant Medication Form. Submitted to the Department of Health by Authorised Prescribers when initiating, modifying or terminating treatment with stimulant medication in Western Australia.

Re-Notification Submitted by the Authorised Prescriber to advise the Department of Health of any change in drug, drug form, dose, patient details or co-prescriber for patients for whom the prescriber has previously submitted a Notification.

IX

Stimulant Notification Record Table A table in the Monitoring of Drugs of Dependence System (MODDS) which contains records of Notification of Treatment Using Stimulant Medication Forms submitted by Authorised Prescribers.

Stimulant Prescriber Number Issued by the Department of Health to authorised prescribers who may then initiate treatment with stimulant medication in Western Australia.

Stimulant Regulatory Guidelines A document which sets out the criteria for the prescribing of stimulant medication in Western Australia. Based upon the Poisons Regulations 1965.

Stimulant Regulatory Scheme A framework developed to regulate the prescribing of stimulant medicine in Western Australia.

Stimulants Assessment Panel Panel of clinicians, convened by the Department of Health, to provide clinical advice on applications to prescribe stimulant medication outside the criteria set out in the Stimulant Regulatory Guidelines in Western Australia.

Termination Notification of cessation of treatment with stimulants for a specified patient by an Authorised Prescriber.

1

Overview

Introduction The Stimulant Regulatory Scheme commenced in August 2003 in response to the policy, “Attentional Problems in Children: diagnosis and management of Attention Deficit Hyperactivity Disorder (ADHD) and associated disorders”. The Stimulant Regulatory Scheme sets the criteria for the prescribing and dispensing of stimulant medicines (dexamphetamine and methylphenidate) in Western Australia. This is the third report of the data generated by the Scheme and reports for the period 1 January to 31 December 2006.

Stimulant Prescribing in WA The Stimulant Regulatory Guidelines (Appendix 1) set out the criteria for the prescribing of stimulant medicines in WA. The Guidelines are based on the Poisons Regulations 1965. The Guidelines state that treatment with stimulant medicines may only be initiated by an authorised prescriber who is registered with the Medical Board of WA with specialist qualifications in psychiatry, paediatrics, neurology, or other approved qualifications, and has obtained a Stimulant Prescriber Number from the Department of Health (DOH). Stimulant medicines may only be prescribed for the treatment of ADHD, depression, brain damage, narcolepsy, and other conditions as approved by the Chief Executive Officer (CEO) of Health. For patients meeting the specific criteria set out in the Guidelines, the authorised stimulant prescriber must submit a Notification of Treatment Using Stimulant Medication Form (‘Notification Form’) (Appendix 2) to the DOH at the time stimulant treatment is initiated. Once a Notification is submitted it remains in force until:

a Re-notification is submitted by the authorised stimulant prescriber advising the DOH of a change in stimulant medicine, medicine form or dose, patient details or nominated co-prescriber,

a notification of Termination is submitted by the authorised stimulant prescriber, a Notification is submitted by a different authorised stimulant prescriber for the same patient, or the Notification is revoked by the CEO of Health.

Authorised stimulant prescribers may nominate a medical practitioner (usually a general practitioner (GP)) to co-prescribe a stimulant medicine for a particular patient. Co-prescribers may only prescribe according to the Notification submitted to the DOH by the authorised stimulant prescriber. Children under the age of 2 years cannot be prescribed stimulant medicines under any circumstances. Children from the age of 2 years and up to 4 years can be prescribed stimulant medicines with prior written approval from the CEO of Health. Children aged 4 years and over can be prescribed stimulant medicines within the criteria set out in the Stimulant Regulatory Guidelines with the completion of a Notification form by the authorised stimulant prescriber at the initiation of stimulant treatment. The Stimulant Regulatory Guidelines outline the maximum doses of stimulant medication/s that may be prescribed per day: Children (≥4 to <18 years) dexamphetamine: 1 mg/kg/day to a maximum dose of 60 mg/day methylphenidate: 2 mg/kg/day to a maximum dose of 120 mg/day

2

Adults (≥18 years) dexamphetamine: 60 mg/day methylphenidate: 120 mg/day These doses apply when dexamphetamine or methylphenidate is used alone. When both methylphenidate and dexamphetamine are prescribed for a patient, the methylphenidate dose is converted to the ‘dex equivalents’ (see Methodology) dose and the maximum dose criteria are applied as per dexamphetamine. Authorised stimulant prescribers who wish to treat patients outside the criteria set out in the Guidelines (in terms of patient age, co-morbidities, dose to be prescribed or condition) must receive prior written authorisation from the CEO of Health and are required to provide additional information to justify stimulant use. Applications to prescribe stimulant medicines outside the criteria set out in the Guidelines for the treatment of ADHD may be referred to the Stimulants Assessment Panel for ADHD for clinical advice. The Panel is made up of clinicians from the public and private sector with expertise in the treatment of ADHD.

Methodology The DOH maintains records relating to the Stimulant Regulatory Scheme in the Monitoring of Drugs of Dependence System (MODDS) database, which includes: the Stimulant Notification Record table and the Dispensed Medication table. The Notification table contains the following information used in this report:

Patient name, address, date of birth, gender and weight (mandatory for children only), Authorised stimulant prescriber details, Details of nominated co-prescriber (if applicable), Diagnosis (ADHD, brain damage, depression, narcolepsy or other), Number and type of other psychotropic medications prescribed, Stimulant medicine, form and dose to be prescribed.

Data were extracted from the Stimulant Notification Database and Dispensed Medication Database, for the period 1 January to 31 December 2006. Data were extracted for all patients with a Notification and/or at least one dispensed stimulant prescription written during 2006. Notification data were extracted based on the date the most recent Notification was completed (Date doctor signed: ≥1 January and ≤31 December 2006) and the date the prescription was written (Date prescribed: ≥1 January and ≤31 December 2006). The ADHD cohort for this report consisted of all patients with a current Notification Form as at 31 December 2006 with a diagnosis of ADHD and a dispensed prescription for dexamphetamine and/or methylphenidate written during 2006. Data were exported to an Access database and frequencies generated according to the specifications outlined in Appendix 3. Additional descriptive statistics and figures presented in the report were generated using MS Excel. Rates and percentages are presented in this report rounded to 1 decimal place. The majority of the report displays results separately for children and adults as the Stimulant Regulatory Guidelines set out different provisions for these two groups. Where possible descriptive statistics are reported by gender and for the following age groups ≥2 and <4, ≥4 and <10, ≥10 and <15, ≥15 and <18, ≥18 and <20, ≥20 and <30, ≥30 and <40, ≥40 and <50, ≥50. Although the spread of ages in each group is not standard across the population, rates per 1,000 population are reported to provide a comparable measure. Rates per 1,000 population were calculated for the age groups specified using Rates Calculator Version 9.1.5 (© Jim Codde, 1993-2005) provided by the Epidemiology Branch of the Department of Health.

3

Population denominators for 2006 were estimated projections from data obtained from the Australian Bureau of Statistics for 30 June 2005. Populations used in the analysis are included in Appendix 4 and 5. Patients were assigned to an Area Health Service (AHS) and Health District based on the postcode of the address listed on the Notification form. Postcodes were allocated to an AHS and Health District based on information provided by the Epidemiology Branch of the Department of Health. Postcodes per Health District are included in Appendix 6. For children, average daily notified doses were presented in milligram per kilogram per day and milligram per day. Patient weight is only routinely collected for children on stimulant treatment where it is used to determine the maximum daily dose that may be prescribed within the criteria set out in the Stimulant Regulatory Guidelines. Average daily notified doses for adults are presented as milligram per day only. To provide an indication of overall stimulant use, irrespective of which medicine (dexamphetamine or methylphenidate) is prescribed, methylphenidate doses were converted to their ’dex equivalent’ doses for sections of this report. A ‘dex equivalent’ dose is calculated by dividing the methylphenidate dose (in milligrams) by two. For patients notified as being prescribed a combination of stimulant medicines the dex equivalent dose is used to calculate the total dose prescribed and the maximum dose that may be prescribed according to the criteria set out in the Guidelines. In dex equivalents the maximum daily dose that may be prescribed for children within the Guidelines is 1 mg/kg/day to a maximum of 60 mg/day. For adults the maximum daily dose that may be prescribed within the Guidelines is 60 mg/day.

4

2006 Results

Overview

Authorised stimulant prescribers As at 31 December 2006 there were 229 authorised stimulant prescribers in Western Australia. Figure 1 shows a proportional breakdown of authorised stimulant prescribers by professional category. Approximately half of all authorised prescribers are psychiatrists (n=115, 50.2%) and one third are paediatricians (n=76, 33.2%).

Figure 1. Number and proportion of authorised stimulant prescribers by professional category

Rehabilitation physician, 1 (0.4%)

Paediatrician, 76 (33.2%)

Paediatric neurologist,

8 (3.5%) Child & adolescent

psychiatrist, 30 (13.1%)

Adult psychiatrist, 85 (37.1%)

Adult neurologist,

16 (7.0%)

Respiratory & sleep physician,

13 (5.7%)

Stimulant Notifications Received During 2006 Table 1 shows the notification forms processed by the DOH during 2006. Over 7,000 notification forms were processed during 2006 with Re-Notifications or Terminations comprising over half the forms processed (n=4,072, 56.5%). There were 25 Notifications (0.3%) that were coded as incomplete at the

5

time the data was extracted for the report. Incomplete notifications require clarification or amendment before they can be finalised and coded into one of the other notification categories.

Table 1. Number and type of notifications processed for 2006

Notification type Frequency Percent Incomplete 25 0.3%

Notification 3,056 42.4%

Outside Guidelines 54 0.7%

Re- Notification 2,597 36.0%

Termination 1,475 20.5%

TOTAL 7,207 100.0%

Patients with a Notification and/or Dispensed Medication Data were extracted from the Dispensed Stimulant Medication table and compared with Notification data. Figure 2 shows the number of patients and prescriptions for each combination of prescription and notification data. Appendix 3 further illustrates the number of patients in each of the subgroups described in this analysis. The majority of patients with a Notification recorded in the MODDS had a stimulant prescription dispensed in 2006 (n=15,031, 70.0%). There were 938 records in the Dispensed Medication table that, at the time of writing, could not be linked to a patient with a Notification. Of these patients, 700 (74.6%) were treated by authorised stimulant prescribers with the remainder treated by other medical practitioners (usually GPs) (n=238, 25.4%). These patients have been followed up by the Department of Health but have been excluded from further analysis in this report.

Figure 2. Patients notified or dispensed stimulant medicines during 2006

Notification +

Not Dispensed Medication

Patients= 6,427Scripts=0

No Notification +

Dispensed Medication

Patients= 938Scripts= 4,808

Notification +

Dispensed Medication

Patients= 15,031Scripts= 117,058

Dispensing data n= 15,969

Notification data n= 21,458

There were 6,427 patients who had a Notification but no dispensed stimulant prescription written in 2006. This number is made up of patients who have had a Notification submitted at some stage since the commencement of the Scheme but have either had their treatment terminated or have been lost to follow-up and ceased treatment.

6

Patients with a Terminated Notification of Treatment Using Stimulant Medication Of the 21,458 records in the Notification table, 20,649 (96.2%) were current and 809 (3.8%) were terminated as at 31 December 2006. The breakdown of reasons for termination of treatment is illustrated in Figure 3. There were 30 patients (3.7% of terminations) whose treatment was ceased because of substance abuse, diversion or non-adherence to stimulant treatment. Stimulant treatment was ceased for 5 patients due to psychosis.

Figure 3. Number and proportion of patients with a terminated stimulant notification by reasons for treatment termination

Patient transferred overseas, 3 (0.4%)

Substance abuse, 13 (1.6%)

Retirement of prescriber,69 (8.5%)

Patient transferred interstate, 16 (2.0%)

Deceased, 1 (0.1%)

Diversion of medication, 13 (1.6%)

Patient seeing another

consultant, 13 (1.6%)

Non-adherence to treatment,

4 (0.5%)

Psychosis, 5 (0.6%)

No longer requires

treatment, 672 (83.1%)

Patients with a Current Notification of Treatment Using Stimulant Medication Prescribers do not always submit Termination notifications for patients when treatment with stimulant medications ceases as patients may be lost to follow up rather than treatment being discontinued by the prescriber. Therefore to ensure that the report focused on patients currently receiving treatment with stimulant medicines, patients who did not have a dispensed stimulant prescription written in 2006 were excluded from further analysis along with patients with a terminated Notification. Of the 20,649 patients with a current (i.e. non-terminated) Notification as at 31 December 2006, 72.0% (n=14,859) had a dispensed stimulant prescription that had been written in 2006. Table 2 shows the diagnosis of patients with a current Notification who, at the time of data extraction, had a dispensed stimulant prescription written during 2006. The majority of these patients (n=14,425, 97.1%) were notified as being prescribed stimulant medicines in the treatment of ADHD.

7

Table 2. Patients with a current notification and dispensed stimulant prescription by diagnosis on Notification form.

Age Group Children (2 to >18 years) Adults (>=18 years) TOTAL Condition Frequency Percent Frequency Percent Frequency Percent

ADHD 7,283 99.7% 7,142 94.6% 14,425 97.1% OTHER

Narcolepsy 4 0.1% 226 3.0% 230 1.5%

Depression 8 0.1% 157 2.1% 165 1.1%

Brain Damage 10 0.1% 24 0.3% 34 0.2%

Other Conditions 2 0.0% 3 0.0% 5 0.0%

Total Other 24 0.3% 410 5.4% 434 2.9%

TOTAL 7,307 100.0% 7,552 100.0% 14,859 100.0%

A more detailed analysis was performed on the cohort of patients prescribed stimulant medicines for the treatment of ADHD.

The ADHD Cohort Patients were eligible for inclusion in the cohort if they met the following criteria:

current Notification of Treatment Using Stimulant Medication as at 31 December 2006, primary diagnosis of ADHD, a dispensed stimulant prescription, written during 2006.

A total of 14,425 patients met the criteria for inclusion in the 2006 cohort. Patients in the cohort had 113,076 dispensed stimulant prescriptions written in 2006. Table 3 outlines the breakdown of children and adults in the ADHD cohort. There were approximately an equal proportion of children (n=7,283, 50.5%) and adults (n=7,142, 49.5%) in the cohort.

Table 3. Patients in the ADHD cohort by age group and gender

Patients Scripts Age Group Frequency Percent Frequency Percent

Children (≥2 to <18) 7,283 50.5% 52,374 46.3%

Adults (≥18) 7,142 49.5% 60,702 53.7%

TOTAL 14,425 100.0% 113,076 100.0% There were 159 authorised stimulant prescribers (69.4% of all currently authorised prescribers) who submitted notifications for patients in the 2006 ADHD cohort. There were 32 prescribers (20.1%) who treated only children, 54 prescribers (34.0%) who treated only adults and 73 prescribers (45.9%) who treated both children and adults. There was a mean of 91 and a median of 18 patients (adults and children) per prescriber. The total number of patients (adults and children) per prescriber ranged from 1 to 1,127. The majority of prescribers (n=104, 65.4%) were treating 50 or less patients, as shown in Table 4.

8

Table 4. Authorised stimulant prescribers by number of patients notified

Number of patients Frequency Percent Cumulative

Percent ≥1 and ≤10 71 44.6% 44.6%

≥11 and ≤50 33 20.8% 65.4%

≥51 and ≤100 17 10.7% 76.1%

≥101 and ≤500 33 20.8% 96.9%

>500 5 3.1% 100.0%

TOTAL 159 100.0% Further analysis of the ADHD cohort was conducted on children and adults separately.

9

Children (≥2 to <18 years) Authorised stimulant prescribers treating children There were 7,283 children in the cohort (50.5% of the cohort) who were treated by 105 authorised stimulant prescribers. Figure 4 shows the proportion of children in the cohort by the professional category of the authorised prescriber. Over 90% of the children in the cohort were notified as being treated by paediatricians (n=6,568, 90.2%). There were 37 children in the ADHD cohort (0.5%) who were notified as being treated by adult psychiatrists, who may initiate treatment in patients from age 17.

Figure 4. Number and proportion of children in the ADHD cohort by professional category of notified stimulant prescriber

Child & adolescent

psychiatrist, 563 (7.7%) Paediatric

neurologist, 116 (1.6%)

Adult psychiatrist,

37 (0.5%)

Paediatrician, 6,568 (90.2%)

There was a mean of 69 and a median of 21 patients (≥2 and <18 years) per authorised prescriber who treated children in 2006. The number of children per prescriber ranged from 1 to 854. Forty percent of prescribers treated 10 or less children, whilst 2 prescribers treated more than 500 children (Table 5).

Table 5. Authorised stimulant prescribers by number of patients notified - children


Percent ≥1 and ≤10 42 40.0% 40.0%

≥11 and ≤50 27 25.7% 65.7%

≥51 and ≤100 14 13.3% 79.0%

≥101 and ≤500 20 19.1% 98.1%

>500 2 1.9% 100.0%

TOTAL 105 100.0%

10

Children with a nominated co-prescriber There were 2,078 children in the 2006 ADHD cohort (28.5% of the cohort) with a nominated co-prescriber. Approximately one third of these patients (n=629, 30.2%) had another authorised stimulant prescriber (usually a paediatrician) nominated as co-prescriber.

Table 6. Children in the ADHD cohort with a nominated co-prescriber by professional category of co-prescriber

Co-prescriber Type Frequency Percent Authorised Stimulant Prescriber (SPN)

Adult neurologist 0 0.0% Adult psychiatrist 2 0.1% Child & adolescent psychiatrist 5 0.2% Paediatric neurologist 4 0.2% Paediatrician 618 29.7%

Other medical practitioner 1,449 69.7%

TOTAL 2,078 100.0%

Number of children per co-prescriber There were 752 practitioners nominated as co-prescribers for children in the ADHD cohort. There was a mean of 3 and a median of 1 patient per co-prescriber. The number of children per co-prescriber ranged from 1 to 226. Table 7 shows the number of patients (≥2 and <18 years) per co-prescriber. Most co-prescribers who treated children in the cohort were nominated as co-prescriber for 10 or less children (n=733, 97.5%).

Table 7: Stimulant co-prescribers by number of patients notified

Number of patients Frequency Percent Cumulative Percent

≥1 and ≤10 733 97.5% 97.5%

≥11 and ≤50 15 2.0% 99.5%

≥51 and ≤100 2 0.3% 99.8%

>100 2 0.3% 100.0%

TOTAL 752 100.0%

Patients by Age and Gender There was a male to female ratio of 4.1 to 1 for children in the ADHD cohort (Figure 5). The average age of children in the cohort was 12.4 years. This was similar for girls (12.6 yeas) and boys (12.4 years).

Continued next page

11

Figure 5. Children in the ADHD cohort by gender

Male5,864 (80.5%)

Female1,419 (19.5%)

Table 8 shows children in the ADHD cohort by age group and gender. There were no children less than 4 years in the cohort in 2006. There were 16.6 children per 1,000 population in Western Australia included in the cohort. Boys had higher rates of notification than girls at each age group with the highest rate of notification occurring in boys between 10 and 15 years of age (43.8 per 1,000 population).

Table 8. Children in the ADHD cohort by age group and gender

Female Male TOTAL

Age group Frequency Percent

Rate per

1,000 Frequency Percent

Rate per


Rate per

1,000

≥2 and <4 0 0.0% 0.0 0 0.0% 0.0 0 0.0% 0

≥4 and <10 230 16.2% 3.0 1,056 18.0% 13.0 1,286 17.7% 8.1

≥10 and <15 756 53.3% 10.9 3,185 54.3% 43.8 3,941 54.1% 27.7

≥15 and <18 433 30.5% 10.2 1,623 27.7% 36.1 2,056 28.2% 23.4

TOTAL 1,419 100.0% 6.6 5,864 100.0% 26.1 7,283 100.0% 16.6

Figure 6 shows the number, per 1,000 population, of children included in the ADHD cohort. Although the overall magnitude was different, boys and girls showed the same trend in rates of notification.

Continued next page.

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Figure 6. Number of patients (≥2 and <18 years) per 1,000 population in the ADHD cohort

10.2

43.8

36.1

8.1

23.4

10.9

3.0

13.0

27.7

0.05.0

10.015.020.025.030.035.040.045.050.0

≥2 and <4 ≥4 and <10 ≥10 and <15 ≥15 and <18

Girls per 1,000 Boys per 1,000 Total per 1,000

Children in the ADHD cohort by location of residence There were 2,765 children (≥2 and <18 years) in the ADHD cohort (38.0% of the cohort) who resided in the North Metropolitan Area Health Service (NMAHS) and 2,883 (39.6%) who resided in the South Metropolitan Area Health Service (SMAHS). A smaller number (n=1,621, 22.3%) resided in the WA Country Health Service (WACHS). There were 14 children with interstate or overseas postcodes that were coded as other and excluded from further analysis based on location of residence. The rate of notification was highest in the SMAHS (18.5 per 1,000 population).

Figure 7. Number of children per 1,000 population, in the ADHD cohort by Area Health Service

15.015.9

18.5

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

North Metropolitan South Metropolitan WA Country

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Table 9 lists the number of children per 1,000 population in each of the 34 Health Districts. The number of children in the ADHD cohort per Health District ranged from 4.1 to 28.9 per 1,000 population. The mean rate of notification per Health District was 16.0 per 1,000 population and the median was 15.9 per 1,000 population. There were 10 Health Districts with more than 20 patients per 1,000 population in the cohort (3 in the SMAHS and 7 in the WACHS). There were 5 Health Districts with less than 10 patients per 1,000 population in the cohort – all in the WACHS.


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Table 9. Number, percentage and rate per 1,000 population of children in the ADHD cohort by Health District

Area Health Service Health District Frequency Percentage Rate per 1,000 pop’n

NMAHS Oceanic 338 4.6% 15.4

NMAHS Stirling SEC 262 3.6% 13.4

NMAHS Joondalup 569 7.8% 15.8

NMAHS Wanneroo 502 6.9% 17.5

NMAHS Bayswater-Bassendean 202 2.8% 16.7

NMAHS Valley and Hills 556 7.6% 17.1

NMAHS Kalamunda 190 2.6% 16.3

NMAHS Stirling Coastal 151 2.1% 13.3

SMAHS Armadale 771 10.6% 20.5

SMAHS Bentley 565 7.8% 17.6

SMAHS Fremantle 636 8.7% 15.3

SMAHS Peel 364 5.0% 21.3

SMAHS Rockingham - Kwinana 547 7.5% 20.2

WACHS Blackwood 33 2.8% 23.4

WACHS Bunbury 205 0.7% 21.4

WACHS Busselton 54 0.7% 8.2

WACHS Central Great Southern 34 0.5% 14.7

WACHS East Pilbara 36 0.5% 7.8

WACHS Eastern Wheatbelt 46 0.6% 21.1

WACHS Gascoyne 36 0.5% 15.9

WACHS Geraldton 204 2.8% 25.7

WACHS Kimberley 45 0.6% 4.6

WACHS Leeuwin 13 0.2% 4.8

WACHS Leschenault 112 1.5% 14.5

WACHS Lower Great Southern 114 1.6% 11.7

WACHS Midwest 49 0.7% 16.4

WACHS Murchison 9 0.1% 11.9

WACHS Northern Goldfields 93 1.3% 10.2

WACHS South East Coastal 31 1.3% 8.4

WACHS Southern Wheatbelt 98 1.3% 23.6

WACHS Warren 36 0.5% 15.2

WACHS Wellington 90 1.2% 28.9

WACHS West Pilbara 73 1.0% 13.1

WACHS Western Wheatbelt 205 2.8% 21.3

Other 14 0.2% -

TOTAL 7,283 100.0% 16.6

15

Children in the ADHD cohort by medicine notified Figure 8 shows the number and rate per 1,000 population of children in the ADHD cohort by medicines notified. Over 90% of children in the cohort were notified as being treated with a single stimulant medicine (n=6,699, 92.0%). Over half the cohort were notified as being treated with dexamphetamine (n=4,090, 52.0%), alone or in combination with other stimulants. Patients treated with a combination of stimulant medicines (n=584, 8.0% of the cohort) were most likely to be treated with methylphenidate and methylphenidate long-acting.


16

Figure 8. Children in the ADHD cohort by medicine(s) notified

Dexamphetamine n= 4,090 (52.0%) Rate per 1,000 population = 9.3

Dexamphetamine Only Male = 3,169 (79.6%)Female = 813 (20.4%)

TOTAL = 3,982Rate/1,000 pop’n = 9.1

Dex + Meth Male = 60 (84.5%)

Female = 11 (15.5%)TOTAL = 71

Rate/1,000 pop’n= 0.2

Dex + Meth LA Male = 24 (70.6%)

Female = 10 (29.4%)TOTAL = 34

Rate/1,000 pop’n= 0.1Dex + Meth + Meth LA

Male = 3 (100.0%)Female = 0 (0%)

TOTAL = 3Rate/1,000 pop’n = <0.1

Methylphenidate LA Only Male = 1,430 (82.3%)Female = 308 (17.7%)

TOTAL = 1,738Rate/1,000 pop’n = 4.0

Methylphenidate Only Male = 785 (80.2%)

Female = 194 (19.8%)TOTAL = 979

Rate/1,000 pop’n = 2.2

Meth + Meth LA Male = 393 (82.6%)

Female = 83 (17.4%)TOTAL = 476

Rate/1,000 pop’n= 1.1

Methylphenidate n= 1,529 (19.4%) Rate per 1,000 population = 3.5

Methylphenidate LAn= 2,251 (28.6%)

Rate per 1,000 population = 5.1

Average daily notified dose Table 10 outlines the daily notified doses for children in the ADHD cohort expressed in dex equivalents. Presenting the information in dex equivalents allows for the illustration of total stimulant use regardless of medicine notified. The average daily notified dose for children in the ADHD cohort, expressed in dex

17

equivalents, was 0.4 mg/kg/day and 16.9 mg/day. Doses ranged from 1.5 to 75 mg per day. On a milligram per kilogram basis doses ranged from <0.1 to 2.1 mg/kg/day. To prescribe stimulants for patients at a dose above the maximum set out in the Stimulant Regulatory Guidelines, prior written authorisation from the CEO of Health is required.

Table 10. Average daily notified dose in dex equivalents for children in the ADHD cohort by age group and gender

Age category Frequency

Rate per 1,000 pop’n

Average Dose in mg/day

(SD)

Average Dose in

mg/kg/day (SD)

Range mg/day

Range mg/kg/day

Female ≥2 and <4 0 0 - - - -

≥4 and <10 230 3.0 10.6 (4.7) 0.4 (0.2) 2.5-30.0 0.1-1.0

≥10 and <15 756 10.9 15.4 (7.0) 0.4 (0.2) 2.5-50.0 0.1-1.5

≥15 and <18 433 10.2 21.4 (9.6) 0.4 (0.2) 3.7-60.0 0.1-1.0

Total - Female 1,419 6.7 16.5 (8.4) 0.4 (0.2) 2.5-60.0 0.1-1.5 ≥2 and <4 0 0 - - - -

≥4 and <10 1,056 13.7 11.7 (5.2) 0.5 (0.2) 2.5-40.0 0.1-1.1

≥10 and <15 3,185 45.9 16.0 (7.1) 0.4 (0.2) 2.5-80.0* <0.1-1.9

≥15 and <18 1,623 38.0 22.3 (9.6) 0.4 (0.2) 5.0-62.5* 0.1-2.2*

Total-Male 5,864 26.1 17.0 (8.5) 0.4 (0.2) 2.5-80.0* <0.1-2.2*

TOTAL 7,283 16.6 16.9 (8.5) 0.4 (0.2) 2.5-80.0* 0.1-2.2* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing stimulants at a dose

above the maximum set out in the Stimulant Regulatory Guidelines Table 11 presents average notified doses for children notified as being prescribed a single medicine and for children notified as being prescribed a combination of stimulant medicines. Boys and girls in the cohort who were notified as being prescribed a single stimulant had lower doses than those prescribed a combination of medicines.

Table 11. Average daily notified dose in dex equivalents for children in the ADHD cohort by number of medicines prescribed (single/combination)

Treatment Type Gender Frequency



(SD)

Average Dose in

mg/kg/day (SD)

Range mg/day

Range mg/kg.day

Single Medicine Female 1,315 6.2 15.9 (8.2) 0.4 (0.2) 2.5-60.0 0.1-1.2

Male 5,384 24.0 16.2 (8.1) 0.4 (0.2) 2.5-60.0 <0.1-1.7

TOTAL 6,699 15.3 16.2 (8.1) 0.4 (0.2) 2.5-60.0 <0.1-1.7 Combination Female 104 0.5 23.5 (7.8) 0.6 (0.2) 10.0-60.0 0.2-1.5

Male 480 2.1 25.0 (8.9) 0.6 (0.2) 7.5-80.0* 0.2-2.2*

TOTAL 584 1.3 24.7 (8.7) 0.6 (0.2) 7.5-80.0* 0.2-2.2* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing stimulants at a dose

above the maximum set out in the Stimulant Regulatory Guidelines

18

A separate analysis was also conducted for each stimulant medicine notified.

Dexamphetamine only There were 3,982 patients (≥2 and <18 years) in the cohort (54.7% of children in the cohort) notified as being prescribed dexamphetamine only. The average daily notified dose of dexamphetamine for these patients was 0.4 mg/kg/day and 17.4 mg/day. Doses ranged from 0.1 to 1.7 mg/kg/day and 2.5 to 60.0 mg per day.

Table 12. Notification statistics for children in the ADHD cohort treated with dexamphetamine only




(SD)

Average Dose in

mg/kg/day (SD)

Range mg/day

Range mg/kg/day

Female ≥2 and <4 0 0 - - - -

≥4 and <10 109 1.4 10.2 (4.8) 0.4 (0.2) 2.5-30.0 0.1-0.9

≥10 and <15 421 6.1 14.7 (6.8) 0.4 (0.2) 2.5-50.0 0.1-1.0

≥15 and <18 283 6.6 21.7 (10.0) 0.4 (0.2) 5.0-60.0 0.1-1.0

Total - Female 813 3.8 16.6 (8.9) 0.4 (0.2) 2.5-60.0 0.1-1.0 ≥2 and <4 0 0 - - - -

≥4 and <10 447 5.5 11.1 (5.7) 0.4 (0.2) 2.5-40.0 0.1-1.0

≥10 and <15 1,739 23.9 15.6 (7.4) 0.4 (0.2) 2.5-55.0 0.1-1.7

≥15 and <18 983 21.9 22.5 (10.3) 0.4 (0.2) 5.0-60.0 0.1-1.0

Total-Male 3,169 14.1 17.4 (9.3) 0.4 (0.2) 2.5-60.0 0.1-1.7 TOTAL 3,982 8.9 17.4 (9.4) 0.4 (0.2) 2.5-60.0 0.1-1.7


19

Methylphenidate only There were less children (≥2 and <18 years) in the ADHD cohort treated with methylphenidate only (n=979, 13.4%) than with dexamphetamine or methylphenidate long-acting. The average daily notified dose for these patients was 0.9 mg/kg/day and 28.5 mg/day. Daily notified doses ranged from 0.1 to 2.3 mg/kg/day and from 5.0 to 120 mg/day.

Table 13. Notification statistics for children in the ADHD cohort treated with methylphenidate only




(SD)

Average Dose

mg/kg/day (SD)

Range mg/day

Range mg/kg/day

Female ≥2 and <4 0 0 - - - -

≥4 and <10 68 0.9 18.2 (7.2) 0.8 (0.3) 5.0-30.0 0.2-1.5

≥10 and <15 100 1.4 28.0 (14.6) 0.8 (0.4) 5.0-80.0 0.1-2.0

≥15 and <18 26 0.6 23.9 (7.5) 0.9 (0.5) 7.5-120.0 0.2-2.0

Total - Female 194 0.9 16.7 (5.0) 0.8 (0.4) 5.0-120.0 0.1-2.0 Male

≥2 and <4 - - - - - -

≥4 and <10 309 3.8 22.0 (10.3) 0.9 (0.4) 5.0-60.0 0.2-2.3*

≥10 and <15 387 5.3 29.8 (14.0) 0.9 (0.4) 5.0-80.0 0.1-2.0

≥15 and <18 89 2.0 42.9 (18.6) 0.8 (0.4) 10.0-110.0 0.8-2.0

Total-Male 785 3.5 28.7 (15.1) 0.9 (0.4) 5.0-110.0 0.1-2.3*

TOTAL 979 2.2 28.5 (15.6) 0.9 (0.4) 5.0-120.0 0.1-2.3* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing stimulants at a dose



20

Methylphenidate LA only There were 1,738 patients (≥2 and <18 years) in the ADHD cohort (23.9% of children in the cohort) who were notified as being prescribed methylphenidate long-acting only. Overall notified doses ranged from 10.0 to 120.0 mg per day. On a milligram per kilogram basis, doses ranged from 0.2 to 2.4 mg/kg/day.

Table 14. Notification statistics for children in the ADHD cohort treated with methylphenidate long-acting only




(SD)

Average Dose in

mg/kg/day (SD)

Range mg/day

Range mg/kg/day

Female ≥2 and <4 0 0 - - - -

≥4 and <10 43 0.6 23.5 (8.3) 0.9 (0.4) 10.0-54.0 0.4-1.9

≥10 and <15 180 2.6 31.4 (11.6) 0.9 (0.3) 10.0-90.0 0.3-2.4*

≥15 and <18 85 2 37.0 (13.6) 0.7 (0.3) 18.0-94.0 0.3-1.6

Total - Female 308 1.4 31.9 (12.5) 0.8 (0.3) 10.0-94.0 0.3-2.4* Male ≥2 and <4 0 0 - - - -

≥4 and <10 248 0.3 25.1 (8.1) 1.0 (0.3) 10.0-60.0 0.4-2.0

≥10 and <15 832 11.4 31.5 (11.4) 0.9 (0.3) 10.0-120.0 0.2-2.2*

≥15 and <18 350 7.8 39.1 (13.3) 0.7 (0.3) 10.0-100.0 0.3-1.9

Total-Male 1,430 6.4 32.4 (12.3) 0.8 (0.3) 10.0-120.0 0.2-2.2*

TOTAL 1,738 4 32.5 (12.5) 0.9 (0.4) 10.0-120.0 0.2-2.4* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing stimulants at a dose



21

Patients on combination treatment There were 584 patients (≥2 and <18 years) in the cohort (8.0% of children in the cohort) notified as being treated with a combination of stimulant medicines. To present summary statistics for this group, the notified doses were converted to their dex equivalents so that they could be displayed as one unit. Doses ranged from 0.2 to 2.2 mg/kg/day or 7.5 to 80 mg per day.

Table 15. Notification statistics for children in the ADHD cohort treated with a combination of stimulant medicines (doses presented in dex equivalents)




(SD)

Average Dose in

mg/kg/day (SD)

Range mg/day

Range mg/kg/day

Female ≥2 and <4 0 0 - - - -

≥4 and <10 10 0.1 17.9 (4.2) 0.7 (0.2) 12.5-25.0 0.4-1.0

≥10 and <15 55 0.8 22.7 (7.1) 0.6 (0.2) 10.0-40.0 0.3-1.5

≥15 and <18 39 0.9 26.2 (8.6) 0.5 (0.2) 15.0-60.0 0.2-1.0

Total - Female 104 0.5 23.6 (7.8) 0.6 (0.2) 10.0-60.0 0.2-1.5 Male ≥2 and <4 0 0 - - - -

≥4 and <10 52 0.6 18.0 (4.8) 0.7 (0.2) 7.5-35.0 0.3-1.0

≥10 and <15 227 3.1 24.0 (8.0) 0.6 (0.2) 10.0-80.0* 0.2-1.9

≥15 and <18 201 4.5 28.1 (9.4) 0.5 (0.2) 10.0-62.5 0.2-2.2*

Total-Male 480 2.1 25.2 (8.9) 0.6 (0.2) 7.5-80.0* 0.2-2.2*

TOTAL 584 1.3 24.9 (8.8) 0.6 (0.2) 7.5-80.0* 0.2-2.2* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing stimulants at a dose



22

Comparison of average daily notified doses Table 16 presents the average daily notified doses for children in the ADHD cohort by medicine(s) notified. The results are presented in dex equivalents to allow comparisons between medicines prescribed. Patients notified as being prescribed a combination of stimulants had higher average daily notified doses than those prescribed a single stimulant. Of patients notified as being prescribed a single stimulant, patients treated with dexamphetamine had a higher overall average daily doses (17.4 mg/day) but doses were the same on a milligram per kilogram basis (0.4 mg/kg/day).

Table 16. Average notified daily dose of stimulant medicine(s) for children in the ADHD cohort by medicine(s) notified (doses presented in dex equivalents)

Dexamphetamine only Methylphenidate only Methylphenidate Long-acting only

Combination treatment

Age category

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Female ≥2 and <4 - - - - - - - -

≥4 and <10 10.2 0.4 9.1 0.4 11.7 0.4 17.9 0.3

≥10 and <15 14.7 0.4 14 0.4 15.7 0.4 22.7 0.3

≥15 and <18 21.7 0.4 11.9 0.4 18.5 0.3 26.2 0.2

Total - Female 16.6 0.4 8.3 0.4 15.9 0.4 23.6 0.3 Male ≥2 and <4 - - - - - - - -

≥4 and <10 11.1 0.4 11 0.4 12.5 0.5 18 0.7

≥10 and <15 15.7 0.4 14.9 0.4 15.7 0.4 24 0.6

≥15 and <18 22.5 0.4 21.4 0.4 19.5 0.3 28.1 0.5

Total-Male 17.4 0.4 14.3 0.4 16.2 0.4 25.2 0.6

TOTAL 17.4 0.4 14.2 0.4 16.2 0.4 24.9 0.6


23

Children in the ADHD cohort treated with other psychotropic medicines Approximately one in ten children in the ADHD cohort were notified as being prescribed other psychotropic medicines in conjunction with stimulant treatment (n=720, 9.9%). Table 17 shows the number and proportion of children in the ADHD cohort by the number of other psychotropic medicines notified as being prescribed.

Table 17. Number of children in the ADHD cohort prescribed other psychotropic medicines

No. of other psychotropic

medicines prescribed Frequency Percent 0 6,563 90.1%

1 675 9.3%

2 40 0.5%

3 5 0.1%

TOTAL 7,283 100.0% For children prescribed other psychotropic medicines, anti-depressants were the most common medicine specified (n=238, 34.5%) but the most common medicines prescribed fell into the “Other psychotropic medicines” category (n=299, 43.4%).

Figure 9. Other psychotropic medicines prescribed to children in the ADHD cohort

Unspecified other

psychotropic medicines, 299 (43.4%)

Mood Stabilising Agents, 65 (9.6%)

Anxiolytics, 29 (4.2%)

Anti-psychotics, 57 (8.3%)

Anti-depressants, 238 (34.5%)

The total number of medicines prescribed to children in the cohort, as illustrated in Figure 9, is greater than the number of children prescribed other psychotropic medicines, as illustrated in Table 17, as some children were prescribed more than one other psychotropic medicine.

24

Adults (≥18 years) Authorised stimulant prescribers treating adults There were 7,142 patients (≥ 18 years) in the ADHD cohort in 2006 (49.5% of the total cohort), treated by 127 authorised stimulant prescribers. Child and adolescent psychiatrists (psychiatrists with additional qualifications in child and adolescent psychiatry) notified approximately half the adults in the cohort (n=3,517, 49.3%). Authorised stimulant prescribers specialising in the treatment of children may initiate treatment in patients up to and including the age of 18 years and may continue treatment in these patients up to the age of 25 years. These prescribers (paediatricians and paediatric neurologists) were the notified stimulant prescriber for 12.6% (n=901) of adults in the cohort.

Figure 10. Number and proportion of adults in the ADHD cohort by professional category of authorised stimulant prescriber

Child & adolescent

psychiatrist, 3,517 (49.3%)

Paediatric neurologist,

28 (0.4%)

Paediatrician, 873 (12.2%)

Adult neurologist,

4 (0.1%) Adult psychiatrist, 2,720 (38.1%)

The number of adult patients per authorised stimulant prescriber who treated adults in 2006 ranged from 1 to 851. There was a mean of 56 and a median of 7 adult patients per prescriber. Most prescribers (n=78, 61.4%) treated 10 or less patients (Table 18).

Table 18. Number of stimulant prescribers by number of adult patients notified


Percent ≥1 and ≤10 78 61.4% 61.4%

≥11 and ≤50 25 19.7% 81.1%

≥51 and ≤100 13 10.2% 91.3%

≥101 and ≤500 8 6.3% 97.6%

>500 3 2.4% 100.0%

TOTAL 127 100.0%

25

Adults in the ADHD cohort with a nominated co-prescriber There were 2,627 adult patients (36.8% of adults in the cohort) with a co-prescriber nominated by the authorised stimulant prescriber. Authorised stimulant prescribers were nominated as co-prescriber for 4% of patients (n=105).

Table 19. Number of adults in the ADHD cohort with a nominated co-prescriber by professional category of co-prescriber.

Co-prescriber Type Frequency Percent Authorised Stimulant Prescriber (SPN) Adult neurologist 0 0.0% Adult psychiatrist 3 0.1% Child & adolescent psychiatrist 4 0.2% Paediatric neurologist 0 0.0% Paediatrician 98 3.7%

Other medical practitioner 2,522 96.0%

TOTAL 2,627 100.0%

Number of adult patients per co-prescriber There were 1,071 practitioners nominated as co-prescribers for adults in the ADHD cohort. Almost all co-prescribers (n=1,058, 98.8%) treated 10 or less patients. The number of adult patients per co-prescriber ranged from 1 to 368. There was a mean of 2 and a median of 1 patient per prescriber.

Table 20. Stimulant co-prescriber by number of adults notified


Percent ≥1 and ≤10 1,058 98.8% 98.8%

≥11 and ≤50 10 0.9% 99.7%

≥51 and ≤100 2 0.2% 99.9%

≥101 and ≤500 1 0.1% 100.0%

TOTAL 1,071 100.0%

Patients by Age and Gender There were 4,500 men and 2,642 women in the ADHD cohort giving a ratio of men to women of 1.7 to 1 (Figure 11).


26

Figure 11. Number and proportion of adults in the ADHD cohort by gender

Male4,500 (63.0%)

Female2,642 (37.0%)

Table 21 shows adults in the ADHD cohort by age group and gender. The mean age of adults in the cohort was 31.4 years (women=33.3 years, men = 30.3 years) and the median age was 27 years (women = 31 years, men=26 years). The age of men in the cohort ranged from 18 to 78 years and women ranged from 18 to 81 years. There were 737 adults in the cohort (10.3% of adults in the cohort) who were at least 50 years of age. Young adults (18 and 19 years) had the highest rate of notification per 1,000 population (16.1 per 1,000 population).

Table 21. Adults in the ADHD cohort by age and gender

Female Male TOTAL


Rate per


Rate per


Rate per

1,000

≥18 and <20 248 9.4% 8.6 707 15.7% 23.2 955 13.4% 16.1

≥20 and <30 1,013 38.3% 7.4 2,026 45.0% 14.1 3,039 42.6% 10.8

≥30 and <40 556 21.0% 3.8 796 17.7% 5.3 1,352 18.9% 4.6

≥40 and <50 495 18.7% 3.2 564 12.5% 3.6 1,059 14.8% 3.4

≥50 330 12.5% 1.1 407 9.0% 1.4 737 10.3% 1.2

TOTAL 2,642 100.0% 3.4 4,500 100.0% 5.8 7,142 100.0% 4.6 Whilst the number of men in the cohort was consistently higher than the number of women, both genders showed the same trend in the rate of notification (Figure 12).

27

Figure 12. Number of adult patients per 1,000 population in the ADHD cohort

7.4

23.2

14.116.1

10.8

3.8

8.6

3.2 1.1

5.33.6

1.44.6

3.41.20

5

10

15

20

25

≥18 and <20 ≥20 and <30 ≥30 and <40 ≥40 and <50 ≥50

Men per 1,000 Women per 1,000 Total per 1,000

Age at first Notification for adults in the cohort The age at first Notification was determined for the adult patients in the ADHD cohort. The age of first Notification is not a true indication of the age at which a patient commenced stimulant treatment, as the Notification system only commenced in August 2003. A proportion of patients who were first notified as adults will have received treatment with stimulant medicines under the previous regulatory system. However over time, age at first Notification will become a more realistic indication of the age a patient commenced stimulant treatment. The age at first Notification for adult patients in the ADHD cohort is shown in Table 22. One patient’s date of birth was amended in the data cleaning process and they were excluded from this section of the analysis.

Table 22. Age at first Notification for adults in the ADHD cohort Age Frequency Percentage <18 979 13.7% ≥18 and <20 845 11.8% ≥20 and <30 2,411 33.8% ≥30 and <40 1,340 18.8% ≥40 and <50 994 13.9% ≥50 572 8.0% TOTAL 7,141 100.0%

Table 22 shows that 13.7% of the adult patients in the 2007 ADHD cohort were first notified when they were children. The majority of adults in the ADHD cohort were first notified when they were ≥18 years of age (n=6,162, 86.3%). A small proportion of adults were first notified when they were ≥50 years of age (n=572, 8.0%).

28

Adults in the ADHD cohort by location of residence There were 3,374 adult patients (47.2% of adults in the cohort) who resided in the NMAHS and 2,925 (41.0%) who resided in the SMAHS. A smaller number (n=806, 11.3%) resided in the WACHS. There were 37 adult patients with interstate or overseas postcodes that were coded as “Other” and excluded from further analysis by location of residence. Figure 13 shows the number of adult patients in the cohort per 1,000 population, by Health Service. This was similar in both metropolitan health services but lower in the WACHS.

Figure 13. Number of adults per 1,000 population, in the ADHD cohort, by Area Health Service

5.2 5.1

2.4

0

1

2

3

4

5

6

North Metropolitan South Metropolitan WA Country

Table 23 lists the number of adults per 1,000 population in each of the 34 Health Districts. The number of patients per Health District ranged from 0.6 to 8.9 per 1,000 population.


29

Table 23. Number, percentage and rate per 1,000 population of adults in the ADHD cohort by Health District

Area Health Service Health District Frequency Percentage Rate per 1,000 pop’n

NMAHS Oceanic 943 13.2% 8.9

NMAHS Stirling SEC 418 5.9% 4.4

NMAHS Joondalup 583 8.2% 4.9

NMAHS Wanneroo 296 4.1% 3.7

NMAHS Bayswater-Bassendean 274 3.8% 4.8

NMAHS Valley and Hills 356 5.0% 3.7

NMAHS Kalamunda 178 2.5% 4.6

NMAHS Stirling Coastal 332 4.6% 6.3

SMAHS Armadale 564 7.9% 4.8

SMAHS Bentley 824 11.5% 5.7

SMAHS Fremantle 890 12.5% 5.5

SMAHS Peel 252 3.5% 4.0

SMAHS Rockingham - Kwinana 395 5.5% 4.9

WACHS Blackwood 11 1.1% 2.2

WACHS Bunbury 78 0.7% 2.5

WACHS Busselton 47 0.7% 2.2

WACHS Central Great Southern 22 0.3% 3.2

WACHS East Pilbara 18 0.3% 1.4

WACHS Eastern Wheatbelt 14 0.2% 1.9

WACHS Gascoyne 7 0.1% 1.0

WACHS Geraldton 111 1.6% 4.7

WACHS Kimberley 23 0.3% 0.9

WACHS Leeuwin 13 0.2% 1.4

WACHS Leschenault 55 0.8% 2.5

WACHS Lower Great Southern 104 1.5% 3.1

WACHS Midwest 15 0.2% 1.5

WACHS Murchison 2 0.0% 0.6

WACHS Northern Goldfields 49 0.7% 1.8

WACHS South East Coastal 14 0.5% 1.2

WACHS Southern Wheatbelt 38 0.5% 2.6

WACHS Warren 32 0.4% 4.6

WACHS Wellington 13 0.2% 1.3

WACHS West Pilbara 23 0.3% 1.5

WACHS Western Wheatbelt 111 1.6% 3.5

Other 37 0.5% -

TOTAL 7,142 100.0% 4.6

30

Adults in the ADHD cohort by medicine notified Figure 14 shows the number and rate per 1,000 population of adults (≥18 years) in the ADHD cohort by medicine(s) notified. Over 97% of adults (n=6,972, 97.6%) were notified as being treated with a single stimulant medicine. Most adults in the cohort (n=6,428, 87.9%) were treated with dexamphetamine either alone or in combination with other stimulants.


31

Figure 14. Adults in the ADHD cohort by medicine(s) notified

Dexamphetamine n= 6,428 (87.9%) Rate per 1,000 population = 4.1

Dexamphetamine Only Male = 3,942 (62.2%)

Female = 2,398 (37.8%)TOTAL = 6,340

Rate/1,000 pop’n=4.1

Dex + Meth Male = 49 (71.0%)

Female = 20 (29.0%)TOTAL = 69

Rate/1,000 pop’n= <0.1

Dex + Meth LA Male = 13 (72.2%)

Female = 5 (27.8%)TOTAL = 18

Rate/1,000 pop’n= <0.1Dex + Meth + Meth LA

Male = 1 (100.0%)Female = 0 (0.0%)

TOTAL = 1Rate/1,000 pop’n = <0.1

Methylphenidate LA Only Male = 180 (81.7%)

Female = 62 (18.3%)TOTAL = 242

Rate/1,000 pop’n = 0.2

Methylphenidate Only Male = 248 (63.6%)

Female = 142 (36.4%)TOTAL = 390

Rate/1,000 pop’n= 0.3

Meth + Meth LA Male = 67 (81.7%)

Female = 15 (18.3%)TOTAL = 82

Rate/1,000 pop’n = <0.1

Methylphenidate n= 542 (7.4%) Rate per 1,000 population = 0.3

Methylphenidate LAn= 343 (4.7%)

Rate per 1,000 population = 0.2

Average daily notified dose Table 24 outlines the average daily notified dose for adults in the ADHD cohort expressed in dex equivalents. The information is presented in dex equivalents which allows for the illustration of total

32

stimulant use regardless of medicine notified. The average daily notified dose for adults in the ADHD cohort, expressed in dex equivalents, was 33.2 mg/day. Average daily notified doses ranged from 2.5 to 80 mg per day. Men had higher average daily notified doses in each age group but the over all average daily notified dose was the same for men and women. Men aged 18 and 19 years had the highest rate of notification (24.5 per 1,000 population). The rate of notification decreased with age in both men and women.

Table 24. Average daily notified dose in dex equivalents for adults in the ADHD cohort by age group and gender



Average Dose

(mg/day) SD Min Dose

Max Dose

Female ≥18 and <20 248 8.6 25.2 11.1 5.0 60.0

≥20 and <30 1,013 7.4 32.3 14.1 5.0 60.0

≥30 and <40 556 3.8 34.5 14.4 5.0 75.0*

≥40 and <50 495 3.2 35.4 15.0 5.0 60.0

≥50 330 1.1 36.4 17.3 5.0 60.0

Total - Female 2,642 3.4 33.2 14.8 5.0 75.0* Male ≥18 and <20 707 24.5 26.3 11.0 5.0 60.0

≥20 and <30 2,026 14.8 33.3 13.2 2.5 80.0*

≥30 and <40 796 5.4 36.7 14.2 5.0 60.0

≥40 and <50 564 3.6 35.6 14.3 5.0 60.0

≥50 407 1.3 34.8 16.0 5.0 60.0

Total-Male 4,500 5.8 33.2 13.9 2.5 80.0*

TOTAL 7,142 4.6 33.2 14.2 2.5 80.0* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing

stimulants at a dose above the maximum set out in the Stimulant Regulatory Guidelines Table 25 compares average notified daily doses for adults in the ADHD cohort prescribed a single versus a combination of stimulant medicines. Men and women notified as being prescribed a combination of stimulants had higher average daily notified doses than those prescribed a single stimulant medicine.

Table 25. Average daily notified dose in dex equivalents for adults in the ADHD cohort by number of medicines prescribed (single/combination)

Treatment Type Gender Frequency


Average Dose


Max Dose

Single Medicine Female 2,602 3.3 33.2 14.8 5.0 75.0*

Male 4,370 6.1 33.2 14.0 2.5 80.0*

TOTAL 6,972 4.5 33.2 14.3 2.5 80.0* Combination Female 40 <0.1 34.5 14.9 9.5 60.0

Male 130 0.2 33.4 11.9 15.0 60.0

TOTAL 170 0.1 33.6 12.6 9.5 60.0 * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing

stimulants at a dose above the maximum set out in the Stimulant Regulatory Guidelines

33

Dexamphetamine only There were 6,340 adults (88.8% of adults in the cohort) notified as being prescribed dexamphetamine only. Notified doses ranged from 2.5 to 80 mg per day. Average daily notified doses peaked in the 30 to 39 year age group for both men and women. Men had higher rates of notification than women in each age group.

Table 26. Notification statistics for adults in the ADHD cohort treated with dexamphetamine only



Average Dose


Max Dose

Female ≥18 and <20 197 6.8 25.7 11.7 5.0 60.0

≥20 and <30 926 6.8 31.3 12.9 6.0 60.0

≥30 and <40 514 3.5 34.0 13.7 5.0 75.0*

≥40 and <50 459 3.0 33.5 14.0 5.0 60.0

≥50 302 1.0 33.9 16.2 5.0 60.0

Total - Female 2,398 3.1 30.9 13.0 5.0 75.0* Male ≥18 and <20 517 17.0 26.9 11.2 5.0 60.0

≥20 and <30 1,831 12.8 33.4 13.0 3.0 80.0*

≥30 and <40 727 4.9 36.1 13.6 5.0 60.0

≥40 and <50 510 3.3 35.6 13.3 5.0 60.0

≥50 357 1.2 34.7 15.2 5.0 60.0

Total-Male 3,942 5.1 32.3 13.1 2.5 80.0*

TOTAL 6,340 4.1 31.6 13.2 2.5 80.0* * Prior written authorisation from the Chief Executive Officer of Health is required before prescribing

stimulants at a dose above the maximum set out in the Stimulant Regulatory Guidelines


34

Methylphenidate only There were 390 adult patients (5.5% of adults in the cohort) that were notified as being prescribed methylphenidate only. Notified doses ranged from 5 to 120 mg per day. The overall average daily notified dose was higher for women (55.3 mg/day) than for men (54.4 mg/day).

Table 27. Notification statistics for adults in the ADHD cohort treated with methylphenidate only



Average Dose


Max Dose

Female ≥18 and <20 12 0.4 39.2 17.8 10.0 60.0

≥20 and <30 59 0.4 54.3 25.1 10.0 120.0

≥30 and <40 30 0.2 48.9 21.4 10.0 80.0

≥40 and <50 21 0.1 64.0 26.8 30.0 120.0

≥50 20 <0.1 64.8 33.3 10.0 120.0

Total - Female 142 0.2 55.3 26.5 10.0 120.0 Male ≥18 and <20 48 1.6 50.9 26.2 10.0 120.0

≥20 and <30 94 0.7 50.8 22.7 5.0 120.0

≥30 and <40 43 0.3 56.8 28.2 20.0 120.0

≥40 and <50 31 0.2 60.5 30.6 10.0 120.0

≥50 32 0.1 50.5 27.6 15.0 120.0

Total-Male 248 0.3 54.0 26.7 5.0 120.0

TOTAL 390 0.3 54.4 26.9 5.0 120.0


35

Methylphenidate LA only There were less adults prescribed methylphenidate long acting (n=242, 3.4% of adults in the cohort) than prescribed dexamphetamine or methylphenidate. Notified doses ranged from 10 to 120 mg per day. Average notified daily doses peaked in the 30 to 39 year age group for men and women.

Table 28. Notification statistics for adults in the ADHD cohort treated with methylphenidate long-acting only



Average Dose


Max Dose

Female ≥18 and <20 25 0.9 40.2 14.6 20.0 80.0

≥20 and <30 17 0.1 46.9 29.0 18.0 120.0

≥30 and <40 7 <0.1 52.3 32.8 18.0 108.0

≥40 and <50 8 <0.1 47.3 18.8 20.0 80.0

≥50 5 <0.1 40.4 18.2 20.0 70.0

Total - Female 62 0.1 44.3 22.0 18.0 120.0 Male

≥18 and <20 87 2.9 41.3 15.2 10.0 80.0

≥20 and <30 51 0.4 45.3 21.2 18.0 100.0

≥30 and <40 20 0.1 55.3 31.6 20.0 120.0

≥40 and <50 13 0.1 49.9 25.7 18.0 80.0

≥50 9 <0.1 42.7 12.4 30.0 60.0

Total-Male 180 0.2 44.9 20.4 10.0 120.0

TOTAL 242 0.2 44.9 20.9 10.0 120.0


36

Patients on combination treatment There were 170 adult patients notified as being prescribed a combination of stimulants (2.4% of adults in the cohort). Doses of stimulants were converted to their dex equivalent doses to enable the average daily dose to be expressed as one unit. Notified doses ranged from 9.5 to 60 mg per day. Average daily notified doses increased with age for women whilst they peaked in the 30 to 39 year age group for men.

Table 29. Notification statistics for adults in the ADHD cohort treated with a combination of stimulant medicines (doses presented in dex equivalents)



Average Dose


Max Dose

Female ≥18 and <20 14 0.5 31.8 8.5 20.0 50.0

≥20 and <30 11 0.1 33.6 19.3 9.5 60.0

≥30 and <40 5 <0.1 35.6 13.9 25.0 60.0

≥40 and <50 7 <0.1 37.1 17.1 15.0 60.0

≥50 3 <0.1 41.7 23.6 15.0 60.0

Total - Female 40 <0.1 35.0 14.7 9.5 60.0 Male ≥18 and <20 55 1.8 30.3 10.8 15.0 60.0

≥20 and <30 50 0.4 35.5 11.5 15.0 60.0

≥30 and <40 6 <0.1 40.8 12.0 30.0 60.0

≥40 and <50 10 <0.1 29.9 11.3 15.0 50.0

≥50 9 <0.1 40.2 15.7 15.0 60.0

Total-Male 130 0.2 33.3 12.0 15.0 60.0

TOTAL 170 0.1 33.8 12.5 9.5 60.0


37

Comparison of average daily notified doses Table 30 presents the average daily notified doses for adults in the ADHD cohort by medicine(s) notified. The results are presented in dex equivalents to allow comparisons between medicines prescribed. Patients notified as being prescribed a combination of stimulants had higher average daily notified doses than those prescribed a single stimulant medicine. Of the patients prescribed a single stimulant, patients notified as being prescribed dexamphetamine had higher average daily notified doses than patients prescribed methylphenidate or methylphenidate long acting only.

Table 30. Average notified daily dose (in dex equivalents) of stimulant medicine(s) for adults in the ADHD cohort by medicine(s) notified

Age category

Dexamphetamine Average Dose

(mg/day)

Methylphenidate Average Dose

(mg/day)

Methylphenidate long-acting

Average Dose (mg/day)

Combination Average

Dose (mg/day)

Female ≥18 and <20 25.7 19.6 20.1 31.8

≥20 and <30 31.3 27.1 23.4 33.6

≥30 and <40 34.1 24.4 26.1 35.6

≥40 and <50 33.5 32.0 23.6 37.1

≥50 33.9 32.4 20.2 41.7

Total - Female 30.9 27.6 22.1 35.0 Male ≥18 and <20 26.9 25.5 20.6 30.3

≥20 and <30 33.4 25.4 22.7 35.5

≥30 and <40 36.1 28.4 27.6 40.8

≥40 and <50 35.6 30.3 24.9 29.9

≥50 34.7 25.3 21.3 40.2

Total-Male 32.3 27.0 22.5 33.3

TOTAL 31.6 27.2 22.5 33.8

Adults in the ADHD cohort treated with other psychotropic medicines There were 27.7% (n=1,977) of adult patients in the cohort who were notified as being prescribed other psychotropic medicines in conjunction with stimulant treatment.


38

Table 31. Number of adults in the ADHD cohort prescribed other psychotropic medicines

Number of other psychotropic

medicines prescribed Frequency Percent 0 5,165 72.3%

1 1,693 23.7%

2 240 3.4%

3 39 0.5%

4 4 0.1%

5 1 0.0%

TOTAL 7,142 100.0% Of the patients prescribed other psychotropic medicines, anti-depressants were the most common medicine prescribed (n=1,630, 71.3%), followed by mood stabilising agents (n=326, 14.3%).

Figure 15. Other psychotropic medicines prescribed to adults in the ADHD cohort

Anxiolytics,159 (7.0%)

Mood Stabilising Agents,

326 (14.3%)

Unspecified other

psychotropic medicines, 78 (3.4%)

Anti-psychotics, 92 (4.0%)

Anti-depressants, 1,630 (71.3%)

The total number of medicines notified, as illustrated in Table 31, is greater than the number of adults prescribed other psychotropic medicines, as illustrated in Figure 15, as some adults were prescribed more than one other psychotropic medicine.

39

Naïve Patients in 2006 There were 1,906 patients (13.2% of the cohort) who were notified for the first time in 2006. Whilst some of these patients may have been previously treated with stimulant medicines prior to the introduction of the Stimulant Regulatory Scheme, as the Scheme progresses the first notification received for a particular patient is likely to represent a patient naïve to stimulant treatment. A separate analysis has been performed on this group to compare patients naïve to stimulant treatment with the ADHD cohort overall. Further analysis of this subgroup will be conducted on an annual basis to assess trends in prescribing. There were 980 children and 926 adults in the cohort who were notified as receiving treatment with stimulant medication for the first time in 2006 with age ranging from 4 years to 78 years. Table 32 shows the number of patients in the ADHD cohort who were notified as being treated with stimulant medicines for the first time in 2006. Children in the 4 to 9 year age group had the highest rate of notification (2.8 per 1,000 population).

Table 32. Naïve patients in the ADHD cohort by age and gender

Female Male TOTAL


Rate per


Rate per


Rate per

1,000

Children ≥2 and <4 0 0.0% 0.0 0.0 0.0% 0 0 0.0% 0.0

≥4 and <10 85 41.1% 1.1 363 47.0% 4.5 448 45.7% 2.8

≥10 and <15 76 36.7% 1.1 305 39.5% 4.2 381 38.9% 2.7

≥15 and <18 46 22.2% 1.1 105 13.6% 2.3 151 15.4% 1.7

Total Children 207 100.0% 1.0 773 100.0% 3.4 980 100.0% 2.2 Adults ≥18 and <20 40 11.0% 1.4 62 11.0% 2 102 11.0% 1.7

≥20 and <30 143 39.3% 1.0 254 45.2% 1.8 397 42.9% 1.4

≥30 and <40 93 25.5% 0.6 123 21.9% 0.8 216 23.3% 0.7

≥40 and <50 54 14.8% 0.4 79 14.1% 0.5 133 14.4% 0.4

≥50 34 9.3% 0.1 44 7.8% 0.1 78 8.4% 0.1

Total Adults 364 100.0% 0.5 562 100.0% 0.7 926 100.0% 0.6 Figure 16 illustrates the number of naïve patients per 1,000 population in the ADHD cohort in 2006. The number of females notified for the first time in 2006 peaked in the 18 to 19 year age group (1.4 per 1,000 population) and the number of males peaked in the 4 to 9 year age group (4.5 per 1,000 population).


40

Figure 16. Number of stimulant naïve patients per 1,000 population in the ADHD cohort by age group and gender

0

1

0.40.10

4.2

2.3

1.8

0.10

2.8

1.71.4

0.10.6

1.41.11.11.1

0.50.8

2

4.5

0.4

0.7

1.7

2.7

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

≥2 and<4

≥4 and<10

≥10 and<15

≥15 and<18

≥18 and<20

≥20 and<30

≥30 and<40

≥40 and<50

≥50

Female Male Total

Figure 17 shows the proportion of naïve patients in the ADHD cohort by age group and medicine(s) notified. The proportion of patients (adults and children) prescribed dexamphetamine was lower in patients notified for the first time in 2006 (children=43.5%, adults=83.4%) than in the cohort overall (children=54.7%, adults=88.8%). The proportion of patients prescribed methylphenidate was higher in patients notified for the first time in 2006 (children=25.7%, adults=13.2%) than in the cohort overall (children=13.4%, adults=5.5%). Methylphenidate was listed on the Pharmaceutical Benefits Scheme in 2006 which may account for the change.

Continued next page

41

Figure 17. Proportion of patients in the ADHD cohort (stimulant naïve and total) by medicine notified

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Children - naïve2006

Children - cohorttotal

Adults - naïve 2006 Adults - cohorttotal

Dexamphetamine Methylphenidate Methylphenidate LA Combination

Table 33 compares the average daily notified dose for patients notified for the first time during 2006 with the ADHD cohort overall. Doses were expressed in dex equivalents to allow comparison of overall stimulant use between the two groups. Average daily notified doses (milligrams per day) for children and adults who were notified for the first time in 2006 were lower than the cohort overall, however on a milligram per kilogram basis for children the doses remained the same. Patients are required to be commenced on a low dose that is titrated according to patient response. Patients who commenced treatment in 2006 may not have yet reached a stable, final dose which may account for this difference.

Table 33. Average daily notified dose (expressed in dex equivalents) for patients in the ADHD cohort (naive and total)

Naïve patients Total ADHD Cohort

Average dose

(mg/day)

Average dose

(mg/kg/day)

Average dose

(mg/day)

Average dose

(mg/kg/day)

Children (≥2 to <18 years)

Female 14.2 0.4 16.5 0.4

Male 13.3 0.4 17.0 0.4

Total Children 13.5 0.4 16.9 0.4 Adults (≥18 years)

Female 28.5 - 33.2 -

Male 29.7 - 33.2 -

Total Adults 29.2 - 33.2 -

42

Comparisons with 2004 & 2005 Data

A limited comparison with the results from the 2005 Annual Report, including 2004 data, is presented here. A more detailed analysis of trends in notification and prescribing will be undertaken in subsequent reports when the Scheme has been in operation for a sufficient time period to make these comparisons meaningful.

Authorised stimulant prescribers

The number of authorised stimulant prescribed increased to 229 in 2006, up 6% from the previous year (n=216).

Number of Notifications

The number of notifications processed during 2006 increased from the previous year largely due to an increase in the number of terminations processed. This number is representative of patients moving between prescribers rather than a reduction in the number of patients treated. Table 34 outlines the number of notifications processed by the DOH from 2004 to 2006.

Table 34. Number and type of stimulant Notifications processed 2004-2006

Notification type 2004 2005 2006 Incomplete 290 12 25

Notification 7,974 3,026 3,056

Outside Guidelines 157 70 54

Re- Notification 2,892 2,556 2,597

Termination 285 858 1,475

TOTAL 11,598 6,522 7,207

Patients with a Notification and/or Dispensed Medication

From 2004 to 2006 there was a small reduction in the number of patients who had a Notification and were dispensed a stimulant prescription. There was also a reduction in the number of patients who had a dispensed stimulant prescription without a Notification having been submitted. This decrease is primarily due to a more thorough data matching process between prescription and notification records rather than a true decrease in the number of patients prescribed stimulants without a notification having been submitted. These patients were subsequently followed up by the Department of Health, but have been excluded from further analysis as the DOH had no additional information on these patients (that normally would have been included on the Notification form). The number of patients with a notification (either current or terminated) and without a dispensed stimulant prescription increased each year (n=6,427 in 2006). This represents patients who have had a notification submitted at some stage since the commencement of the new scheme but have had their treatment terminated by the prescriber or have been lost to follow-up and ceased receiving treatment.

43

Table 35. Patients with notification and/or dispensed medication 2004-2006

Notification/Dispensing combination Frequency

2004 Frequency

2005 Frequency

2006 Notification with Dispensed Medication 15,702 15,333 15,031

Notification without Dispensed Medication 992 3,844 6,427

Dispensed Medication without Notification 2,047 1,818 938

TOTAL 18,741 20,995 22,396 Table 36 outlines the number of patients with current notification who had prescriptions dispensed, by the diagnosis for which stimulants were prescribed. The number of patients prescribed stimulant medicines for conditions other than ADHD increased each year. The number of patients included in the ADHD cohort decreased approximately 5% between 2004 and 2006.

Table 36. Diagnosis of notified patients with stimulant prescriptions dispensed 2004-2006

Diagnosis 2004 2005 2006 Other condition

Narcolepsy, brain damage, depression or other approved condition 337 395 434

ADHD

Children 8,859 8,057 7,283

Adults 6,304 6,756 7,142

Total ADHD Cohort 15,163 14,813 14,425

TOTAL 15,500 15,208 14,859

The ADHD Cohort

Table 37 shows the number and of patients in the ADHD cohort by age group (children and adults) and gender. The number of children in the cohort decreased each year whilst the number of adults increased.

Table 37. Number of patients in the ADHD Cohort by age and gender (2004-2006)

2004 2005 2006

Frequency Rate per

1,000 Frequency Rate per

1,000 Frequency Rate per

1,000

Girls 1,718 8.1 1,557 7.3 1,419 6.6

Boys 7,141 31.8 6,500 29.0 5,864 26.1

Women 2,310 3.1 2,485 3.2 2,642 3.4

Men 3,994 5.4 4,271 5.6 4,500 5.8

44

Figure 19 shows the number of patients per 1,000 population in the ADHD cohort in 2004 to 2006 by age group. The number of patients in the cohort per 1,000 population followed the same trend each year, peaking in the 10 to 14 year age group.

Figure 19. Number of patients per 1,000 population in the ADHD cohort 2004-2006

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

≥2 and<4

≥4 and<10

≥10 and<15

≥15 and<18

≥18 and<20

≥20 and<30

≥30 and<40

≥40 and<50

≥50

2004 2005 2006

Patients with Co-prescribers

The number and proportion of children in the cohort with a nominated co-prescriber decreased each year from 2004 to 2006, whilst the number of adults in the cohort with a nominated co-prescriber has increased each year (Table 38).

Table 38. Number and proportion of patients in the ADHD cohort with a nominated co-prescriber (2004-2006)

2004 2005 2006

Frequency Percentage of cohort Frequency

Percentage of cohort Frequency

Percentage of cohort

Children 3,129 35.3% 2,677 33.3% 2,078 28.5%

Adults 1,692 26.8% 1,940 29.5% 2,627 36.8%

Average daily dose

Table 39 shows the average daily dose of stimulant medicine, expressed in dex equivalents, for patients in the ADHD cohort 2004 to 2006. The average daily notified dose decreased each year for both children and adults. There was a small increase in dose on a milligram per kilogram basis for children in 2006 (2005=0.44 mg/kg/day, 2006=0.45mg/kg/day).

45

Table 39. Average daily notified dose in dex equivalents for patients in the ADHD cohort by age group and gender 2004-2006

2004 2005 2006

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Average Dose

(mg/day)

Average Dose

(mg/kg/day)

Children (≥2 to <18 years)

Female 16.8 0.4 16.6 0.4 16.5 0.4

Male 17.6 0.4 17.2 0.5 17.0 0.5

Total Children 17.4 0.4 17.1 0.4 16.9 0.5 Adults (≥18 years)

Female 33.9 - 33.5 - 33.2 -

Male 33.8 - 33.7 - 33.2 -

Total Adults 33.8 - 33.6 - 33.2 -

Naïve patients in the ADHD cohort

Patients who were notified for the first time made up 14.8% (n=2,196) of the cohort in 2005 which decreased to 13.2% (n=1,906) in 2006. The average daily notified dose for these patients was slightly lower for boys (2005=13.7 mg/day, 2006=13.3 mg/day), girls (2005=14.3mg/day, 2006=14.2mg/day) and men (2005=30.4mg/day, 2006=29.7mg/day) but remained stable for women (28.5mg/day). The average daily notified dose in milligrams per kilogram per day remained stable for children notified for the first time in 2005 and 2006 (0.4mg/kg.day).

46

Appendices

Appendix 1: Stimulant Regulatory Guidelines A reference to a stimulant drug in these Guidelines means dexamphetamine and methylphenidate in any form.

1. Overview

The regulatory control framework for stimulants requires prescribers initiating treatment with a stimulant to apply to the Department of Health (DOH) and obtain a ‘Stimulant Prescriber Number’. Authorised prescribers can initiate treatment for patients who meet the criteria set out in these Regulatory Guidelines by forwarding a completed ‘Notification Form’ to the DOH. Where a patient does not meet the criteria set out in these Regulatory Guidelines an authorisation from the Chief Executive Officer (CEO) is required before treatment can be initiated.

2. Registration of Prescribers

2.1 A medical practitioner must apply to the Department of Health and obtain a unique Stimulant Prescriber Number (SPN) to initiate treatment with a stimulant drug.

2.2 To apply for a SPN, a medical practitioner must be registered with the Medical Board of

Western Australia and be recognised as having specialist qualifications as a paediatrician, paediatric neurologist, neurologist, thoracic medicine physician, rehabilitation physician, psychiatrist, child and adolescent psychiatrist or other approved qualification as determined by the Commissioner of Health.

2.3 An Application to obtain a Stimulant Prescriber Number (SPN1) is to be completed and

forwarded to the Department of Health.

2.4 Medical practitioners requesting a SPN will be required to be familiar with and comply with the Stimulant Regulatory Guidelines (WA) and agree to participate in a clinical audit of patients at a later date. This, or any future audits will be based upon research principals including the requirement for informed patient consent to access medical records.

3. Criteria for the Prescribing of a Stimulant

3.1 Diagnosis

Patients must be diagnosed as having ADHD, brain damage, narcolepsy or depression. 3.1.1 Treatment of narcolepsy with stimulants may only be initiated by a paediatric

neurologist, neurologist or a medical practitioner approved by the CEO.

3.1.2 Treatment of brain damage with stimulants may only be initiated by a neurologist, paediatric neurologist or a medical practitioner approved by the CEO.

47

3.1.3 Treatment of depression with stimulants may only be initiated by psychiatrist, a child

and adolescent psychiatrist or a medical practitioner approved by the CEO.

3.1.4 Treatment of ADHD with stimulants may only be initiated by a neurologist, paediatric neurologist, paediatrician, psychiatrist, a child and adolescent psychiatrist or a medical practitioner approved by the CEO. Patients are required to meet the ICD-10 or DSM-IV diagnostic criteria.

3.1.5 A urine drug screen should be undertaken by all patients aged 13 years and above

before treatment with a stimulant is initiated. Further testing is recommended annually or as clinically appropriate.

3.2 Requirements for patients diagnosed with ADHD

3.2.1 Dose

All patients must be started on a low dose that is titrated according to the patient’s response. Doses must not be greater than 1mg/kg/day for dexamphetamine up to a maximum of 60mg per day; or be greater than 2mg/kg/day for methylphenidate up to a maximum of 120mg per day. Where both dexamphetamine and methylphenidate are prescribed for the same patient there is a maximum of 12 tablets per day.

3.2.2 Age

Treatment of ADHD with a stimulant may be initiated in children between 4 years and 18 years by a medical practitioner specialising in children in accordance with section 3.1.4. For patients aged 17 years and over, treatment with a stimulant must be initiated by a medical practitioner specialising in adults in accordance with section 3.1.4. Treatment of ADHD with a stimulant may be continued in patients aged between 18 to 25 years by a medical practitioner specialising in children in accordance with section 3.1.4. Treatment of ADHD with a stimulant in children aged between 2 and 4 years by a medical practitioner in accordance with section 3.1.4 will require an authorisation from the CEO (see section 4). Treatment with a stimulant for ADHD in children below 2 years of age will not be authorised.

3.2.3 Co-morbidity

Patients with a history of psychosis, bipolar disorder, or sustained significant substance abuse will require an authorisation from the CEO. Applications will be forwarded to the Stimulant Assessment Panel for consideration.

48

4. Application for an Authorisation to Prescribe a Stimulant.

4.1. To prescribe stimulants for the treatment of a patient diagnosed with a disorder not approved in section 3.1 requires a comprehensive clinical report to be forwarded to the CEO. If possible reports should include the published literature for treating the condition proposed with stimulants. Treatment cannot be commenced with stimulants until the medical practitioner has received written authorisation from the CEO.

4.2. To prescribe stimulants for clinical research, will require a copy of the research proposal

with approval from an Ethics Committee constituted in accordance with the Guidelines issued by the National and Medial Research Council (NHMRC) to be submitted. A comprehensive report for each patient should be submitted. Treatment cannot be commenced with stimulants until the medical practitioner has received written authorisation from the CEO.

4.3. Application to prescribe stimulants for ADHD where a patient does not meet the criteria set

out in section 3.2 is to be forwarded to the CEO for consideration by the Stimulants Assessment Panel. Treatment cannot be commenced with stimulants until the medical practitioner has received written authorisation from the CEO.

5. Notification Form

5.1. An authorised medical practitioner (SPN) will be required to complete a notification form for each patient for whom they wish to initiate treatment with a stimulant where the patient meets the criteria set out in section 3.

5.2. A Notification of Treatment Using Stimulant Medication Form (SNF1) is to be completed

and forwarded to the DOH at the same time as the first prescription for a patient is written.

5.3. A new notification will be required to be completed when there is a change in: • dose, when the quantity of drug required for the new dose will result in an additional

standard pack to be supplied per month; • drug; • drug form (i.e. long acting or short acting); • nominated co-prescriber (when the nominated co-prescriber is not at the same medical

practice as the authorised prescriber); • Authorised medical practitioner (with a SPN); • Treatment is discontinued; or • Patients details change (i.e. surname and/or address)

5.4. The authorised medical practitioner should provide a copy of the notification form to the

nominated co-prescriber to ensure they are aware of the patient’s current treatment regime.

5.5. A co-prescriber is not permitted to change a patient’s treatment; only the authorised

medical practitioner (SPN) may do this.

49

6. General Regulatory Matters

6.1. The CEO may revoke an authorisation or cancel a notification forwarded to the DOH.

6.2. A medical practitioner who has completed a notification form or has received a written authorisation from the CEO may request in writing that their notification or authorisation be cancelled.

6.3. Registrars are required to have prescriptions for stimulants countersigned by their

supervising consultant except where the registrar has been endorsed as a co-prescriber in the notification form by the authorised prescriber.

6.4. Medical practitioners should notify the CEO in writing if replacement prescriptions are

required for lost, stolen or otherwise inaccessible medication.

6.5. Pharmacists are required to be familiar with the prescriber’s handwriting or verify with the medical practitioner that the prescription is valid.

6.6. Medical practitioners are required to include on prescriptions for stimulants, repeat

intervals between prescriptions. 7. Authorised medical practitioners on leave

7.1. Any authorised medical practitioner on leave from their practice should advise the DOH in writing of the alternative arrangements they have made for patients to obtain a prescription for stimulants. Information to be included is the time period on leave, the name of the locum specialist and where there is no nominated co-prescriber whether a general medical practitioner may write an interim prescription.

7.2. A locum medical practitioner should ensure they have a SPN and may continue to

prescribe based on the notification or authorisation that the authorised medical practitioner has submitted. If they wish to prescribe outside the previously notified details then re-notification will be required.

7.3. If a locum authorised medical practitioner wishes to initiate treatment they will be required

to complete a notification form. If they wish to prescribe outside the Stimulant Regulatory Guidelines, then they will be required to obtain an authorisation.

7.4. Where an authorised medical practitioner has agreed to a general medical practitioner

(GP) prescribing stimulant medicine in their absence, the GP must obtain authorisation from the Commissioner of Health prior to writing a prescription. A copy of the authorisation will be sent to the authorised medical practitioner. An authorisation will only be based on the treatment rationale previously notified by the authorised medical practitioner. The GP will not be able to initiate treatment with stimulants.

7.5. Where a notification has not been submitted by an authorised medical practitioner or a

notification has been submitted but is pending consideration by the Assessment Panel, no authorisation will be issued to the GP in their absence.

8. Transition

Authorised medical practitioners will be required to review existing patients treated with stimulants by 31 July 2004 and submit a notification form to the Department of Health for each patient.

50

Appendix 2: Stimulant Notification Form SNF 2.1

First Name

Surname

Full Address

Postcode Medicare No

Weight (kg) (Children only)

DOB Male Female

Please tick Notification (for use within the Stimulant Regulatory Guidelines) Re-notification (please circle change since last notification)

Dose Drug Drug form Co-prescriber Patient details

Termination of treatment. Reason: Prescribing outside the Stimulant Regulatory Guidelines (please circle)

Age High Dose Hx bipolar Hx Psychosis Substance Abuse

Primary condition being treated:

ADHD* Brain damage Narcolepsy Depression Other

Please attach a comprehensive report. If fo * Children aged 4-12 years with a diagno1. Have alternative diagnoses or explanation

episode, anxiety disorder, oppositional defiadisorder been considered ?

2. a) If the child is of school age, has communication strategy with the schoo

b) If the answer to 2 a) is ‘No’, is this due

Stimulant(s) to be prescribed and total

PATIENT / PARENT / GUARDIAN I am aware that the information included on this

Name

Signature

MEDICAL PRACTITIONER ACKNOWLEDI hereby notify the Chief Executive Officer of Health thGuidelines.

Medical Practitioners Signature

Medical Practitioner’s DetailsFirst Name Surname

SPN Please forward completed form to: Pharmaceutical Ser

6849. Enquiries:

If ADHD is the primary diagnosis:Which Diagnostic Criterion was used? ICD-10 DSM-

IV Is the patient on other psychotropic drugs? Yes No If yes, please specify:

Antidepressants Mood stabilising agents Antipsychotics Other psychotropics

r research purposes,

sis of ADHD (ples such as pervasivnt disorder, learnin

a management plal? to a parental reques

daily dose:

ACKNOWLEDGMform will be forward

GEMENT at the patient will be t

MedFirst

Medi

vices, Department of Telephone: 9388 4980

NOTIFICATION OF TREATMENT USING STIMULANT MEDICATION

please also attach a copy of the research proposal

ase circle): e development disorder, manic episode, depressive g disability, post traumatic stress disorder or conduct

Yes / No n been developed for the child that includes a

Yes / No t? Yes / No

Dexamphetamine mg/day

Methylphenidate mg/day

Methylphenidate Long Acting mg/day

ENT (Please indicate) ed to the Department of Health (WA).

Date

reated as above in accordance with the Stimulant Regulatory

Date

ical Practitioner Nominated (Co-Prescriber) Name Surname

cal Practice Address Postcode

Health, PO Box 8172, PERTH BUSINESS CENTRE WA , Facsimile: 9388 4988

Appendix 3: Queries used in the data extraction from the MODDS database

Description of the Scheme in 2006 Tables will be produced outlining the following:

Number Notification forms processed in 2006 Type of Notifications (Notification, Re-Notification, Termination, Outside the Guidelines)

processed in 2006 Number of patients outside the Guidelines Total number and type (psychiatrist, neurologist, CAP, paediatrician, paediatric neurologist) of

SPN holders as at 31.12.2006 As at date of data extraction, number of patients with prescription:

o Notification form and dispensed medication during 2006, o Notification form without dispensed medication during 2006 o Dispensed medication during 2006 without Notification

Patient sub-groups to be described by analysis

Patients with a diagnosisof ADHD

(n= 14,425)

ADHD COHORT Children

≥2 and <18 years (n= 7,283)

As at 31.12.2006: Number of patients with a Notification of Treatment

Using Stimulant Medication (n= 21,458)

Analysis of the ADHD Number and p

paediatric neu Number and p

paediatric neu

Patients with a current Notification (n= 20,649)

Patients without stimulant script written in

2006 (n= 5,790)

Patients with other diagnoses (n= 434)

Cohort roportion of SPN holders by type (psychiatr

ro) roportion of patients per SPN type (psychiatrro)

Patients with a terminated Notification (n= 809)

Patients with a stimulant script written in 2006

(n= 14,859)

ADHD COHORT Adults

≥18 years (n= 7,142)

51

ist, neurologist, CAP, paediatrician,

ist, neurologist, CAP, paediatrician,

52

Number of patients per authorised prescriber (1-10, 11-50, 51-100, 100-499, 500+) Number and proportion of patients with a nominated co-prescriber Number and proportion of co-prescribers by type (SPN or non-SPN) Number and proportion of patients per co-prescriber (1-10, 11-50, 51-100, 100-499, 500+) Number per 1,000 population and proportion of adults (>18 years) and children (≥2 and <18 years)

in cohort Adults and children to be reported separately and will be broken into specific age groupings

(Children: <4, 4-9, 10-14, 15-<18, Adults: 18 –19, 20-29, 30-39, 40-49, >50 Number and proportion of children and adults in cohort by Area Health Service and Health District

(postcode) Number, number per 1,000 population and proportion of males and females in cohort Notified drug type (including single and combined drug treatment) by age and gender (in

frequency and number per 1,000 population) Notified dose in mg/day and mg/kg/day (children only) by drug type, age and gender (in

frequency and number per 1,000 population) Number and proportion of patients prescribed other psychotropic medicines by number of drugs

prescribed (0,1,2,3,4,5) Of those on other psychotropics, number and proportion of patients prescribed each drug type

(antipsychotic, anxiolytic etc) Naïve patients notified in 2006 compared with patients Notified previously Comparisons with 2004/5 data

53

Appendix 4: Estimated Population by Project Specific Age-Groups

2004

Age Group Males Females All ≥0 and <3 24,436 23,929 48,394 ≥2 and <4 25,313 24,312 49,625 ≥4 and <10 81,776 77,195 158,971 ≥10 and <15 72,373 68,840 141,213 ≥15 and <18 45,139 43,226 88,366 ≥18 <20 29,917 28,680 58,596 ≥20 and <30 135,801 131,775 267,576 ≥30 and <40 147,559 147,360 294,919 ≥40 and <50 149,611 151,235 300,846 ≥50 275,701 291,964 567,665 Total Children (≥2 and <18 years) 224,601 213,573 438,175 Total Adults (≥18 years) 738,589 751,014 1,489,602 Total Population (≥2 years) 963,190 964,587 1,927,777

2005


2006


Population denominators for 2004-2005 were provided by the Epidemiology Branch of the Department of Health via Rates Calculator Version 9.1.3 (© Jim Codde, 1993-2003) and are estimated projections from data obtained from the Australian Bureau of Statistics for 30 June 2003. Population denominators for 2006 were provided by the Epidemiology Branch of the Department of Health via

54

Rates Calculator Version 9.1.5 (© Jim Codde, 1993-2005) and are estimated projections from data obtained from the Australian Bureau of Statistics for 30 June 2005.

Appendix 5: Projected populations per Health District for children and adults in 2006

Area Health Service Health District Population

≥2 and <18 years Population ≥18 years

NMAHS Oceanic 21,961 105,999 NMAHS Stirling SEC 19,599 96,002 NMAHS Joondalup 36,022 118,742 NMAHS Wanneroo 28,715 80,319 NMAHS Bayswater-Bassendean 12,070 56,524 NMAHS Valley and Hills 32,587 95,560 NMAHS Kalamunda 11,669 38,978 NMAHS Stirling Coastal 11,345 52,646 SMAHS Armadale 37,647 118,105 SMAHS Bentley 32,148 144,409 SMAHS Fremantle 41,593 162,982 SMAHS Peel 17,117 62,380 SMAHS Rockingham - Kwinana 27,017 81,336 WACHS Blackwood 1,413 5,062 WACHS Bunbury 9,578 31,578 WACHS Busselton 6,600 21,155 WACHS Central Great Southern 2,318 6,934 WACHS East Pilbara 4,600 12,268 WACHS Eastern Wheatbelt 2,182 7,507 WACHS Gascoyne 2,261 7,271 WACHS Geraldton 7,936 23,513 WACHS Kimberley 9,769 25,750 WACHS Leeuwin 2,720 9,095 WACHS Leschenaults 7,714 21,766 WACHS Lower Great Southern 9,703 33,517 WACHS Midwest 2,988 9,885 WACHS Murchison 755 3,364 WACHS Northern Goldfields 9,153 27,659 WACHS South East Coastal 3,698 11,458 WACHS Southern Wheatbelt 4,153 14,328 WACHS Warren 2,374 6,959 WACHS Wellington 3,116 10,203 WACHS West Pilbara 5,573 15,160 WACHS Western Wheatbelt 9,630 31,564 TOTAL 437,755 1,550,376

Population denominators for 2006 were provided by the Epidemiology Branch of the Department of Health

via Rates Calculator Version 9.1.5 (© Jim Codde, 1993-2005) and are estimated projections from data obtained from the Australian Bureau of Statistics for 30 June 2005.

55

Appendix 6: Health Districts by Postcode Area Health Service Health District Postcode NMAHS Oceanic >=6000 and <=6017 NMAHS Stirling SEC >=6021 and <=6022, 6050, 6052, >=6059 and <=6061 NMAHS Joondalup >=6023 and <=6028 NMAHS Wanneroo >=6030 and <=6038, >=6064 and <=6065 NMAHS Bayswater-Bassendean >=6051 and <=6054,

NMAHS Valley and Hills >=6055 and <=6056, 6063, >=6061 and <=6074, 6076, >=6081 and <=6090, 6500

NMAHS Kalamunda >=6057 and <=6058, 6076 NMAHS Stirling Coastal >=36018 and <=6020, 6029 SMAHS Armadale >=6108 and <=6126, >=6201 and <=6206

SMAHS Bentley >=6100 and <=6107, >=6147 and <=6148, >=6151 and <=6152

SMAHS Fremantle >=6149 and <=6150, >=6153 and <=6164, 6166 SMAHS Peel >=6207 and <=6215 SMAHS Rockingham - Kwinana 6165, >=6167 and <=6176 WACHS Blackwood 6244, >=6254 and <=6256 WACHS Bunbury >=6229 and <=6231, 6237, >=6271 and <=6275 WACHS Busselton >=6280 and <=6282

WACHS Central Great Southern >=6316 and <=6320, >=6335 and <=6336, >=6341 and <=6343, >=6394 and <=6395

WACHS East Pilbara >=6721 and <=6724, 6753, >=6758 and <=6762

WACHS Eastern Wheatbelt

>=6368 and <=6369, >=6385 and <=6386, >=6410 and <=6428, >=6472 and <=6473, >=6476 and <=6484, >=6487 and <=6490

WACHS Gascoyne 6537, >=6701 and <=6707 WACHS Geraldton >=6528 and <=6532 WACHS Kimberley >=6725 and <=6743, >=6765 and <=6770 WACHS Leeuwin >=6284 and <=6290

WACHS Leschenaults >=6218 and <=6224, >=6226 and <=6228, >=6232 and <=6236

WACHS Lower Great Southern >=6321 and <=6333, >=6337 and <=6338, >=6396 and <=6397

WACHS Midwest >=6514 and <=6515, >=6517 and <=6519, >=6522 and <=6525, >=6535 and <=6536, >=6614 and <=6632

WACHS Murchison 6439, >=6635 and <=6642 WACHS Northern Goldfields >=6429 and <=6438, >=6440 and <=6442, 6444 WACHS South East Coastal >=6346 and <=6348, 6343, >=6445 and <=6450

WACHS Southern Wheatbelt >=6306 and <=6315, >=6350 and <=6367, >=6370 and <=6375, >=6390 and <=6393, 6452

WACHS Warren >=6258 and <=6262, 6398 WACHS Wellington 6225, >=6239 and <=6243, >=6251 and <=6253 WACHS West Pilbara >=6710 and <=6720, >=6751 and <=6752, 6754

WACHS Western Wheatbelt

>=6041 and <=6044, >=6302 and <=6304, >=6380 and <=6384, >=6401 and <=6409, >=6460 and <=6471, 6475, 6485, >=6501 and <=6513, 6521, >=6560 and <=6613

Patients were assigned to an Area Health Service (AHS) and Health District based on the postcode of the address listed on the Notification form. Postcodes were allocated to an AHS and Health District based on information provided by the Epidemiology

Branch of the Department of Health.

56

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