A Workshop Lisa Riches, ADHD Nurse Specialist/Prescriber This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014. The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

1. Development of the Nurse
Prescriber role, Adult ADHD
A Workshop
Lisa Riches, ADHD Nurse Specialist/Prescriber
Lisa Riches
Digitally signed by Lisa Riches
DN: cn=Lisa Riches gn=Lisa Riches c=United
Kingdom l=GB e=lisa.riches@cpft.nhs.uk
Reason: I am the author of this document
Location:
Date: 2014-03-31 22:15+01:00

2. Workshop
‘an opportunity for interactive group discussion
and learning’
Please join in….

4. Non-Medical Prescribing 2006:
...designed to improve patients’ access to
medicines, develop workforce capability, utilize
skills more effectively and ensure provision of
more accessible and effective patient care

5. Non-medical prescribing by 2010:
A well-integrated and established means of managing a
patient’s condition and giving him/her access to
medicines
Operating safely and prescribing is clinically appropriate
Patients are satisfied with their experience
Evaluation of nurse and pharmacist independent prescribing, DOH Policy and Research
Programme Project 2010

6. Recent patient views:
The Experiences of Adults with ADHD regarding Impairment, Accessing Services and Treatment Management
Matheson et al 2012
‘There was very little follow-up really and very little
help in working with the medication, which ultimately I
gave up on because…I didn’t have anybody who was
knowledgeable to actually work with me on it, on
tweaking it, or trying different things’
‘There was very little follow-up really and very little
help in working with the medication, which ultimately I
gave up on because…I didn’t have anybody who was
knowledgeable to actually work with me on it, on
tweaking it, or trying different things’

7. Key messages influencing practice:
• Psychosocial burden: ADHD-related impairment had an overwhelmingly
chaotic impact on every aspect of patient’s lives and many felt ill equipped
to cope. A chronic sense of failure and missed potential from living with
the impact of ADHD impairment had led to an accumulated psychosocial
burden, particularly in those diagnosed in later life
• Multi-modal treatment: Medication as a standalone treatment for ADHD
was perceived as having limited effectiveness at alleviating impairment.
Therefore, additional support alongside medication in the form of
psychological therapies or psycho-education was strongly desired
• Specialist support: In some, medication use was often inadequately
monitored with little or no follow-up by healthcare professionals, leading
to poor adherence and a sense of abandonment by the healthcare system
• Matheson et al BMC Health Service Res 2013

9. A ‘partnership’
‘Since the decision about whether to take a medicine
or not ultimately lies with the patient, it is crucial
that health professionals and patients engage
in ‘shared decision-making’ about medicines usage.
Shared decision-making, (similar to the concept
‘concordance’), requires health professionals to
engage with patients as partners, taking into account
their beliefs and concerns.’
GMC 2013

10. How effective?
‘We now know that ADHD medications can
normalize the behaviour of 50-60% of those
with ADHD and result in substantial
improvements…in another 20-30% of people
with the disorder.’
Russell Barkley

11. Consider…
co-morbidityco-morbidity
choice vs. safetychoice vs. safety
placebo
effect
placebo
effect
expect the
unexpected
expect the
unexpected
managing
expectation
managing
expectation
substance
misuse or
dependency
substance
misuse or
dependency
costcost
optimizing
effect
optimizing
effect
evaluating
efficacy
evaluating
efficacy
physical
health
physical
health

13. Managing Expectations
‘Drugs are not a panacea; they won’t magically
make you a different person, nor will they undo
years of ingrained behaviour….They won’t
change your IQ. They won’t necessarily improve
your social skills, organisational abilities, time
management skills, and self-confidence’
From: ‘Succeeding with Adult ADHD’ Levrini/Prevatt

14. Medication for ADHD provides:
a window of
opportunity
a window of
opportunity
an environmentan environment
a
platform
a
platform

15. How can we optimize effect?
• Psycho-education
• Lifestyle management
• Emotion and mood

16. Optimizing effect…..
• Educate about the disorder and its
management
• Adjustment to diagnosis; support the
individual (and those close to them) through
the diagnostic process and its aftermath
• Address mood and self-esteem
• Optimise engagement and adherence
• Support family members

17. Lifestyle management
• Sleep
• Exercise
• Emotional regulation techniques (including
mindfulness)
• Work/education guidance
• Communication & relationships
• Addressing addictions
• Networks and ‘integration’
• Dietary changes
• Outside help: Counselling/ Coaching/ Therapy
• Time management, organisation & structure

19. What should I prescribe?
• NICE guidance: NICE technology appraisal (2006); NICE clinical
guideline 72 (2009); NICE quality standard 39 (2013)
• Manufacturer’s recommendations
• BNF
• Trust policy
• BAP (British Association of Psychopharmocology)

20. Medication Choices
Short-acting methylphenidate HCL
Concerta XL – modified release licensed where treatment
started in adolescence
Equasym XL; Medikinet XL
Strattera (atomoxetine HCL) licensed for adult use
Elvanse (lisdexamfetamine dimesylate) – long-
acting licensed where treatment started in adolescence
Dexamfetamine sulfate

21. Consider differential responses to
stimulant medication:
‘individuals may respond very
differently to different stimulants and non-response
or intolerable side-effects with one stimulant does
not preclude a good response to another’
Arnold: Journal of Attention Disorder 2000

22. Useful publications
Evidence-based guidelines for the pharmacological management of
attention deficit hyperactivity disorder: Update on recommendations from
the British Association for Psychopharmacology
http://www.ncbi.nlm.nih.gov/pubmed/24526134
‘Good practice in prescribing and managing medicines and devices’
GMC Jan 2013
Handbook for attention deficit hyperactivity disorder in adults
UK Adult ADHD Network (UKANN)

23. Case study 1
Mr A, age 21, diagnosis as child age 11 and prescribed medication for ADHD for 1 year and not compliant.
Reassessed and diagnosed as adult. Lives with girlfriend and baby. Dad Jamaican, did not know him. Close to
Mum – he thinks she has ADHD. From age 2-8 brought up by maternal aunt; uncle physically abused him.
Brought up in care from age 13 when house burned down. Did not finish schooling although predicted high
grades. Moved around a lot. Difficulties with temper as child. No employment history. On benefits; difficulties
managing money.
Suspended sentence for 2 years with probation for supplying Class A drugs.
Smokes tobacco roll-ups. Currently no recreational drugs, no alcohol, no coffee, no energy drinks.
Came with friend, older, also has ADHD, acts as ‘mentor’ in supporting him. Presentation - well kempt, fidgety
and had difficulty following conversation in clinic. Describes difficulties including losing focus, procrastination,
frustrated at not being able to carry activities he wants to. No mood disorder, no co-morbid mental health
problems. Motivated to seek help, though admits to not trusting professionals.
GP had started Concerta XL at 18mg and titrated to 54mg; this was not helpful and Mr A self-medicated up to
108mg with no benefit. Told GP who suggested he continue at 54mg.
No physical health contraindication to treatment. No other medication.
Impatient for help with medication.
What issues are there to consider? What concerns do you have? What might you prescribe?
How might you optimize medication?

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