Not long before Roger Cook became the McGowan Government Minister for Health, the Western Australian Health Department revealed that a single psychiatrist prescribed amphetamine to 2,074 patients in 2015. So what did Minister Cook do when he became responsible for over-sighting the prescription of drugs of addiction? Did he demand an audit of Dr 2074 prescribing practices? Did he beef up amphetamine accountability measures put in place by the Gallop Government?
NO! He allowed them to be gutted. Now we are not even able to know how many 'patients' Dr 2074 prescribes to. Under Minister Cook's watch WA's amphetamine prescribing rates have continued to spiral upwards and there is compelling evidence that the non-medical use (a polite way of saying abuse) of amphetamines, originally prescribed for ADHD, is very, very common. Wilful ignorance about the contribution ADHD drugs, particularly dexamphetamine, make to Western Australia's notorious amphetamine problem must end.
Minister Cook has been made fully aware of, but so far chosen to ignore, the following facts about ADHD in WA:
In 2017, 3.0% of WA high school students self-reported abusing dexamphetamine.[1] This is more than double the number prescribed 'dexies'.[2] There is no data regarding the abuse of other ADHD drugs, like Ritalin. However, it is very likely these near amphetamines are also frequently abused.
As demonstrated in Figure 11 below WA adults are about 3 times more likely than other Australian adults to be prescribed amphetamines for ADHD.[5]
More research would be nice, but all the available evidence is consistent with the hypothesis that the non-medical use of ADHD drugs, particularly dexamphetamine, is a significant part of WA’s problematic amphetamine culture.
The obvious question is why has the Minister chosen to ignore the facts? I believe the most likely answer is that Roger Cook doesn’t think it is worth the fight.
This is understandable. The ADHD Industry is massive, with a slick, but fundamentally dishonest, marketing machine that across the globe generated a staggering US$16.4 Billion in drug sales in 2018. (That was bigger than the GDP of 75 of the world’s 193 countries in 2018). Minister Cook possibly thinks tackling WA’s heavy prescribers of ADHD medications means taking on some very well resourced vested interests, and risks incurring the wrath of Australia’s most powerful union, the Australia Medical Association (AMA).
That it is exactly what happened 17 years ago. In 2002 Gallop Labor Government Health Minister Bob Kucera worked with me to crack down on heavy ADHD prescribers. Minister Kucera put in place the WA Stimulant Regulatory Scheme (the system that Minister Cook is now allowing to be gutted) which made heavy prescribers accountable for their actions. It resulted in some prominent ADHD specialists - most notably a paediatrician who prescribed to 2,077 children in 17 months - retiring from prescribing. At the time WA AMA President Dr Bernard Pearn-Rowe heaped praise on the heavy prescribers and didn’t hold back in his criticism of Minister Kucera.
Perhaps Minister Cook fears this will happen to him. But attitudes have changed since 2002. The media, the public, the medical profession, and even the current national leadership of the AMA seem much more open to concerns about over-diagnosis. The AMA owned journal, the MJA, has published multiple articles about problems associated with over-diagnosis and inappropriate treatment of multiple conditions, including ADHD. A recent MJA poll indicated that most medical doctors believe ADHD is over-diagnosed an over-treated.
Arguing that very heavy amphetamine prescribers, like the WA psychiatrist who prescribed to 2,074 patients in 2015, should be audited to see if they are doing the right thing is hardly a radical idea.
One of the major reforms implemented by the Gallop Government was the introduction of detailed, timely Annual Reports on amphetamine prescribing for ADHD. All through the Carpenter and Barnett Governments and until Roger Cook became Health Minister the Annual Reports were published about six months after the end of the end of the year, and they included significantly more detail. Most notably they reported patient numbers for the heaviest child and adult prescribers, and details about average dosage, and geographical differences in prescribing rates. The 2016 and 2017 reports, the first produced under Minister Cook's control, were produced 18 months after the end of the year, and was stripped of important information. It is essential this annual reporting system is reinstated with timely reporting, and future report include the missing details.
Furthermore, as detailed in my book, when it was elected in 2001 the Gallop Government inherited a amphetamine prescribing accountability committee system that was dominated by heavy prescribers. Predictably, these self-declared 'ADHD experts' concluded they and their peers were doing a great job, and needed even less regulation. Bob Kucera had the courage to disagree. He changed the composition of the committee and child prescribing rates fell sharply.
However, since my retirement from state politics, with no one watching, it appears that the Stimulant Assessment Panel has again become dominated by prescriber friendly 'ADHD experts'. Page 20 of the WA Stimulants 2015 Annual Report states “The Panel comprises nine appointed members... Six appointments are public and private sector specialist clinicians (psychiatrist, paediatrician and addiction medicine specialist), nominated by the respective professional college". The problem is that 'specialist clinicians' (i.e. ADHD specialists) inevitably self-nominate to get on committees that affect them. They almost always endorse their, and their peers prescribing practices, and promote increased 'disease awareness' and further prescribing.
This is text-book ‘regulatory capture’ and is the equivalent of the police investigating the police. As detailed in my PhD thesis nearly all prescribing regulation and treatment guidelines development processes for ADHD in Australia have been dominated by those with vested interest, particularly ADHD specialists.
The very notion of an 'ADHD specialist' is flawed. Good psychiatrists and paediatricians don't specialise in a single condition. They spend the time required to understand their individual patients, rather than hastily looking for evidence that supports their specialist diagnosis.
Minister Cook needs to explain if he thinks a psychiatrist who prescribes to 2,074 people a year is getting to know their patients before giving them a daily amphetamine habit?
Perhaps before answering Minister Cook might like to consider how much money Dr 2074 makes specialising in ADHD, and if it is fair to regard DR 2074 as Perth's biggest amphetamine supplier?
In fairness to Minister Cook being Health Minister is the hardest job in WA politics, and he has done a remarkable job for a WA Labor Health Minister in not pissing off the AMA. This is partly because Roger Cook is likeable, charming, reasonable and friendly, and being well liked and avoiding conflict can take you a long way in politics. But it doesn't change the world, it doesn't keep rogue prescribers accountable, and it doesn't protect the vulnerable.
As Deputy Premier, Roger Cook is the senior member of the influential Left faction of the McGowan Government. The Left are supposed to be radical, to challenge the powerful, and shake things up. But in the case of ADHD, Roger Cook is acting like an arch conservative, unwilling to rock the boat, too comfortable with the status quo. This is such a shame because what worked before for the Gallop Government can work again for the McGowan Government.
Minister Cook needs to stop turning a blind eye to the facts, and make Dr 2074 and Perth's other frequent amphetamine prescribers accountable. Specifically Minister Cook needs to do three things:
1- Insist on thorough audits of the prescribing practices of WA’s heavy prescribers (over 500 patients a year) of amphetamines and amphetamine like drugs.
2- Demand that detailed Annual Reports of the WA Stimulant Regulatory Scheme are published on time, like they were before he became Minister.
3- Remove from the WA Stimulants Panel that oversights prescribing, any doctor who prescribes stimulants (or other ADHD medications), to more than 100 patients a year.
Disclosure: Through our joint involvement in the WA Labor Party I (Martin Whitely) have known Roger Cook since 1996. I was a Labor Member of the Western Australian Parliament from 2001 until 2013, and from 2008 and 2013 we were parliamentary colleagues. I take no pleasure in publicly criticising a friend and former colleague. However, after more than two years of trying to work privately with Minister Cook, things have gone from bad to worse. He has the capacity, and the responsibility, to keep heavy amphetamine prescribers accountable. So far has failed to do so.
References
[1] Page 2 of Illicit Drug Trends in Western Australia: Australian School Students Alcohol and Drug Survey 2017 reported that 3% of the WA students aged 12 to 17 surveyed, had used dexamphetamine non-medically in the last 12 months.
[2] In 2017, approximately 1.2% of WA children were prescribed dexamphetamine. This estimate is calculated from data on page 26 of the WA Stimulant Regulatory Scheme 2015 Annual Report and page 7 of the Department of Health Western Australia WA Stimulant Regulatory Scheme 2017 Annual Report prepared by the Pharmaceutical Services Branch of the WA Health Department.
[3] Whitely M, Lester L, Phillimore J, Robinson S, Influence of birth month of Western Australian children on the probability of being treated for ADHD, Medical Journal of Australia, 2017. https://www.mja.com.au/journal/2017/206/2/influence-birth-month-probability-western-australian-children-being-treated-adhd
[4] The WA Stimulant Regulatory Scheme 2017 Annual Report stated on page 7 that 9,587 WA children (0 to 17) received at least one prescription of amphetamine or near amphetamine for ADHD in 2017. This number has increased from 5,580 in 2009 with most growth occurring since 2014. Commonwealth Government data indicates that rates are rapidly growing and it now very likely that well over 10,000 WA children are prescribed amphetamines and amphetamine like drugs.
[5] Australian Government Pharmaceutical Benefits Scheme Drug Utilisation Sub-Committee (DUSC) Attention Deficit Hyperactivity Disorder: Utilisation Analysis, Public Release Document, May 2018 DUSC Meeting. Figure 11 on page 24. Available at http://www.pbs.gov.au/industry/listing/participants/public-release-docs/2018-05/adhd-dusc-prd-2018-05-final.pdf (accessed 5 January 2019)
[6] Australian Institute of Health and Welfare (2017, 2014, 2011). National Drug Strategy Household Survey detailed findings for 2016 p.92, 2013 p.79 and 2010 p.132. https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-3c2079f30af3/21028a.pdf.aspx?inline=true
[7] In 2015 (the latest year for which these data are available), eight WA doctors (paediatricians and psychiatrists) prescribed to over 500 patients each. The clinician with the highest level of prescribing, a psychiatrist, prescribed to 2,074 patients, of whom 1,979 were adults (22.2% of the total WA adult cohort). The 2016 and 2017 Annual reports have not included details about the top prescribers. Department of Health, (2016), Western Australian Stimulant Regulatory Scheme 2015 Annual Report, Pharmaceutical Services Branch, Health Protection Group, Department of Health, Western Australia p 23,39 http://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/medicines%20and%20poisons/PDF/Stimulant%20Annual%20Report%202015.ashx