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Development of the Nurse Prescriber role, Adult ADHD

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A Workshop …

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.

Published in: Health & Medicine

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  • 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….
  • 3. 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
  • 4. 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
  • 5. 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’
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. Medication for ADHD provides: a window of opportunity a window of opportunity an environmentan environment a platform a platform
  • 12. How can we optimize effect? • Psycho-education • Lifestyle management • Emotion and mood
  • 13. 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
  • 14. 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
  • 15. 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)
  • 16. 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
  • 17. 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
  • 18. 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)
  • 19. 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?
  • 20. 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?