A mother walks into your pharmacy wanting the dispensing of long-acting methylphenidate. As a pharmacist, your heart sinks. You know the search for this medication will be long and arduous, and even if you find it, you might dispense it at a loss.
GPs share this frustration. Meanwhile, the patient suffers. It’s a complicated issue, but something is amiss. Let us tease out some root causes.
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The international pharmaceutical industry manufactures the medication, but there are numerous supply chain, production and quality control issues. The ability to manufacture a vast range of both frequently and seldom-used medications within NHS hospitals, has dwindled over the last two generations. This now even applies to the licensed hospital manufacturing units selling “specials”.
One significant downward plunge occurred when Patriot, a subsidiary of Janssen and manufacturer of a long-acting generic methylphenidate, discontinued last year. They only continued to manufacture the more expensive trade-named tablet Concerta. The payment community pharmacies receive for the product depends on an astronomically complex formula and negotiations, just one being the deal thrashed out during the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), the next negotiating duel is not for four years. It is only fair to note that it is crucial for the financial model of the pharmaceutical industry that they make a profit: only then can they plough money back into medicine research such as for Covid-19 vaccine.
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Extra and necessary regulation in the industry is connected with its controlled drug legal status. Such control is social and cultural, and it’s challenging to unpick the deeper root causes in that area.
What is today labelled attention deficit hyperactivity disorder (ADHD) was once considered just a part of the range of human behaviour, not demanding treatment. However, it has been medicalised, defined, and treated as a medical problem.
The term “medicalisation” was used in Ivan Illich’s “Medical Nemesis,” (1975). He was an Austrian polymath and sometime parish priest; he studied theology, philosophy, history, and natural science. He argued that medicalisation often impaired health in various aspects of life, including aging, death, pain, and patients’ expectations. Since then, sociologists have extensively studied medicalisation. ADHD diagnosis has ballooned internationally, not just in the UK.
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Medical practitioners (and pharmacists) are in a non-reciprocal power relationship with patients. Those professionals often hold more knowledge and authority, leading to patients deferring decisions to these perceived experts. Society authorises medical practitioners, in particular, to label people as suffering from a specific disease so they wield immense power over their patients.
In the UK, waiting lists for psychiatric consultation on the NHS are long; wealthy families often pay for earlier private confirmation. A rapidly effective treatment is pharmacological; the stimulant methylphenidate will enhance cognition: particularly important for students during the examination season.
To summarise: more public awareness of ADHD, more diagnosis, demand for methylphenidate, supply difficulty, yet more public awareness. One escape from that vicious circle may be probiotics, prebiotics, and faecal transplantation. They modulate the gut-brain axis and microbiome; recent research suggests that psychiatric disorders including ADHD are linked with an unbalanced microbiome. If dietary interventions, such as eating fermented foods (blue-veined cheese, pickled cabbage etc.), become the go-to treatment, demand for methylphenidate may plummet.
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Alternative diagnoses for ADHD may include anxiety; autism; bipolar disorder; depression; obsessive-compulsive disorder (OCD); oppositional defiant disorder; and posttraumatic stress disorder (PTSD), called “shell shock” in World War 1.
But the underlying problem may well be social, linked to poverty, poor educational facilities or social care. The UK has become economically more vulnerable; its Moody’s credit rating was a proud AAA in 2020; presently it is Aa3.
Politicians find themselves in a pickle: a corrosive one where, metaphorically, the vegetables are not merely soaked in vinegar, but marinated in glacial acetic acid. Politicians must decide whether to spend money on, for example, the NHS, schools, or further education. It is hard to be objective on a policy if your income depends on it. Should the NHS (including pharmacists) receive less but social care and education more?
So, what can individual pharmacists do? When you meet an anxious member of the public professionally, it costs nothing to be kind and empathetic. They will feel better and so, to a degree, be healed.
Dr Malcolm E. Brown is a retired community, hospital and industrial pharmacist, and is a sociologist and honorary careers mentor at the University of East Anglia.
