Is Methylphenidate actually being overused in Sweden?

In this article, I argue that the reasoning on and evidence for, overuse of Methylphenidate in Sweden is flawed and seems to be a biased and more politically motivated propaganda, than science.

Overuse of methylphenidate: an analysis of swedish pharmacy dispensing data

Bjerkeli, P. J., Vicente, R. P., Mulinari, S., Johnell, K., & Merlo, J. (2018).Clinical Epidemiology Dovepress Overuse of methylphenidate: an analysis of swedish pharmacy dispensing data.Clinical Epidemiology, 10–1657.
https://doi.org/10.2147/CLEP.S178638

Summary

This article dismantles the publication from Bjerkeli et al., 2018 and argues that they proposed conclusion of 7,6% overuse of Methylphenidate in Sweden, is not caused by patients overusing or reselling their Methylphenidate, but because the Swedish Health Services do not have any grip on their prescription management, and that the Swedish Maximum Recommended Daily Dose of Methylphenidate, is 50% less, than it is in Denmark, causing the consumption to seem higher than guidelines recommends.

Introduction

In this new study on the overuse of Methylphenidate from the Pernilla J. Bjerkeli from the Department for Biomedicine and Public health research, school of health and Education, University of Skövde, Skövde, Sweden, it is stated that 7.6% of Methylphenidate use in Sweden is consumed as so-called ‘overuse consumption’.

As I was reading this new study, it dawned on me that this might not be so evident that all the Methylphenidate that was (mis)used in Sweden, was actually coming from people with ADHD who sold their drugs illegally to others.


The reference that supports Bjerkeli et al., 2018, is largely based on a report from the Swedish Board of Health and Welfare (Socialstyrelsen) and since it is important to understand the full context for Bjerkeli et al.’s arguments, I have taken some time to explain it in more detail, for you to have the full context.

Excerpt from the conclusion from the article:

[…]Among individuals using methylphenidate in Sweden, 7.6% receive amounts that are larger than what they should have a medical need for, assuming that they were using the maximum recommended daily dose 365 days per year. Notably, the prevalence of overuse was associated with previous diagnosis of alcohol and drug misuse. The prevalence was also positively associated with higher age and previous use of ADHD medication. These findings may point toward a link between exposure time and overuse. However, future studies with long-term data are needed to investigate this.[…] [Bjerkeli et al., 2018]

This is the conclusion from the abstract, so let us see what lies beneath this statement.

[…]The Swedish National Board of Health and Welfare recently published a report concluding that a majority of the methylphenidate confiscated by Swedish police was originally sold in Sweden via the regular pharmaceutical distribution chain.[…] [Bjerkeli et al., 2018]

This report is based on assumptions which the report itself cannot even document. See full explanation further down.

[…]The study sample included 56,922 individuals aged 6–79 years, who had filled at least one prescription of methylphenidate in Sweden between 2010 and 2011. Among these, 4,304 (7.6%) filled prescriptions representing above 150% coverage. These were categorized as overusers[…][Bjerkeli et al., 2018]

In Sweden the Maximum Recommend Daily Dose (MRDD) of Methylphenidate is 80mg/day, but in the EU in general we follow the NICE Guidelines which states that MRDD is 100mg/day (Adults). In Denmark the National Health Services (Sundhedsstyrelsen) have set the limit at 150mg/day but also state that some people may require more than 150mg/day for therapeutic effect.

Even though the limits for MRDD are almost 2x higher in Denmark, the average MRDD taken as an average of all adult use of Methylphenidate from 2013-2017 is at 50mg/day, three times less than the MRDD. [ADDspeaker, 2019].

So this make me wonder if the Swedish patients may be getting closer to the MRDD than those I’ve analysed in Denmark? I believe that it is the case, and I base this on the fact that 80mg/day x 200% (overuse) is 160mg/day or the MRDD in Denmark. This doesn’t give any credence to a massiv overuse in Sweden, as proposed by Bjerkeli et al., 2018.

[…]In the study population, 22.3% (n=12,678) received a prescription of methylphenidate without having a diagnosis of ADHD registered during the study period or the previous 5 years.[…][Bjerkeli et al., 2018]

[…]A total of 32.0% (n=18,238) did not visit a clinic likely to work with ADHD (as defined in the “Materials and methods” section), and 18.6% (n=10,613) had not visited any in- or outpatient care facility during the study period[…][Bjerkeli et al., 2018]

OK, these are clearly a matter of central management of prescription data, and cannot be put on the patients, at all.

[…]Overuse was more common among those who had a registered ADHD diagnosis than among those who did not[…][Bjerkeli et al., 2018]

[…]The prevalence of overuse was also higher among individuals with previous diagnoses of mental and behavioral disorders due to psychoactive substance use than among those without[…][Bjerkeli et al., 2018]

That is highly likely, as 20-30% of all patients with ADHD, suffers from some form of addiction, beside their ADHD.

[…]Our results show that methylphenidate is prescribed to
certain individuals in amounts that are not in concordance
with current guidelines
[…][Bjerkeli et al., 2018]

This seems to be correct, but that is to blame on the GPs, Vårdcentral and Psychiatric Services and poor internal communication, not on the patients!

[…]Among individuals who filled prescriptions of methylphenidate, 7.6% filled prescriptions that represented above 150% of what they should need, assuming that the medication was prescribed according to maximum recommended dosage instructions[…][Bjerkeli et al., 2018]

[…]Similarly, 3.4% filled prescriptions representing above 200% of what they should need.[…][Bjerkeli et al., 2018]

And? Perhaps those 7,6% are those who do not have any efficacy at 80mg/day but must have more to treat their baseline symptoms. ADHD is a biological disorder, not a behavioural or personality disorder, and the fact the different biological entities react differently to various dosages are nothing unique or related to ADHD medication.

[…]Among individuals with a previous diagnosis of mental and behavioral disorders due to psychoactive substance use, 11.3% had coverage of 200% or more. The prevalence of overuse increased with increasing age.[…][Bjerkeli et al., 2018]

See, this is something which is valuable information, maybe the effort should be on helping these 11,3% with their addiction, instead of stigmatising the 88,7% that use the medication that their doctor have prescribed for their biologic, chronic and life-long mental disorder?

The Swedish National Board of Health and Welfare recently published a report concluding that a majority of the methylphenidate confiscated by Swedish police was originally sold in Sweden via the regular pharmaceutical distribution chain. [28]

Bjerkeli et al., 2018

Reference 28

Swedish Board of Health and Welfare. Felanvändning av metylfenidat: En undersökning om avledning och sidoförskrivning. [Misuse of methyl-phenidate: a study of diversion and lateral prescribing]. 2018.
Available from: http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/20798/2018-1-2.pdf. Accessed February 22, 2019. Swedish.

I began reading through the referenced material from the study and it leans heavily on a document from the Swedish Board of Health and Welfare, which states that;

[…]Diversion and side prescription: The term diversion as is used to describe different paths away from the regular drug handling, where leakage from patients is a cause, and other possible causes are theft in the distribution chain or from health care and prescription fraud. With the concept of side prescription, of course, such prescription is done by other prescriber than the main prescriber, i.e. the treating doctor. In this report, workplace codes in the pharmaceutical register have been used to distinguish the prescribers. […] [Swedish Board of Health and Welfare, 2018]

So the Swedish Board of Health and Welfare (Socialstyrelsen) states that the key issue is prescription fraud, not overuse of Methylphenidate. And as you can see in the following, they argue that 21 percent of the illegal drugs seized, can be traced back to the Swedish pharmacies, whereas 79% is of unknown origin.

[…]Of the total number of tablets/capsules, slightly more than 2,000 tablets/capsules possible to trace, which corresponds to about 21 percent of the seized volume.[…][Swedish Board of Health and Welfare, 2018]

They then make the assumption that all usage of Methylphenidate in Sweden is following this trend is likely to be due to the drug being sold in other countries and sold illegally in Sweden.

[…]The analysis is based on the assumption that the traceable fittings reflect the total seizures since only a small proportion (one fifth) of the seized tablets/capsules could be derived from their original sales country.[…][Swedish Board of Health and Welfare, 2018]

With that established, they go on to investigate the origin of the prescriptions and it is revealed that they real key issue is that some patients are able to get the prescription from both their own doctor (GP) as well as from their local health clinic (Vårdcentral), and that the coordination between these institutions are not properly monitored.

[…]The National Board of Health and Welfare has previously stated that there is so-called side-prescription of various drug-classified drugs among adults using methylphenidate [1]. Such side prescription means that the drugs classified drugs are prescribed by independent clinics, that is, the drugs are prescribed alongside and in addition to the actual prescription of methylphenidate. A prescribing doctor at a clinic is thus unaware of other doctors’ prescriptions at other clinics. It is important that prescribing physicians pay attention to possible misuse, in the form of eg self-medication or abuse, of methylphenidate and other drug-classified drugs.[…][Swedish Board of Health and Welfare, 2018]

The next they state is that 29,000 have had 3 or more withdrawals of Methylphenidate in 2015, exclusively prescribed at the psychiatric clinics

[…]About 29,000 people, aged 19 and over, had at least three withdrawals of methylphenidate in 2015. The drug was prescribed exclusively at psychiatric clinics, which is to be expected from the fact that the drug is prescribed by adult psychiatrist specialists when it comes to adults.[Swedish Board of Health and Welfare, 2018]

They then state that 30% of those who were prescribed Methylphenidate from their psychiatrist, also have had at least 3 withdrawals of other drug-classified drugs, such as benzodiazepines or opioids.

[…]Also, among those who had prescribed methylphenidate, about 30 percent also had at least three withdrawals from another drug-classified drug, such as benzodiazepines or opioids.[…] [Swedish Board of Health and Welfare, 2018]

Now it get even weirder as they begin to speculate that ‘several people’ (wonder how many they mean?) had had both Methylphenidate prescribed from their psychiatrist as well as drug-classified drugs from their (GP or Vårdcentral).

[…]Several people also had several different types of drugs classified at the same time prescribed. In contrast to methylphenidate, which was thus prescribed only at psychiatric clinics, drug-classified drugs were extensively prescribed in health centers (GPs).[…][Swedish Board of Health and Welfare, 2018]

So to sum up. Socialstyrelsen assumes that because a patient is prescribed Methylphenidate for their ADHD from their psychiatrist and also gets a sleep-aid medication or pain-reduction medication, they are apparently suspects for something illegal … ?

They then go on concluding that;

  1. The police do seize 0.0002% of the 34,000,000 tablets/capsules of Methylphenidate that is legally prescribed in Sweden, an though they acknowledge that it is “a disappearing small part of the total prescription” they still see this as an “indicator of an increased diversion of the drug out to an illegal market“.
  2. Then they grasp something out of thin air with the statement “The results indicate that the introduction of methylphenidate from other countries is very rare“. That doesn’t make any sense whatsoever, since they have just stated that 79% of the seized Methylphenidate could NOT be traced back to the Swedish pharmacy sales, but was assumed to be illegally imported from outside Sweden?
  3. The worst part is that they propose that; “Based on the results of this report, the National Board of Health and Welfare wants to pay attention to the profession on the occurrence of misuse of methylphenidate, in combination with other drug-classified drugs.“. This is pretty troubling to read, since the report is flawed and full of contradictions in the information provided, and if it is used to make policy decision upon, it is going to be based on biased perceptions, not scientific evidence.
  4. The report then go on to conclude that there is a need for a centrally managed system for prescriptions, to limit the risk of misuse through diversion or side prescriptions. Aha, so the aim of the report is to gather political support for financing a new centrally presciption management system?

Well that sounds great, but why did they have to stigmatise patients who seek medical help for their mental disorder and make up some non-sense about patients with ADHD who swindle the prescription system to gain access to more Methylphenidate than they need for therapeutical consumption, with the goal of selling them as illegal drugs for financial gain.

When the seize amount of Methylphenidate that could be traced back to this kind of behavior in just 0.0002% of all Methylphenidate used, I believe that this is stigmatising a whole group of people, wrongfully, just because they wish to obtain money to make a centralised prescription system in Sweden.

Then what about the overuse then?

Well, as far as I can see, there doesn’t seem to be any problems in the Swedish consumption, but in the prescription management system instead. I can’t help having the notion that maybe Bjerkeli et al., 2018, may have been out to promote an agenda, more than providing scientific evidence, just as we know from Denmark with Storebø et al., and their propaganda work against Methylphenidate. Funny how Bjerkeli et al., cites not just 1, but 2 of Storebø’s Cochrane Reviews, both with the intend of giving Methylphenidate a bad reputation.

I stand to be corrected, so please comment, if you feel I’ve made errors here.

/ADDspeaker


References

Excerpts from : Swedish Board of Health and Welfare. Felanvändning av metylfenidat: En undersökning om avledning och sidoförskrivning. [Misuse of methylphenidate: a study of diversion and lateral prescribing]. 2018.
Available from: http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/20798/2018-1-2.pdf. Accessed February 22, 2019. Swedish.

[…]The seizures that the police do are, in terms of quantity, a disappearing small part of the total prescription of methylphenidate (about 7,000 compared to 34 million tablets / capsules). However, the increased seizure amounts can be seen as an indicator of an increased diversion of the drug out to an illegal market. The results indicate that the introduction of methylphenidate from other countries is very rare. In all essentials, methylphenidate originates in the illegal market from prescribing in Swedish health care. Based on the results of this report, the National Board of Health and Welfare wants to pay attention to the profession on the occurrence of misuse of methylphenidate, in combination with other drug-classified drugs. In cases where people have several drug-classified drugs prescribed by several different health centers, in addition to simultaneous prescription of methylphenidate, there is an obvious risk that this constitutes an aspect of misuse of methylphenidate. Such misuse constitutes a patient safety risk, as there may be a risk of overdose or serious side effects. Furthermore, the National Board of Health and Welfare wants to pay attention to the number of prescribers of different combinations of methylphenidate and other drug-classified drugs, which to a not insignificant part is done through several independent authors. One factor that is of ten mentioned in connection with possible misuse of drugs is the lack of opportunities for the prescribers to get an overall picture of a patient’s drug treatment. It is against this background that the work of developing a so-called national drug list should be seen [8]. A national drug list must provide a correct and up-to-date picture of the patient’s medication, regardless of where in the country it has retrieved its medicines. It is also important that the healthcare system has established procedures for evaluating the use of drug treatment regarding effects and risks, with regular positions on the need for continued treatment, as well as that prescribing takes place under strictly controlled forms, in order to minimize the risk misuse. At the same time, it is worth emphasizing that the medicine in question, correctly used and by the right person, as a rule is of decisive importance for his or her quality of life. Problems with leakage and side prescription must, of course, be addressed, though not at the expense of the treatment form as such.[…]

This site uses Akismet to reduce spam. Learn how your comment data is processed.