In 2007, state psychiatrists were up in arms about a decision by the then Western Cape Department of Health to withdraw the long-acting form of Ritalin, Ritalin LA, from the public sector as of December of that year. Psychiatrists said the decision was a major setback in the treatment of Attention Deficit Hyperactivity Disorder (ADHD).
The Western Cape Department of Health (DOH) decision was financial: the manufacturer, pharmaceutical company Novartis, unexpectedly increased the government tender price by 300%. According to a DOH spokesperson, Ritalin LA was only made available in the past as it was offered to the public sector at an almost equivalent price as the standard formulation.
Novartis said that it "regrets the decision taken by the Western Cape Department of Health".
The pharmaceutical company explained that it had provided Ritalin LA at a competitive price until now, but decided to increase their public price to bring it closer to the international price level for the product in comparable countries. There is no generic for Ritalin LA as the patent for the product only expires in 2015. A generic alternative is, however, available for the short-acting and slow-release formulations.
Ritalin LA (methylphenidate) had been available free of charge in state clinics for two years and was been regarded as a major improvement on short-acting Ritalin. State psychiatrists said that the fact that children now had to revert back to taking the short-acting preparation had major implications for children with ADHD, parents, teachers and clinicians in the public sector.
New decision 'short-sighted'
The Western Cape DOH said it didn't foresee any problems returning to Ritalin SA as it was used without any complaints in the past.
However many parents and local child health experts, as well as some of the DOH's own psychiatrists, disagreed with the DOH’s stance.
"The decision is short-sighted and was taken too lightly. Maybe Novartis is putting profit before people. Great progress was made when Ritalin LA was introduced a few years ago. It made it a lot easier for children to take their medicines. Rather than having to take it two or three times a day, they could take it once before school and this would last them throughout the school day," says a state psychiatrist who wishes to remain anonymous.
"As it works for eight hours, it helps children to be more in control of their behaviour by minimising dips associated with the older short-acting forms that wear off after four hours. It has a smoother action and there is less dumping, irritability and tearfulness with Ritalin LA than with the older short-acting Ritalin."
"We are now back where we were years ago," says Dr Adri van der Walt, a paediatrician in private practice who is also a consultant at a state special school for children with learning disabilities.
"How can you expect a child, especially one who struggles with attention and concentration difficulties, to remember to take his medication? One of the side-effects of Ritalin is that it suppresses appetite. Children therefore often skip a mid-morning snack and would then have no reminder to take their medication. It is a schedule 6 drug which is dangerous to be included in a child's lunchbox anyway. Some children don't understand why they are on medication and hand out tablets to friends."
A parent of a child who had taken Ritalin LA for the past two years agreed.
"My child could not even remember to take his school bag to school and continually lost things. It would be impossible to leave the responsibility to take medication up to him. It just wouldn't happen. Not even small children without ADHD have the ability to think systematically and to remember to take medication at prescribed times."
One of the senior officials of the Directorate: Specialised Education Support of the Western Cape Education Department said it wasn't aware that Ritalin LA had been withdrawn and that it had not been consulted in the decision-making process.
"The resulting problems with concentration, impulsivity and hyperactivity during the second half of the school day will impact negatively on learners’ performance, impede peer relationships and place a huge burden on teachers who are already struggling to cope with large classes," she said.
"The only way to make sure that children continue to receive their mid-morning dose is if teachers administer the medication. A written contract would have to be drawn up between parents and schools. There will be additional administration of signing medication in, daily recording of whether Ritalin was administered and careful monitoring of the medication and its effects."
It would also mean that teachers would have to leave the classroom to fetch the medication from a locked cupboard or a safe.
State psychiatrists were also concerned that some teachers don't agree that children with ADHD should be medicated and might therefore refuse to administer medication.
The stigma of 'mal pille'
Another concern parents pointed out, was that children on psychiatric medication are often ridiculed that they are on 'mal pille' (crazy pills). As one parent said: “The chances are great that especially older children would simply stop taking medication because they don't want their peers to know that they are on medication in order to concentrate.
"Who is going to monitor that children take their tablets? If children are being lined up during breaktime by teachers to receive their medication, it will be very obvious to other children. The fact that children with ADHD will be unmedicated from 11am would also result in chaos in schools."
Still many myths about Ritalin
"There are still many myths about Ritalin," said one state psychiatrist. "One such myth is that Ritalin is the same as the street drug tik because it also acts on dopamine receptors. The action in the brain is completely different. Ritalin results in a minor and slow release of dopamine and not in a sudden rush as with tik. It is also important to stress that Ritalin is not addictive. Research has shown over and over that Ritalin in fact reduces the risk of substance abuse."
Special schools for children with learning disabilities have medical staff who are qualified to administer medication. They are, however, faced with other challenges.
"Medical personnel at these schools are already overburdened. According to international figures, three to seven percent of children in mainstream schools have ADHD. This increases to 40% in special schools. The Western Cape has a particularly high incidence of ADHD because we have the highest number of children with foetal alcohol syndrome in the country. 60-70% of children with foetal alcohol syndrome also have ADHD and learning problems," says Dr Van der Walt.
Decision could be reversed
The DOH said it would reconsider its decision if Novartis were to lower their tender price.
"All is not lost," said Mr Noel Guliwe, President of Novartis South Africa. "There is always an opportunity to provide medication at a better price."
He said his company would continue negotiating with the DOH and would consider applying to the national tender authorities to resubmit an alternative tender.
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