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General practitioners have been increasingly made the gatekeepers of ADHD stimulant medications, a role normally meant for specialists. Though GPs are used to managing several chronic conditions, the unique risks associated with stimulant medications-those being misuse and dependency-demand special expertise in neuropharmacology and management of mental health. This shift raises ethical and clinical dilemmas, as many GPs feel unprepared for stimulant prescribing without specialist support.Stimulant medications in adults are particularly concerning, as they are controlled substances with high abuse potential. GPs effectively need to balance symptom relief with their ethical responsibility regarding the potential for misuse. This adds to the already high workload through the need for monitoring for adverse effects, adjusting dosages, and trying to recognise signs of misuse. It is a delicate juggling act that often leaves GPs feeling unsupported and exposed to future risks in a health system offering minimal specialist guidance or structured protocols for long-term ADHD management.The major challenges faced by GPs include a lack of specialist training in neurodevelopmental disorders and the prescribing of sVmulants. In a UK pilot randomised controlled trial involving 109 general pracVVoners, a brief web-based ADHD awareness training significantly improved parVcipants' knowledge and confidence scores, and reduced misconcepVons, with gains sustained at two-week follow-up. 5 Treatment for ADHD needs to be highly individualised, involving VtraVon of medicaVons, monitoring of side effects, and management of comorbidiVes, such as anxiety and depression. However, most general pracVVoners have scant training in these domains during medical educaVon and professional development. 6 Whereas psychiatrists and neurologists have specific, intensive training in the management of ADHD, GPs are usually trained to have knowledge that is more superficial but covers a wider range of condiVons. Frequent medicaVon adjustments require precision that many GPs may not have the training to manage. This issue is furthered by a lack of clear, accessible guidelines for the GP regarding long-term management of ADHD. The pressure of managing cases effecVvely with a lack of sufficient training increases the likelihood that doctors in general pracVce may become overwhelmed and perhaps make criVcal mistakes in the care of their paVents. This shi` in management has resulted in general pracVVoners increasingly being posiVoned as the primary prescribers of sVmulant medicaVons.In addiVon to training gaps and structural limitaVons, GPs face professional, ethical, and legal pressures in their daily pracVce. A major issue in ADHD management is the blame GPs face for poor sVmulant prescribing outcomes. GPs must balance the benefits of sVmulants with their potenVal harms, o`en without adequate support. 7 With sVmulants being controlled drugs, there is always the potenVal for abuse, dependence, or diversion, which may leave GPs vulnerable to professional and legal consequences of pracVce. This concern is heightened by a lack of specialist support and clear guidelines on long-term management of ADHD. Shared care arrangements o`en leave GPs solely responsible once paVents are deemed "stable". However, stability in ADHD can be a bit transient, and the needs of the paVents may alter very fast.ParVcularly, GPs fear that in cases of a paVent misusing their medicaVon or developing dependency, they will be held responsible for failing to idenVfy these signs early enough when they actually lack the resources or training to do so. GPs also fear retrospecVve blame, which can strain doctor-paVent relaVonships. GPs may tend to be overcauVous while prescribing, delay the necessary treatment, or under-prescribe sVmulants due to fear of possible legal or regulatory acVon. This trepidaVon leaves the paVents under-treated, thus opening up another set of risks. Without becer legal protecVon and clearer protocols, this fear will always overhang ADHD care in primary sedngs and might affect the outcomes for both the paVents and general pracVVoners themselves. 8A growing body of concern suggests that the trajectory of sVmulant use may mirror past public health crises, most notably the opioid epidemic. The uncomfortably familiar trend in sVmulant prescribing for ADHD echoes the early years of the opioid epidemic. Both are medical treatments that, while clinically beneficial, are fraught with considerable risks for misuse, dependency, and long-term harm. In the case of the sVmulants methylphenidate and lisdexamfetamine, addicVve potenVal is well-noted, but there remains an emphasis on only efficacy in symptom management for ADHD in the short run. Without safeguards, we risk a future public health crisis. 8 Patients often feel caught in this system too with very long waiting times for assessment in specialist NHS clinics (often three years or more). This concern is compounded by the pressures placed on GPs to manage these medications in complex cases. Stimulants carry a high risk of psychological dependence, especially among vulnerable populations, including adults with undiagnosed ADHD or co-occurring psychiatric conditions. 8 Beyond psychological dependence, the risks of diversion and community-level misuse are also significant. Apart from dependence, there is also a risk for diversion and misuse of stimulants, a controlled substance. Patients may begin using medications in higher doses than prescribed, or these medications can be sold to or shared with other individuals, furthering the risk for societal public health problems. 9 Despite these risks, the lack of adequate monitoring and follow-up mechanisms leaves GPs managing complex patients without the systems in place to pick up early signs of misuse.As demand for stimulant medication rises, these risks may become more deeply embedded in routine prescribing practices. As more patients seek stimulant medication-either for symptoms related to genuine ADHD or as cognitive enhancers-the health system risks normalising long-term stimulant use. 10 This is what happened with the opioid crisis: that started with an effort to treat legitimate conditions and spiralled into widespread misuse. The key to success is early recognition of potential harm. In the absence of stronger regulation, enhanced training, and better monitoring systems, the unrestrained increase in stimulant prescribing could again lead to a new wave of addiction and public health consequences that might have been avoidable.To address these growing challenges, a series of practical and innovative strategies must be considered to support GPs and mitigate the risks associated with stimulant prescribing. 11 Integrating Clinical Decision Support Systems (CDSS) into GP practices could provide real-time guidance. AI-driven CDSSs could provide GPs with specific evidence-based recommendations on ADHD management, such as dosage adjustments, potential drug interactions, and alerts for suspicious misuse. Integrating these systems into EHRs would reduce cognitive load and prescribing errors.A complementary solution involves strengthening external monitoring and support systems. Another innovative idea is setting up regional pharmacovigilance teams focused on ADHD medication management. These would include teams of pharmacists, ADHD specialists, and GPs responsible for monitoring prescription trends and taking requisite interventions. A teambased model would ease GP burden and catch misuse early. On the patient side, formalising expectations and responsibilities can enhance adherence and safety.Enhancing training in ADHD care is a pivotal step towards safer more equitable care in general practice. In addition to structural innovations, there is an imperative to develop nationally standardised, general practice-focused training programmes. This might involve modular online education through e-Learning for Healthcare or RCGP Learning, centered in core topics such as titration of stimulants, detection and treatment of side effects, detection of diversion or misuse, and treatment of common co-morbidities such as anxiety or drug use. In order to maximise clinical applicability, these modules would need to be case-based, updated periodically by specialists in ADHD, with embedded knowledge checks to assess understanding. Simulation-based prescribing workshops might also be integrated into protected learning time (PLT) sessions, allowing GPs to practice challenging ADHD consultations in a protected learning setting (Table 1).Local induction procedures and formal mentorship would also help to address gaps in confidence and knowledge. Shared care responsibilities undertaken by GPs might have to undergo consultant-led inductions in medication guidelines, long-term care plans, and ethics. The development of regional ADHD mentorship groups-involving GPwERs (GPs with extended roles), ADHD nurse specialists, and child or adult psychiatrists-would facilitate case-based discussions during scheduled meetings as well as asynchronous advice channels. Such arrangements would minimize clinical isolation and facilitate evidence-based prescribing in various settings. ADHD, along with other neurodevelopmental disorders, would also be included in the vocational training scheme (VTS) education to ensure that subsequent generations of GPs are adequately trained to address increasing ADHD-related demand.To assist mid-career GPs and practice teams, accredited continuing professional development pathways might be implemented-offering optional modules in ADHD certification as part of overall mental health education portfolios. They would have the dual role of formal recognition upon completion of upskilling as well as providing an incentive to become an ADHD specialist in general practice settings. Last but not least, partnerships with higher education institutes and ICS-level educational teams would underpin research-linked training pilots to facilitate evidence development in terms of optimal formats of ADHD education in general practice. Enhancing such training infrastructure would not just enhance clinical quality but also decrease variability as well as mitigate medicolegal risk in such a high-demand clinical area.To support GPs further, patient contracts could be considered: formal agreements with patients around responsibility in using medications for ADHD and adherence. 12 Coupled with digital tools for adherence, such as smart pill dispensers or mobile applications that track medication use in real time, GPs would be well positioned to monitor this behaviour rather than having to rely on patient self-report. Such technologies would immediately alert the GPs to anomalies and ensure immediate intervention.Periodic reassessment and deprescribing strategies can also help reduce long-term risks. Similarly, a structured framework for stimulant deprescribing could be supplied, which includes periodic reassessments for the need of stimulants in the long run. 13 A structured deprescribing framework would guide GPs in reducing long-term stimulant use when appropriate, minimising dependency risks. The suggested framework would be similar to how deprescribing has been well implemented in polypharmacy amongst elderly patients and would put GPs in control of long-term medicines more frequently.Embedding specialised professionals within GP practices can enable a broader model of care. Another significant suggestion is the embedding of behavioural health specialists within GP practices. These could be the professionals who will lead such non-pharmacological interventions as CBT and lifestyle counselling, and this can be done by clinical psychologists or ADHD nurse practitioners. This interdisciplinary model ensures GPs can focus on prescribing while specialists provide holistic care.A national system for tracking prescribing and outcomes could enhance oversight and consistency. Setting up a national ADHD register is another plausible line of approach whereby prescription practices and patient outcomes across every level of care are under scrutiny. This would form a centralised system where GPs would access the patient's full medication history-a help in identifying potential red flags for misuse or doctor shopping. Second, the registry will provide feedback tools to GPs, enabling them to compare their prescribing practices against national benchmarks and influence change where necessary.Exploring non-stimulant treatment options can offer safer alternatives for certain patients. Innovative pilot programs could investigate the utilisation of non-stimulant first-line treatments of ADHD and provide more options to GPs where the use of stimulants is risky. Complementary programs funding, such as mindfulness-based therapies or neurofeedback, would offer another direction away from stimulant medications as a major approached treatment for ADHD, hence reducing dependency risks.Finally, redesigning the structure of consultations may give GPs the time they need to manage ADHD effectively. Adaptive appointment models have the potential to support GPs in managing complex ADHD cases. Extended consultations or follow-up appointments staggered over time would give GPs the time to provide proper care, and not overrun their lists of patients.In conclusion, the model of care concerning the management of ADHD in general pracVce presents significant challenges to GPs. Limited training, high prescribing risks, and inadequate support leave GPs in a precarious posiVon amid an escalaVng public health concern. InnovaVve iniVaVves such as CDSS, regional pharmacovigilance teams, paVent contracts, and non-sVmulant alternaVves should, therefore, be complemented with more robust monitoring systems and relevant legal protecVons that assist GPs in providing safe and effecVve ADHD care. A mulVdisciplinary approach is essenVal to prevent sVmulant misuse and support GPs.