Changes to psychostimulant medicines prescribing: what this means for primary care

Psychostimulant medicines for ADHD: prescribing changes

From 1^st February, 2026, a wider range of healthcare professionals can initiate treatment with psychostimulant medicines, i.e. methylphenidate, lisdexamfetamine and dexamfetamine, for adults with attention-deficit/hyperactivity disorder (ADHD) without the written recommendation of a psychiatrist or paediatrician (Table 1).¹ These changes to the Pharmaceutical Schedule and prescribing rules have occurred after consultation from Pharmac and Medsafe with the sector.

From 1^st February, 2026:¹

• Vocationally registered general practitioners and nurse practitioners working in their area of practice can initiate psychostimulant medicines for patients aged 18 years and over with ADHD
• Nurse practitioners working within their area of practice of paediatric services or child and adolescent mental health services can initiate psychostimulant medicines for patients aged 17 years and under with ADHD
• Vocationally registered psychiatrists and paediatricians will continue to be able to initiate psychostimulant medicines for any patient
• Medical practitioners and nurse practitioners can continue psychostimulant medicines for any patient with ADHD if they have written approval from one of the authorised prescribers (mentioned above)

The written recommendation for the treatment of ADHD allows methylphenidate, lisdexamfetamine and dexamfetamine to be prescribed interchangeably, where clinically appropriate, e.g. if there is a supply issue affecting the psychostimulant medicine the patient was initially prescribed, as long as the recommendation does not include any restrictions.¹

Table 1. Authorised prescribers of psychostimulant medicines from 1^st February, 2026.^{1, 2}

* Initiation of prescribing means to diagnose a patient, either personally or in collaboration with a multi-disciplinary team, as having a specified condition and to personally prescribe or provide a written recommendation to another prescriber to prescribe, methylphenidate, dexamfetamine or lisdexamfetamine for the treatment of that condition

For further information on the prescribing rules for psychostimulant medicines, see: Restriction on the Supply of Dexamfetamine, Lisdexamfetamine, and Methylphenidate—Approval to Prescribe, Supply and Administer

These changes will take time to implement in primary care

The decision for primary care prescribers to initiate psychostimulant medicines for patients aged 18 years and over with ADHD in the community is voluntary. It is not a regulatory requirement to have specific training in ADHD diagnosis and management before prescribing psychostimulant medicines. However, it is expected that primary care clinicians who choose to prescribe these medicines will have a special interest in ADHD and have competence and confidence in ADHD care. Training courses in ADHD management are available; however, clinicians will typically need to self-fund their attendance.

It is likely that many practices will not currently have the resources or expertise to offer ADHD diagnosis and management for patients, but this may be introduced over time. Practices will need to develop strategies and protocols for structuring and costing appointments for this.

Prescribing psychostimulant medicines in primary care^* will typically occur in the following scenarios:

• Initiating psychostimulant medicines after making a diagnosis of ADHD in an adult patient
• Initiating psychostimulant medicines in an adult patient who has received a diagnosis of ADHD from another health professional, e.g. a psychologist, psychiatrist, another general practitioner or nurse practitioner
• Restarting psychostimulant medicines in an adult patient with a historical diagnosis of ADHD, who has previously trialled psychostimulant medicines
• Continuing a prescription for a patient with ADHD who has been initiated on a psychostimulant medicine by another prescriber

* See Table 1 for guidance on the authorised prescribers of psychostimulant medicines

Psychostimulant treatment of ADHD in primary care

Methylphenidate, lisdexamfetamine^* or dexamfetamine (unapproved indication) are all recommended as first-line treatment options for adults with ADHD who have symptoms that significantly impact their daily lives, e.g. family life, education, employment.³ Several formulations of these medicines are available (Table 2) and funded with Special Authority approval (see: “Special Authorities for psychostimulant medicines”). They have different release mechanisms and pharmacokinetic profiles, and are not all considered interchangeable (see: “Switching regimens if a preferred medicine is not available”).⁴ There is also substantial inter-person variability in treatment response and adverse effects.⁴ Understanding of these factors is critical for safe and effective prescribing.

* Special Authority criteria for lisdexamfetamine require the patient to have previously trialled atomoxetine, methylphenidate or dexamfetamine, be unable to access other psychostimulant medicine due to supply issues or the prescriber has concerns regarding diversion or abuse of immediate-release medicines

Prescribers should refer to the New Zealand Formulary, local HealthPathways, New Zealand Clinical Principles Framework for Attention Deficit Hyperactivity Disorder and international clinical guidelines for information on the pharmacological management of adults patients with ADHD:

• Australian Evidence-Based Clinical Practice Guideline for ADHD (2022). These guidelines have been endorsed by the Royal Australian and New Zealand College of Psychiatrists, and the Royal Australasian College of Physicians.
• NICE guidelines (2018; updated 2019)
• Canadian ADHD Practice Guidelines (2020)

Discussion with a psychiatrist is recommended if there are any queries or concerns prior to initiation of psychostimulant medicines. Primary care clinicians should have a low threshold for consulting with a psychiatrist if initiating psychostimulant medicines in patients with concomitant mental health conditions, e.g. schizophrenia or bipolar disorder, personality disorders, eating disorders, post-traumatic stress disorder, or substance misuse. Patients with complex needs or high-risk clinical features should not be managed in primary care; referral to psychiatric services is recommended.⁵

Table 2. Overview of funded psychostimulant medicines for managing ADHD in adults and children aged six years and over as of 1^st February, 2026.^8–16 N.B. This table is based on information contained within New Zealand medicine data sheets for these products and is intended as a guide; onset and duration of action for specific medicines may differ due to inter-person variability and other factors.

Switching regimens if a preferred medicine is not available

Due to differences in pharmacokinetics between formulations of methylphenidate, along with inter-person variability in response, clinicians are generally advised to specify the brand of methylphenidate when prescribing to avoid patients experiencing insufficient treatment response or adverse effects due to unnecessary brand changes. However, recent global supply issues have meant that switching between brands is often necessary; therefore, the advice has been updated to consider prescribing immediate-release methylphenidate generically where appropriate to make this process easier.⁸ Modified-release methylphenidate preparations must still be prescribed by brand.⁸

For further information on bioequivalence and switching brands, see: A reminder: generic medicines, bioequivalence and switchability (Medsafe)

General principles for switching psychostimulant formulations

Caution is recommended when switching patients to a different brand of medicine in any clinical situation.¹⁸ Advice for switching between psychostimulant medicine formulations in patients with ADHD is largely based on expert clinical opinion. Key considerations include:

• Establish a baseline for symptoms and daily functioning to guide dose titration for the new formulation.¹⁹ Validated symptom questionnaires (diagnostic/screening tools) can be used to assess symptoms and measure improvement and treatment response, e.g. Adult ADHD Self-Report Scale.²⁰ Re-evaluation for substance misuse or diversion may also be appropriate.
• Check the patient’s medical history to see if they have previously trialled other brands of methylphenidate or amfetamines, and if so, how they responded. Brands (or medicines) that previously resulted in a good treatment response and were well tolerated should be the first choice when switching.
• Ideally, select another brand that is most similar to the current medicine, (e.g. if prescribed the extended-release methylphenidate, Concerta, choose another extended-release brand, i.e. Methylphenidate Sandoz XR or Methylphenidate ER – Teva; see Table 2). However, be aware that some patients may not respond/experience the same effect even with a similar brand; close monitoring and regular follow-up is required.
• Theoretically, all brands of methylphenidate have daily dose equivalence, i.e. 20 mg of immediate-release methylphenidate taken in divided doses is equivalent to 20 mg of sustained release methylphenidate. However, a new brand is often started at a reduced dose, to evaluate treatment response before titrating back up. If switching from an immediate-release to a longer-acting formulation, calculate the total daily dose and delivery over a similar duration, e.g. a patient prescribed 10 mg immediate-release methylphenidate to be taken in the morning and early afternoon could be switched to a once daily 20 mg dose of a modified-release formulation, e.g. Rubifen SR or Ritalin LA.
  • If switching from a modified-release (or prodrug) formulation to divided doses of an immediate-release formulation, warn patients that they may experience variations in symptom control because of peaks and troughs in plasma levels caused by repeated dosing
• Close monitoring is required whenever a patient is switched to a different psychostimulant medicine (brand or formulation type).⁴ Evaluate treatment response and adverse effects, e.g. appetite suppression, mood swings and sleep disturbance, one to two weeks after any change in formulation or dose.
• Consider dosing adjustments before switching again. Confirm that any new adverse effects are not related to the duration of action, e.g. the patient is experiencing insomnia because the duration of action is too long (or too short, i.e. the patient cannot “shut off” their brain before bed), or low mood and irritability due to a rapid reduction in plasma level (rebound effect). Adjust the dosing schedule if required.
• Trial a second alternative within the same class before switching to a different medicine if the patient does not respond/tolerate the first formulation, e.g. trial two brands of methylphenidate before switching to an amfetamine, or trial both types of amfetamine before switching to a methylphenidate formulation.

Best Practice Tip: Contact the patient’s preferred pharmacy before prescribing a different brand, formulation type or medicine to confirm what stock is currently available, and work with your local pharmacies to establish the best way of staying informed about their stock levels. Latest information on supply issues is also available on the Pharmac website.