Stimulants and PD

[Attending1985]

what do you tell patients regarding long term stimulant use and risk of PD? It seems to be another good reason not to use them. I wonders what pediatricians think of this.

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[whopper]

As far as I know there's no definitive link. There is data of neurotoxicity with stimulants and animals but the dosage given to the animals was far than that considered therapeutic to humans when adjusting for things like weight. Further there's data showing that no treatment of ADHD leads to loss of neurons.

https://pdfs.semanticscholar.org/e614/2095d05f469d7389d8a9e9f8ff939b2bcee2.pdf

This also brings up some other issues. We live in a new era where older men are exposed to commercials showing a 65 year old man cut, lean, and fit with a 20 year old girlfriend claiming how great his sex is thanks to testosterone. It could be that testosterone use could lead to serious risks.

So if you read the paper I put above notice it mentions males had increased risk of PD but not women? The authors suggest perhaps it's because boys get more ADHD treatment than girls (which is a leap that can't be proven, the authors even acknowledge so). There's other data suggesting it was really the testosterone causing problems and not ADHD meds.
Effects of Oxidative Stress and Testosterone on Pro-Inflammatory Signaling in a Female Rat Dopaminergic Neuronal Cell Line. - PubMed - NCBI

We know that abusing stimulants causes damage to the dopaminergic neurons but also know that being sober from meds for 3 years greatly lowers that risk.

I don't have a better answer for you but this is IMHO something that should be better explored.

Just wanted to add, and this doesn't answer the question in a scientific sense but does in legal sense, it's not within the standard of care to start inserting the fear of Parkinson's into a patient with ADHD who takes stimulants no more than it is reasonable to start telling anyone who drives a car that they're at risk for a serious car accident.

It does, however, IMHO create a reasonable argument that patients on stimulants, even if doing well, should be told to consider perhaps Wellbutrin and/or Strattera if they're going require long-term treatment for their ADHD.

 

[Attending1985]

As far as I know there's no definitive link. There is data of neurotoxicity with stimulants and animals but the dosage given to the animals was far than that considered therapeutic to humans when adjusting for things like weight. Further there's data showing that no treatment of ADHD leads to loss of neurons.

https://pdfs.semanticscholar.org/e614/2095d05f469d7389d8a9e9f8ff939b2bcee2.pdf

This also brings up some other issues. We live in a new era where older men are exposed to commercials showing a 65 year old man cut, lean, and fit with a 20 year old girlfriend claiming how great his sex is thanks to testosterone. It could be that testosterone use could lead to serious risks.

So if you read the paper I put above notice it mentions males had increased risk of PD but not women? The authors suggest perhaps it's because boys get more ADHD treatment than girls (which is a leap that can't be proven, the authors even acknowledge so). There's other data suggesting it was really the testosterone causing problems and not ADHD meds.
Effects of Oxidative Stress and Testosterone on Pro-Inflammatory Signaling in a Female Rat Dopaminergic Neuronal Cell Line. - PubMed - NCBI

We know that abusing stimulants causes damage to the dopaminergic neurons but also know that being sober from meds for 3 years greatly lowers that risk.

I don't have a better answer for you but this is IMHO something that should be better explored.

Just wanted to add, and this doesn't answer the question in a scientific sense but does in legal sense, it's not within the standard of care to start inserting the fear of Parkinson's into a patient with ADHD who takes stimulants no more than it is reasonable to start telling anyone who drives a car that they're at risk for a serious car accident.

It does, however, IMHO create a reasonable argument that patients on stimulants, even if doing well, should be told to consider perhaps Wellbutrin and/or Strattera if they're going require long-term treatment for their ADHD.

These are the things I struggle so much with in psych. These studies are from 2011 why wasn’t I taught this in residency. I feel that patients have a right to know all possible risks even if I’m not legally required to do so.

 

[whopper]

When I was in residency what most of the attendings would've said was there was no link without looking into it at all.

 

[Attending1985]

When I was in residency what most of the attendings would've said was there was no link without looking into it at all.

Exactly my experience

 

[hamstergang]

I feel that patients have a right to know all possible risks even if I’m not legally required to do so.

But you can't tell patients of all possible risks. That would take too much time. Plus, without a medical background, how can they properly evaluate all of these risks? Not to be too paternalistic but we're experts for a reason.

You should talk about common things and major things. They have the Internet available to them.

 

[Attending1985]

But you can't tell patients of all possible risks. That would take too much time. Plus, without a medical background, how can they properly evaluate all of these risks? Not to be too paternalistic but we're experts for a reason.

You should talk about common things and major things. They have the Internet available to them.

to me this is a major thing

 

[Attending1985]

From what I’m reading it seems like the risk that s there with amphetamines but not Ritalin

 

[whopper]

But you can't tell patients of all possible risks. That would take too much time.

Yes. I tell patients, when they ask me of the risks, "I could be here for the next 12 hours telling you of all the risks and we still would've have covered most of them."

BUT IMHO if I were the patient I would like to be told that use of ADHD meds long-term into adulthood may be an issue but it's never been settled, there's no strong data backing it up but it could warrant keeping the dosages of the stimulants to the minimum needed, not using them if not needed, and consideration of Buproprion or Atomoxetine as alternatives. IMHO that would be completely appropriate.

I also want to clarify that while the "system" never mandated it or categorized it as such, stimulant medications are largely considered for use in minors then the expectation is as an adult they will likely not need them anymore.

E.g. a major study showed that stimulants don't raise cardiac risk....but guess what? It was only done in children! The article didn't address that so many adults use them too.

But this unofficial categorization has, IMHO, mentally turned off the curiosity a physician should have as to the risks stimulants will have on adults who use them long-term.

Exactly my experience

And it's a reason why I felt my education needed to go much further than residency. Douglas Mossman was my PD in forensic psychiatry, considered one of the nation's top physicians, and whenever you mentioned something he didn't know, his eyes lit up and he'd say he didn't know about that, asked about it, and looked into it himself which is the foundation of life-long learning. It was for that reason he rarely didn't know something.

And I've found so many physicians that, if they don't know something brought up, brush off the person mentioning it especially if they're not a physician.

I don't want to hear, for example, that there's no link between a disease and a medication unless there's solid data showing so. I'd rather hear, "we don't have any solid data showing a connection, but it hasn't been answered. Given the existing data I would still continue taking the medication given that you're doing well on it so far, but I can't say without lying that science has answered this."