I’m sure everyone has heard by now about the commentary that appeared in Nature on use of stimulants as cognitive enhancers. Unfortunately, I didn’t have a chance to read the commentary myself until this weekend, when I curled up (at the lab, no rest for the grad student) with a cup of delicious coffee, some Moose Munch, and the latest issue of Nature. Unfortunately, this commentary has completely destroyed my peace of mind. The arguments laid out for the use of cognitive enhancers are persuasive, but there are also some interesting flaws.
I’m sure most people have thought about cognitive enhancement. All my life I have envied, to some extent, those who are more successful than I am. Somehow they can focus when I cannot, can study for much longer hours than I can, and consequently get better grades. Some can focus on training more than I can, can stick to nutritional advice, practice when they are supposed to. What if I could get myself a little pill that made me match them all?
Part of me (the part that is competitive and in grad school) says sign me up. The other part, the part of me that worries about the effects of drugs and the way the public reacts to statements like the one in Nature, says hold it, is this another “Listening to Prozac”?
The argument the authors lay out is clear: cognitive enhancers, such as Ritalin, Adderall, and Provigil should be made open for use, surrounded by enforceable policies to support fairness, and research should be done on the cognitive effects. They argue that the use of cognitive enhancers is already occurring illicitly on college campuses, so why should it remain illegal (to this I would say, yes, and crack is also used illicitly on street corners, but that does not mean we should make it legal). They also argue that cognitive enhancement could be personally and societally beneficial, and that, in the right policy environment, it would pose no addictive potential and no substantial risk.
So far, I can think of five main reasons as to why this commentary makes me uncomfortable. They are below, and I would welcome commentary from people who might have another take on it, or who might think quite the opposite.
1) Stimulants:
There are lots of different kinds of stimulants out there; caffeine, nicotine, cocaine, Ritalin, Adderall, the list goes on. However, not all of these stimulants work in the same way, and the way they work has a great deal to do with their abuse potential. For example, caffeine works in a way very different from cocaine, and has little, if any, effects on dopamine. Caffeine doesn’t give you a rush that is pleasurable. Cocaine does, and other stimulants such as Ritalin and Adderall also do. The reason that prescription ADHD medications do not give a rush when they are prescribed has a great deal to do with the method of administration. The pills are slow release formulations, which release a small amount of drug over a long period of time, avoiding a spike in dopamine levels and the feeling of a “rush”.
But that’s not to say that stimulants are always taken as pills. All you have to do is grind it up and snort it. And even without the rush, the effects of chronic increases in dopamine levels (such as those produced by Ritalin and Adderall) are still relatively unknown. Even less is known about modafanil, a newer synthetic agonist. This call for reasonable use is premature. Far more research into the long term effects of low dose stimulants needs to be done before we can start prescribing to normal individuals.
For example, side effects of chronic high levels of neurotransmitters like dopamine and norepinephrine (two of the neurotransmitters affected by Ritalin and Adderall) in humans have never really been examined, though some studies have been done in mice and rats. These chronic high levels of neurotransmitter could have some important effects, possibly making chronic stimulant users more prone to using drugs like cocaine and alcohol. Some studies in rats have shown that animals exposed to Ritalin self-administer more cocaine than those with no exposure (Brandon, 2001). Studies of non-medical prescription stimulant use in college students has shown that students using Ritalin or Adderall without a prescription are far more likely to binge drink, more likely to use Ecstasy, and 20 TIMES more likely to use cocaine (McCabe et al., 2005). These students may not be using the prescription stimulants for cognitive enhancement, and everyone knows that correlation is not causation, but clearly more studies of the effects of Ritalin and Adderall in healthy individuals need to be done.
So we don’t know the chronic effects of stimulants. Do we really want to be giving them out as cognitive enhancers? Could this commentary encourage their use before the necessary research has been done?
2) The need for cognitive enhancement: Coercion and competition
Some institutions do have coercion to take cognitive enhancers. The army, for example. The authors do state that no one should ever be coerced into taking cognitive enhancers. But they fail to fully address the issue of competition. People may not want to take cognitive enhancers, but if everyone else is taking them, or a significant minority, the pressure to take them is increased, as someone without cognitive enhancement may not be able to succeed at the level they need to keep up, and would get out-competed by those on cognitive enhancement.
3) Cognitive enhancement in students:
The authors point out that it would be unfair if only those who could afford them got access to enhancement, in, say, a school setting. So they propose making it freely available, like we make computers available to all students on a college campus. If I worried about the use of stimulants among normal people, I worry about it more here. We really don’t know the chronic effects of stimulants long-term, even in the people we normally prescribe it to, such as children with ADHD. Teens are undergoing massive changes in neurological function that persist well into the college years, and I don’t know if I want to be messing with that so my child could get a better score on his MCAT.
4) Cosmetic psychiatry: this is a term that I first came across while reading the book “Listening to Prozac” (which I will have to review sometime). There is nothing WRONG with a person, but a drug makes them, to use the author’s phrase “better than well”. There may not be depression, or ADHD, but using the drugs makes you better, a different person, a person who happens to succeed better in the society you are in.
But here I run into a dilemma. Why is it necessary to be MORE than you are in order to succeed? What does it say about our society that “getting ahead” or getting that extra leg up is so overwhelmingly important? In the case of Emergency physicians, who may very well need the stimulants to help them get through their 24 hour shifts, WHY are they working such insane hours in the first place? Perhaps we are simply requiring too much of ourselves, and perhaps, if that is the case, we shouldn’t cure that with drugs, we should cure that with fewer hours and more reasonable expectations.
And would access to cognitive enhancers really enable people to “live better” and “better achieve their goals” as the authors state? If everyone’s taking them, the general bar is raised, so in theory, you’d have to work harder to achieve those goals because everyone else around you is cognitively enhanced.
5) Conflicts of interest: The authors are open about their conflicts of interest, and the conflicts of interest here are rather interesting. I find it especially interesting when the authors imply that, though methylphenidate (Ritalin) and amphetamine (Adderall) might be dangerous, the newer drug modafinil (Provigil) might be ok. Look carefully at the bottom of the paper. Under ‘competing interests’, it states that one of the authors consults for and holds shares in CeNeS, the company that produces modafinil. One of the other authors also consults for pharmaceutical companies and has received grants from them. It’s clearly the right thing for them to express their conflicts of interest, but it makes you question just how unbiased they can be in their assessments.
I would say that no one is ever fully unbiased. I research stimulants, and I am not a fan of using them in daily life, partially because of my research. And as yet, it appears that modafinil not have any addictive potential (Deroche-Gamonet, 2002). So despite the conflicts of interest, modafinil might prove to be a better candidate for cognitive enhancement, at least compared to Adderall or Ritalin. But modafinil still doesn’t have many studies on its cognitive enhancing abilities, and as yet is only approved for narcolepsy, sleep apnea, and shift-work sleep disorder, and its cognitive anhancing effects may be limited (Normann, 2008).
Bottom line: I don’t like it. I feel this call is premature, and that the drugs available may not be efficacious, or worse, may have addictive potential. And I’m worried that such a publicized commentary will make people reach for these drugs to “live better”, when we are still not entirely assured of their safety. This became the issue when Peter Kramer published “Listening to Prozac”. People read about patients becoming “better than well”, and prescriptions for Prozac skyrocketed. Could “cognitive enhancement” be the next Prozac?
Some issues I’m still hung up on:
1) Is cognitive enhancement via drugs ethically the same as hiring a tutor? I feel that it’s not, but a gut feeling is not an argument.
2) The concept of cosmetic psychiatry: is it ok to prescribe drugs to someone so they can “live better”, even if their quality of life is not reduced in the first place? With psychiatric disorders such as anxiety and depression (as well as ADHD), the quality of life is substantially reduced, what about cases where it isn’t?
3) Is cognitive enhancement fundamentally different from other advances in technology that have ‘advanced’ the human species, such as good nutrition, the internet, or anything else?
