Stimulants as Cognitive Enhancers?

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?

19 Responses

  1. What is your position on the use of motherfucking Jameson as a cognitive enhancer?

  2. I would dispute your assertion that caffeine doesn’t provide a pleasurable rush, but that’s beside the point…
    Many years ago I got interested in whether or not cognitive-enhancement “nootropic” drugs and/or nutritional supplements would be useful. After reading around I started to notice the same common theme that seems to apply to most “enhancement” products: the degree to which they are helpful is (in general) directly proportional to how deficient you are in the first place. It seemed that people with serious mental deficiencies might sometimes see dramatic improvements from some of these, while people who are already reasonably intelligent would see only negligible effects.
    I’m guessing that most people who really care about how smart they are already possess at least normal intellectual powers, and therefore (assuming my hypothesis is correct) would get very little advantage from “cognitive enhancers”. I’m reminded of the guys on the swim team who insisted on shaving their legs in hopes of taking a few more milliseconds off of their lap times…
    I’m a lot more concerned that they’d be ineffective rather than unsafe. If I were Supreme Overlord of the United States, I’d be inclined to meet the authors halfway by opening up a huge controlled study on “cognitive enhancers” to anyone who wants to volunteer.

  3. A while back there was a well done satirical article circulating on the net, mirroring the sports doping news, that claimed the government would be cancelling the grants of any scientist discovered to be using intelligence enhancing drugs.
    An interesting comparison, because there really would be a very close parallel. At a time that the sports world has gone bonkers, banning over the counter cold medicine and ‘high altitude tents’ (ironic because atheletes who can afford to go to actual high altitude training would still acquire an advantage). Is science done under such influence tainted? Is sports similarly tainted?

  4. Epicanis: yes, it is true that cognitive enhancement shows the largest effects in those of lower cognitive ability in the first place. I did think of bringing up that point, but I figured the post was long enough. I’m glad you mentioned it. And it’s true, the overachievers are the ones most likely do take cognitive enhancers, and probably are getting the least benefit. Some would say we just need better cognitive enhancers.
    And yes, caffeine does provide a rush sometimes, but I don’t know how many people would describe it as pleasureable. Additionally, anyone who tries to quit caffine, can, even with the headaches, the craving just isn’t strong. But the main reason people don’t consider it addictive is because animals won’t self-administer caffeine.
    jayh: I think I came across that, and I do know that a lot of scientists use cognitive enhancement when writing grants. The authors did talk a little bit about sports doping, and saying that sports doping was only considered cheating because it was against the rules. Therefore, if we changed the rules it would be fine, and the same goes for cognitive enhancement, they just want to take away the negative connotations of the word “enhancement”.
    PP: you are probably the only person I know who gets cognitive enhancement from Jameson. 🙂 Me, I get it from vodka!

  5. My perspective is different — due to a benign brain tumor and the radiation to treat it, I think I’ve lost about 25 IQ points and I miss them terribly. Inability to concentrate, complete tasks, and general ditziness are also problems.
    I tried Strattera, but discontinued it because of dizziness and nausea — I was having enough problems with these already. Plus, it did not seem to make much of a difference cognitively or increase concentration. I was on it for two months.
    It would be interesting to know how these function on aging brains as well as the long-term side effects for younger people.
    I don’t think I’d recommend them for merely getting a better grade.

  6. ooh, i was hoping someone would start a discussion on this! you are the perfect person to do it. but damnit, i don’t have time to read it all right now. i am traveling to a southern institution department coincidentally also named physiology and pharmacology to learn a technique tomorrow and it’s a bit of a drive.
    i’ve left my email addy because i suspect i’m going to your neighborhood. let me know if you want to meet up for a quick chat 🙂

  7. I don’t have a citation on hand, but I do believe that chronic dopamine elevation leads to schizophrenia-like symptoms. It was in something I read about L-DOPA and Parkinson’s.
    In other news, does anyone else suddenly have Daft Punk stuck in their heads?

  8. For the sake of argument, suppose there existed cognitive enhancers which were known to be safe and have no adverse side effects.
    If a medical doctor could be a better medical doctor by taking them, would it ethical for a medical doctor not to take them? If a doctor has a moral obligation to give the best quality care to their patients that they can, would this include taking pills that would make them a better doctor?

  9. El Christador: An excellent point, and one that Mr. SiT raised as well when I told him about this post. One could argue, in terms of Utilitarian benefits, that yes, if all cognitive enhancers were safe and had no worries associated with them, for the benefit of society, everyone who could take them, should, as it would provide the most benefit to the most people. And hell, sign me up, know what I’m sayin’?

  10. I have been using motherfucking Jameson for the last five years as an academic performance detractor. It has helped me temper any success that I might otherwise have.

  11. I have always thought and will never change my position on this, that learning has always been a cognitive choice. You have right to feel wary about it. While the points you make for your discomfort concerning the issue are true, I think you are missing the full truth. It begins with your second paragraph:
    “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?”
    This is not the hypothetical statement of one wanting to learn in earnest for the sake of learning, but rather a statement with a solid foundation in one’s own personal view of their self-esteem. To pose a question, what if the peers whom one envies were to take cognitive enhancers as well? Would one not still be envious?
    In my own view, for the most part, drugs are exceptionally misused. My take on them is simple. If I need a drug for my own survival, as the author says, sign me up! If I absolutely have to have them in order for my body to continue functioning, for pain, smoking cessation, or erectile dysfunction in my later years no problem. But if it is a drug that affects my mind AND how I think in any way and is not necessary for my survival, NO!
    Now, I would be interested to see how cognitive enhancers could be used to help the mentally retarded whose reality is different from, and I hate saying this, “normal” people. But that is a different topic of discussion.
    I feel as you do in that I do not like the idea. I believe that we learn at different levels due more so to our upbringing and early education more than anything. As an example, my brother was diagnosed with ADHD as a child and of course was prescribed Ritalin. Did it help him in school? Quite simply, no. His conduct was much improved but his learning was not. He was taught memorization over conceptualization, which was more a fault of the educational system back then. But at home, he was mechanically exceptional. Ask him to fix a car: done!, washing machine, done! , clothes dryer, dish washer, you name it, DONE! The point is, he learned those things on his own, he taught himself and understood the concepts of their function, integrated them and utilized them, and as a result, after almost failing out of school, he now repairs helicopters, aircraft and military vehicles. (not to mention he is a fantastic cook)
    As to the issues you are still hung up on,
    1)No, they are not the same, a tutor teaches, a drug does not. Though the results could be for better or worse, regardless.
    2)No, what is the point, if their life is not substantially reduced. Although, I do go back to my earlier statement of using cognitive enhancers with the mentally retarded.
    3)Yes, it is different, it is in a totally different category, life is not that complicated, think right, eat right, live right. Although as far as short-cutting everything in our lives, yes it is the same.
    Maybe the next endeavor should be a drug that allows one to live their life in five seconds with 50 years of memories. There is a short cut for ya! 🙂

  12. my take on the issue is that if we constantly up the ante in productivity, we’re going to hit a brick wall in short order.
    i mean, i have a computer and graphing and data analysis programs. this speeds up my work considerably- now instead of calculating 2400 data point transforms times 6 different paramters by hand, the computer can process it for me. and the more i’m capable of doing, the more i do. would i do 2400 data points for a single experiment if i didn’t have this computer? hellllll no, that would encompass an entire dissertation with all the associated work.
    instead, it’s one study, one part of what i will accomplish as a predoc. and i stupidly feel compelled to put in sometimes 20 straight hours of working over my data anyway, but i mean, in 9 days i have accomplished what would take years by hand.
    this sounds great. look at all that we can get done in such short time periods! but when we get it done, we feel compelled to do even more, and that’s where the spiral begins.
    now look at times to phd. in my department it’s about 5.5 years. but that number has been steadily increasing. it becomes harder and harder to significantly contribute to the body of scientific knowledge because our standards are increasing. the more we can get done, the more they expect. in a way this is good, always pushing harder. but in another way, how far can we push before we start looking for a way to get by without sleeping for 5-6 days at a time? before we sacrifice more of our already stretched schedules, our family lives, our downtime? what of my future kids, who might spend 10 years in a phd program by the time they’re grad-school age? will this result in a net decrease in productivity as we all get burned out?
    and at what point does performance enhancement become not only acceptable but expected? because that’s the point where i’d be bailing out.
    in short, that whole thing made me feel very uncomfortable about where we’re going…
    and don’t EVEN get me started on developmental effects, seriously. that’s another big comment i won’t get started on!

  13. Is there any info about non-stimulants used as cognitive enhancers? My brain is racy enough already.

  14. I’m a geriatric psychiatrist. I prescribe low doses of ritalin fairly often to my patients with early dementia, esp. subcortical or vascular types, where motivation, depression and initiation become an issue. My patients have responded very well to this treatment without any problematic side effects.

  15. 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).

    Actually, in reference to the crack I think it does. The hardcore reality is that these drugs are readily available in almost every major US city. Prohibition is a waste of time and doesn’t work (see the 18 and 21 amendments’ to the US constitution) , regulation is the only way to reduce the amount of damage drugs do to society.
    The idea of legal crack, cocaine, meth, and etc scares the crap out of me too. However, there are drug users who are able to use illegal substances for recreational purposes and still function normally. Also, they’re people who only use the legal substances (alcohol, nicotine, canned air, and etc), and have severely f$%*ed up their personal lives.
    What we need is better education and regulation of drugs, not absolute prohibition. While the increase in availability of these substances will have an immediate effect on society (more addicts). In the long run it seems to be the only sensible move. For what I see as some pretty simple reasons.
    1. Education works much better if done correctly. You can’t teach children that crack and marijuana are equally dangerous. This makes no sense, kids need real information on drugs, just like they do sex.
    2. A majority of gang violence is caused by fighting over territory where a group sells drugs. This problem would disappear if there was no black market(HUGE!!!! profits) for drug dealers.
    3. Government controlled regulation of dosage and quality. Bathtub mixes of illegal drugs make them even more dangerous, lets at least make sure all the addicts are getting safely made drugs. Just like I’d prefer that all the heroin addicts get clean needles.
    4. Freedom of choice. It’s my body and I’ll do anything I want with it.
    This does not mean I’m irresponsible for my own actions when under the influence of drugs.
    5. Putting non violent drug offenders in jail is a waste of time, and adds to our ever increasing prison population. Which means violent offenders are getting out earlier.
    6. Drugs are for adults, and dealers don’t check ID. With government regulation more resources could be spent keeping them out of the hands of children, instead of indiscriminately arresting everyone because they “might” do something bad.
    This issue confuses me a lot, especially since I’m one of the people who has a prescription for cognitive enhancers (Adderall), and I also happen to have a taste for the Mary Jane. I don’t drink, smoke(nicotine), or do any other drugs, but I’m constantly having to jump through hoops because my recreational drug of preference is considered illegal.
    I’ve faked employee drug screenings, I’ve lied to my doctor, and developed a very bitter attitude towards police officers. All of this because mentioning the fact that I like marijuana labels me a drug addict, and while I am a drug user (everybody is, think about it) I am not an addict. I do considerably better in my life (socially and economically), than most of my drug addict, user, and non user friends.
    I’m a responsible adult, and I fully understand the consequences of taking drugs. I also understand it’s my responsibility to make sure that I don’t endanger another person’s life with my recreational activities, and if I ignore this I can/will be punished. This same right is given to everyone who goes drinking on Friday & Saturday night, why should I be treated any different?

  16. What an interesting article. I was prescribed Adderall five years ago after being diagnosed as an adult with ADD. My son has it, as does my sister, so it seems to be hereditary.
    Adderall did help my focus but I became easily angered when using it. It made me easier to accomplish more but impatient with others and endangered my relationships at work and at home. So I don’t take it anymore.
    I am now taking phentaramine – very low doses – and supplemental serotonin for a weight loss program called Serotonin Plus. This drug combination – designed for weight loss – does eliminate my formerly incessant carbohydrate cravings and enables me to lose weight. I can also concentrate better, my mood is steady, and I am able to avoid the usual depression caused by the oncoming winter darkness (I have SAD – Seasonal Affective Disorder).
    Maybe as the brain ages, it produces less and less serotonin, and other neurotransmitters and hormones (melatonin) are not produced at the rate they are needed, when they are needed?

  17. Just want to make it clear: cognitive enchancers which give ‘normal people’ rush, are used by those with ADHD in order to release the rush for them?

  18. My interest would be in using cognitive enhancers to remedy specific mental difficulties, like helping dyslexics to read or people like me to do maths. Does anything like that exist, or do they simply enhance cognition generally? I would also be interested to know if using cognitive enhancers affects other brain functions, eg coordination, social skills etc? After all the pills surely cannot alter the capacity of ones brain (can they?) so do they just reallocate brain “real-estate” to extra cognitive functions, or do they help a lagging brain perform optimally?

  19. I personally have had a very hard time my entire life just being able to function normally, I have Social Anxiety disorder, Anxiety attacks daily along with OCD and severe depression, I know that it is incrediably stupid to take something that was not prescribed for you just to see what would happen, but in this case I did.
    I took some of my sons Ritalin a relatively small dose 20 mg as I am a 150 Pound adult, but it was like something went tah-dah, and everything was better, I was able to strike up conversations with conmplete strangers, in which I have never done in my entire 29 years, and was able to get a sentence out without stuttering on my words.
    I do feel slightly happier, but I don’t know if this is caused from the ritalin or the fact that I’m feeling more like a normal person for the first time.
    I have tried pot before, which in my case I did not like how it made me feel, I also hate the effects of alcohol so I avoid it at all costs, I am currently taking an Anti depressant (prozac) and an Anti Anxiety medication (klonopin) which have both been prescribed to me by a physician, and I am currently feeling no ill effects from the combinations of the 3 medications together.
    I wanted to go to the doctor myself and see about getting my own prescription of Ritalin or something like it, but am worried that I will be precieved as a druggie.
    I really hate the idea of taking anything, but being a 29 year old feeling like I am trapped in a cage unable to touch happiness and a normal life really makes me reconsider the “possible” side effects.

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