Published Online: October 19, 2012
Published in Print: October 24, 2012, as 'Smart Pills' Promising, Problematic
Updated: November 19, 2012

Advent of 'Smart Drugs' Raises Safety, Ethical Concerns

An explosion in the variety and availability of cognitive-enhancing drugs, from prescriptions like Ritalin to commercial drinks like NeuroFuel, raises concerns for scientists and educators alike—not just over the potential for abuse, but also over what educators and researchers consider, and how they approach, normal achievement.

Evidence is still limited—but growing—that some chemicals can boost attention, memory, concentration, and other abilities related to academic performance. Researchers at the Society of Neuroscience conference here questioned whether it is safe and fair to allow healthy people to boost their brain function chemically, or use drugs to correct environmental factors like poverty or bad instruction. Those can lead to brain deficits similar to factors that characterize medical conditions like attention-deficit disorders.

There’s no one “smart drug,” but a slew of different chemicals known as “nootropics” have been found to improve performance in different ways. Stimulants such as Adderall and Ritalin activate the frontal part of the brain, tasked with concentration and decisionmaking, by regulating levels of dopamine and norepinephrine. Those are two neurotransmitters, chemicals that affect how rapidly and easily brain cells can communicate.

By comparison, beta blockers can also act as a nootropic by preventing the effects of adrenaline, stopping the body’s fight-or-flight reaction to stress from interfering with concentration.

Nootropics, Old and New

Cognitive enhancers, known as “nootropics,” are becoming more common on school campuses, and different chemicals can act on a slew of different parts of the brain to quicken neurotransmitters or improve blood flow to the brain, among other things. Here’s a selection of common drugs that might appear—legally or illegally—on an education campus, along with their trademarked names, and how they act on the brain.

Methylphenidate (Ritalin): A common stimulant used to treat children and adults with attention disorders, it affects multiple neurotransmitter systems.

Atomoxetine (Strattera): Prescribed as an anti-anxiety drug, it improves regulatory control in both those with anxiety disorders and, in some studies, in healthy adults.

Modafinil (Provigil): A stimulant originally prescribed to treat narcolepsy and improve alertness for shift workers, it may also improve memory and alertness for those suffering from schizophrenia and healthy adults, according to some recent studies.

Piracetam (NeuroFuel, Noostin): A nonstimulant synthetic derivative of the neurotransmitter Y-aminobutyric acid, or GABA, it is prescribed for some involuntary movement disorders. Some studies have suggested it can improve mental processes for teenagers who have experienced severe head trauma.

Choline: A nutrient used by the body to produce the acetylcholine, a neurotransmitter used in the central nervous system, this chemical is naturally available in eggs, meat and milk, but can also be taken in supplement form.

Acetyl L Carnitine: This antioxydent is naturally produced by the body during vigorous exercise, and is known to regulate the use of fatty acids. Some research has suggested it can protect brain cells from decay in patients with Parkinson’s disease. It has become a common supplement for athletes, but there have been no substantive attempts to use it purely as a cognitive enhancer in healthy people.

Caffeine: The world’s most commonly used cognitive enhancer, caffeine is used as a stimulant by more than 9 out of 10 Americans. A dose of less than 250 milligrams has been shown to improve performance and alertness and reduce fatigue.

Sources: Centers for Disease Control and Prevention, University of Washington, Barbara J. Sahakian.

Dr. Barbara J. Sahakian, a professor of clinical neuropsychology at the University of Cambridge School of Clinical Medicine in Cambridge, England, has been studying one of the earliest identified nootropics, called modafinil (marketed under the brand name Provigil), which was originally developed to treat narcolepsy and sleep disorders caused by night-shift work. During a keynote address at the conference last week, she estimated that 90 percent of modafinil’s use is off-label, meaning that a doctor has prescribed it for other than its official purpose. Off-label prescription can be illegal, but is legal when done by a doctor and can sometimes lead to a new use being added to a drug’s label.

In modafinil’s case, healthy individuals take the drug off-label to improve attention and working memory, particularly during fatigue; it’s often given to combat jet-lag. In recent studies of both mentally ill and healthy adults, Dr. Sahakian has found modafinil improved working and spatial memory as well as the ability to identify emotions in facial expressions—often a problem for both autistic children and those under chronic stress. However, she did not find the drug improved overall learning.

Who's Using?

Proponents of cognitive enhancers note that the world’s most common nootropic—caffeine—is already widely available on high school and even elementary campuses. A small study in the Journal of the American Academy of Child and Adolescent Psychiatry in 1994 found caffeine improves both attention and manual dexterity in normal children, though it can be addictive with regular use and high doses have been found to decrease, rather than increase, performance in tasks that require high levels of working memory.

“It’s one of the ironic things, because everyone is so worried about a pill, but you can get worse side effects with caffeine—tremors and heart palpitations and the like,” Dr. Sahakian said in an interview with Education Week.

While prescription cognitive enhancers are not officially approved for healthy adults or children, doctors can prescribe them off-label, and some online distributors do not require a verified prescription at all.

There’s not much solid research on the number of K-12 students using drugs to improve academically rather than to get high. Emily C. Feinstein, a senior policy analyst at the National Center on Addiction and Substance Abuse at Columbia University, in New York City, said the group generally lumps different types of prescriptions together in surveys about drug use and doesn’t particularly target cognitive-enhancing drugs for prevention.

Yet buried in an appendix of the group’s 2009 report, “Adolescent Substance Use: America’s #1 Public Health Problem,” its most recent one, are some interesting statistics. While less than 3 percent of secondary students reported ever using a prescription painkiller, tranquilizer, or stimulant for fun, 62 percent reported they had used a prescription stimulant in order to study or be more focused at school, and 44 percent said they had used the drugs to be more focused for a job, sports, or extracurricular activities. Nearly 13 percent said they had friends who regularly used prescription stimulants to study and focus at school or work.

In the same survey, CASA found more than four in five parents considered off-label prescription drug use “very dangerous” for their children. However, fewer worried that much about their children taking prescription stimulants, like Adderall or Ritalin, that were not prescribed for them in order “to be more awake or focused” than worried about teenagers using prescription painkillers or tranquilizers to “get high” or “relax.”

Moreover, the study found parents’ top concerns for their children were getting good grades and getting into college, and concern over using prescription drugs to be more alert or study harder barely made the list.

Those findings back up smaller and anecdotal findings among older students. A 2005 study by Martha J. Farrah, a cognitive neuroscience professor at the University of Pennsylvania in Philadelphia, found a steady increase from grade to grade in the percentage of students using methylphenidate (Ritalin) to study without having been given a prescription for it: 2.5 percent of 8th graders, to 3.4 percent of 10th graders to 5.1 percent of 12th graders.

A seminal 2008 report on the emergence of cognitive enhancers from the journal Nature found one in five college- and professional-age readers had taken a drug off-label to improve focus.

Adults and Children

Many researchers question whether cognitive enhancers for adults—even the most effective drugs—will work for children.

In a similar vein, the side effects may also carry different consequences. The side effect of long-term memory loss, which has been found for some stimulants, is less problematic for an 80-year-old with dementia than a 16-year-old studying for the SAT, much less a 6-year-old struggling to learn to read.

The lead author of the Nature study, Stanford University law professor Henry T. “Hank” Greely, called in 2008 for more study of how drugs developed for and tested on adults and seniors would affect those whose brains were still developing.

One small 2009 studyRequires Adobe Acrobat Reader by Ms. Farrah found Adderall, another stimulant, was associated with reduced creativity in adolescents.

“In general, though, there has been less scientific research into the effects, both good and bad, than I would like to have seen,” said Mr. Greely, who is also an expert on legal, ethical, and social issues in bioscience.

Social Equity

Even if the drugs are found to be safe and effective in the long term for young children and adolescents, many experts have argued the idea of healthy people using them represents the ethical equivalent of athletes taking steroids to get an unfair competitive advantage—particularly because wealthier parents may be better able to pay for the drugs and the medical evaluations to prescribe them.

“Why is it that someone with money can hire a personal tutor to do better on a standardized test, but taking a drug to improve cognitive performance for five hours just before the test is wrong?” said Eric H. Chudler, the executive director, of the Center for Sensorimotor Neural Engineering at the University of Washington in Seattle, who also runs the Neuroscience for Kids website. Mr. Chudler said. “I think maybe there’s something about us as humans that makes us want to struggle. Doing something quickly, there’s something in our psyche that rebels against that,” he said.

Dr. Sahakian argues that ensuring that students who want to improve their mental prowess have access to potentially helpful drugs may be a social justice issue.

“Poverty has effects on the brain ...I wouldn’t call it a disease, but it is an environmental factor for cognition,” she said. “There are other ways of doing this, like smaller classrooms and individual tutoring, but all the motion is toward cutting back on education. With children, you do have to err on the cautious side in prescribing, but if there is a clear deficit, you have to treat.”

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“Some people like to make the distinction between treatment and enhancement, but it’s very difficult to separate them out,” Dr. Sahakian said. She noted that attention deficits, autism, and other cognitive disorders have been found to lie along spectrums of severity, “so when does something actually become a disorder? What can we do now to make sure [a] kid’s learning trajectory is much better in the future?”

But taking a drug to be alert or more focused in school is different from taking one to improve permanent intelligence, said Mr. Chudler. And there’s little evidence so far that drugs actually improve permanent intelligence, he said.

“What does it mean to be intelligent? Memorizing 100 words, or something more complicated than that?” Mr. Chudler added. “I think it’s the latter, and scientists don’t know exactly how to measure that.”

Vol. 32, Issue 09, Pages 1,16-17

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