Cognitive Enhancing Drugs & Students

Every year, at exam time, I get questions about cognitive enhancers.

Also, inevitably, about ADHD, and often there will be an addle minded mention of ethics at some point as well.

So, if you are the kind of person who prefers the answers to your questions to be spat at you, in strings of scarcely linked bullet points dressed as paragraphs; well, welcome home!

This brevem investigates the new world of cognitive enhancers (CE).

Ethics

There is a large literature on this now, though arguably unnecessarilyi. Is it ethical to graduate tens of thousands of dollars in debt? To not get to choose your parents? To lose/gain a full grade of your “academic ability” for attendance – and do you really think things like this would be required if attendance contained its own benefits? Will you pay for my internet? Is it ethical children and the hungry made the device you are reading this on?

Is it moral to have a bureaucracy to deal with, after being diagnosed with sarcoma young? Or the same scenario at any age – is that OK? What about just born poorer? And the rest.

Am I “Good“?!

Life requires many skills. At times problems require networking prowess, akin to knowing who to meet at the back of the library stacks. Other times knowing how to build probes that will fry your left pre frontal cortex just enough. Or the ability to convince your friend to try it first, may sometimes be what is called for. But you must be your own self reflective arbiter!

“If it harm none (and one practices self honesty and ownership), then” . . . look, just get off my page.

Well-Being

As to is ADHD real, well it is not really a valid question. But in a word – yes. Really, we are all here to talk about well-being. It is as simple as that. One of the few things social bio-psychiatry and neuro/clinical psychology have got right is talking to the patient. Is there an unwelcome impact on your social, study/vocational, or intra-personal life? If yes, you require intervention. If no, I still have to bill you for the full hour. Sorry.

Always the strongest position is not having to reach outside of the self. Unfortunately, the world reaches in, and will eventually kill you and everyone you think you love – that is a mere fact. A multifaceted approach to well-being is, thus, of best benefit. Always practice clear-focused and system unified cognition, alongside life path re-enforcing behaviour sets. Continue this in conjunction with all clinical intervention. Be creative with self defined interventions. But prescription medication, where available, certainly has a role to play in life. And we will all be on them at some point; so you better learn how to make good choices from data. And own your choices.

Applied meditation and cognitive techniques, as well as aligning to a healthy environment, and a life path you can likely enjoy (as supposed from your current position) is criticalii. No medication can give you these. Most medications do not even do close to what they are suppose to – by a real lot – and are almost always addictive (defined as marked physiological distress on cessation), despite what you are told. Physicians are use to never being questioned, this does not mean that in the past they were actually always right. I will skip malpractice and iatrogenics hereiiiivv. To suffice it to say, it is you who must own your decisions. People in every profession can be annoying, but not a single one of them will live your life. And we all only have a best guess at the likely possible future. But medication can work with you, if you prepare properly, choose wisely, do not confuse your doctors for scientists, and take responsibility for your own choices and investigation.

Nothing can give you well-being. And death is impending. It is a coin toss as to how much we (the extended health community) can assist in the latter, and how you deal with it. However, we can ensure you find resources to better align to path, and do not lose your job, or drop out of school (or worse) in the interim.

Tech

Do not implant, or attach, radiation devices to your head, of any kind (and there are a lot), at this time. This is deserving of its own piece. But do not do it. With Electro Convulsive Therapies (ECT), like nearly all medical procedures, the real risk is likely in the anesthetic. However, this does not account for more permanent memory loss and other deficits (most likely); that’ll be your more classic “brain damage” (not that this is necessarily a bad thing).

Though I am quite partial to memory loss being part of the therapeutic effect (some meditations I practice rely on this as technique), and I am not even against the idea of some form of neural regeneration triggered from the insult: Still, there is a reason we treat epileptic seizures, not just count it as a blessing and control the muscles. It should almost go without saying that ECT is not by default an enhancer. It is a last resort, and not for exam blocks. Now, do we know as much about it as most of the drugs? Unfortunately, arguably yes. But, like the antidepressants, any positive effects would take too long to be seen. Do not count on shock regeneration to assist with encoding.

Implants and trans-cranial (and supra cranial) similarly face too many risks via application techniques or poorly directed specificity in procedure. Decline until further notice. Though nanite enhancement seems robust, depending on the quality of your supplier. However, do not drive with active nanites, and do not partake in nanotech that goes beyond exam block, ie remaining active, except at a sub optimal function charge: enough only to assist in auto-removal relocation/positioning.

Do not use alcohol (as CE). This is a controversial one, and I could make an argument – but just off the shelf and for the general population: of the non prescription drugs, it is the worst on too many dimensions to mention, would be my answer. And, just generally, do not use any prescription drugs, except as a last resort, after all the other strategies are in place as well as they (honestly) can be.

Then definitely use prescription drugs.

CE

Finding personal balance that matches societal expectation is requisite in life. Non medical CE will not be covered here, as research is sparse. Besides – it is too personal to be otherwise. However, all compounds equally rely on how you personally respond, and if you can apply them reliably. Coffee, it is being assumed, finds ubiquitous use among readers. Caffeine is supported at this time (within personal limits up to 500mg/day)vi. Nicotine is a well established memory and focus CEvii. Non cigarette nicotine is being supported at this time. “Vaping” and gum are potential answersviiiix. Smoke in lungs is not an answer, anymore than sticking your head in a chimney isx. Remember state dependent learningxixii. And stay in the state where you remember to remember it during exam time.

None of the sedative/hypnotics can be strongly enough recommended at this timexiii. This is not a simplistic amnesic fallacy, rather it is the feeling of JChron that these classes (though we loathe to treat them as classes. ed.) would fail to surpass caffeine in efficacy amongst most of the population, in most circumstances – though there are additional reasons for concernxiv. The only general exception would be arousal issues under Yerkes-Dodsonxv – though this is too patient specific to comment on verily at this time.



Of the hormones, androgens – especially testosterone – have some work behind them (though can run into similar problems as the benzodiazepines in some cases.)

Similarly, analgesics and antimicrobials (antibiotics/antivirals/antifungals) are not recommended at this time; though there are some application potentials, just sub threshold at this time, and particularly in environmental/situational poly use they do offer obvious benefit (eg if unwell). Further, despite some possible class broad, and other likely unique effects observed under, somewhat strict, task conditionals for at least one drug in every class (eg arguably: aspirin; marijuana; Zolpidum; certain antibiotics et al. ed.) – they are not recommended at this time. This is as the domains are too limited and side effect profiles too high in trade.

Antipsychotics/antidepressants (many of which should arguably be illegalxvi xvii) are also not recommended at this time; this includes so called NERI/Atyps/5HTNERI/Tricycs et al. Though there is an argument for some antidepressants, after acclimatisation (especially the older, if sedation is balanced): the input/output likely benefit ratio is far too dangerously unbalanced. Doubly so during the stress of exam block. If already taking medication do not stop taking it during exam block. And almost universally, do not start one to take exams either.

And just so there is no confusion, let it be reiterated: despite limited and specific cognitive enhancement (in a near useless and highly specialised amount, and at great deficit cost) – marijuana is not recommended at this timexviii.

Stimulants likely do not need to be covered in much depth (especially methylphenidate & damph etal). They are generally effective reasonably short term – unless primarily listed as an antidepressant, have an atypical sedative effect, or are not titrated correctlyxix. Though there are some dangers, of course, and idiosyncratic and drug interactions must always be consideredxx. And they are not magicxxi – quality of work is organised, and focused: but it is never miraculously more than you would have done anyway. And work will still suffer on sleep deprivation; though more control of when deprivation will set in is their most potent power. They are non addictive (defined as marked physiological distress on cessation); and certainly not likely to be a problem for single use or short period, all things being equalxxii.

Novel use off label drugs like modafinil and duromine (and to a lesser degree Atomoxetinexxiii, Khat xxiv and othersxxv) fall into this category as well xxvi. Each appear, at this stage, to enhance different kinds of cognitive ability; even when the mechanism is unknown (or thought to be near identical to other compounds), and each carry correspondingly different risksxxvii. Examples of specific measurable enhancements seen include items such as: memory encoding (longer term); memory recall (medium term); speed encoding (short term); spacial manipulation; mathematical ability; social intelligence; and vigilance – among others (like pseudoephidrine/ephidrine/hypericin/hyperforin – though vigilance above caffeine not demonstrated, and limited if any effect on recall) xxviii. .

For the first time, compounds may have to be task matched for subject field requirements. This is a trend in CE that seems set to continue – even among the brain frying (literally) technology due to be next off the line 30 31 32 33 34 35. In the independent search for novel compounds, a good rule of thumb is to see if said compounds are listed as used by pilots and the militaryxxix, shift workers (especially medical), Alzheimer treatments (and dopamine/norepinephrine precursors), or by older mothers to lose weight; if so, then they likely benefit from further investigationxxx xxxi.

Long-term

Long-term treatment efficacy for enhancement methods (ie in ADHD/shift workers/as antidepressant adjuncts/and in the “normal” population ect) is a far more difficult question to answer. Though it is certainly becoming more common in adults, with the addition of more inclusive diagnostic criteria (rightly so; cf Well-Being), the advent of longer acting preparationsxxxii and less mental health stigma xxxiii.

It is also difficult to find reliable, unbiased (as possible) cohort or longitudinal data on these compounds/technologies. Even with the older ones, this is the case. Hopefully these data will soon be forthcoming, though, or so the chatter in the academy goes.

And there have been some breaking of old dogmas, including ones that made it taboo to highlight any protective effects of stimulants against psychiatric illnessxxxiv (including preventative impacts on, and strategic treatment with, co morbid substance abuse disordersxxxv). And there is a sound case for more wide spread use.

We’ve had some of these drugs a long time. And literally every other clinical class is inferior (re tollerability and efficacy), as well as being closer to entirely ineffective in these domains, even outside of direct comparison xxxvi. With medical data; it tends to be the older the betterxxxvii. Do not be the first if you can help it. These older compounds do have minimal risk, no addiction (defined as clinically significant distress on cessation): but do have personality, plasticity, and neurodepletion with natural decline, genuine philosophical concerns still to considerxxxviii. Cardiovascular concerns, despite the mix in the literature, are almost certainly a concern as well.

As such, the question seems to be: are the ultimate long term quality of life concerns serious enough, and genuine enough, that the impact of no “domain X” success will effectively be the greater risk of “killing you quicker”. Further, that these issues are not amenable to being solved readily by alternate means. It is a decision that can not be made for this “now”; but critically, one has to compute likely future possibilities – with some stark truth to self.

However, the same is true with absolutely every daily medication; prescription or bottle-shop. But especially prescription. This is as public science literacy, and genuine knowledge of selfness, is so abysmal among the general population (cf section on well-being).

Fin

You are always better off having nothing. It is the most powerful position. But it is equally true that society requires you contribute via work or study as best you can with what your environment provides. This is one such option set for some. Nothing is likely to harm you in a single (or rare) use.

Never take anything everyday if it can easily be avoided. If not – do not ever skip a dose, so that the body may adjust for better long term safety. Check there is no evidence for cumulative toxicity. If benefit ceases – stop. But even if there is no withdrawal risk listed (even if it is a technology); always stop properly. Thoughtfully. Always expect at least temporary reversion, or even increased, re-emergence of the symptoms originally being treated on cessation. Always be on a dose in the upper mid-range. Never be on a new drug or technology. Never be on an upper limit of even an approved dose. Avoid polypharmacy with extra vigilance, as far as is reasonably possible.

But do not treat drugs as other than individual. And the same goes for brains and regions. That is to say, if/when polypharmacy and/or technology is required (defined as >5-7+ medications/interventions in some corners of the literaturexxxix – but even more generally); do not fall for “whole classes” or “combinations” being placeholders for specific drug target or region “supposed” outcome effects. There are no guarantees. It is never up and down, on or off. Ever. Certainly not in poly.

And, as always, investigate new claims of harm (relevant to your situation) as they arise. Otherwise, you’ll be fine. Now, count backwards from one hundred, while you just sign here.

JJR

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*JJR is the psychiatry, malpractice and research science investigator for the Chronicle.

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JJR (2015). Cognitive Enhancing Drugs & Students. JChronLettSc, 01516(11), Ed3.

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i Mehlman, M. J. (2004). Cognition-Enhancing Drugs. The Milbank Quarterly, 82(3), 483–506. http://doi.org/10.1111/j.0887-378X.2004.00319.x

ii Sachdeva, A. (2015). Non Pharmacological Cognitive Enhancers – Current Perspectives. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. http://doi.org/10.7860/JCDR/2015/13392.6186

iii ‘John James A New Evidence Based Estimate Of Patient Harms 2013 (1)’. N.p., 2015. Web. 15 Nov. 2015.

iv James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care: Journal of Patient Safety, 9(3), 122–128. http://doi.org/10.1097/PTS.0b013e3182948a69

v Hayward, R. A., & Hofer, T. P. (2001). Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer. JAMA, 286(4), 415. http://doi.org/10.1001/jama.286.4.415

vi Efsa.europa.eu,. ‘Scientific Opinion On The Safety Of Caffeine | European Food Safety Authority’. N.p., 2015. Web. 15 Nov. 2015. http://tinyurl.com/olrx5cw

vii Levin, E. D., McClernon, F. J., & Rezvani, A. H. (2006). Nicotinic effects on cognitive function: behavioral characterization, pharmacological specification, and anatomic localization. Psychopharmacology, 184(3-4), 523–539. http://doi.org/10.1007/s00213-005-0164-7

viii Bostrom, N., & Sandberg, A. (2009). Cognitive Enhancement: Methods, Ethics, Regulatory Challenges. Science and Engineering Ethics, 15(3), 311–341. http://doi.org/10.1007/s11948-009-9142-

ix Palazzolo, D. L. (2013). Electronic Cigarettes and Vaping: A New Challenge in Clinical Medicine and Public Health. A Literature Review. Frontiers in Public Health, 1. http://doi.org/10.3389/fpubh.2013.00056

x Sood, A. (2012). Indoor Fuel Exposure and the Lung in Both Developing and Developed Countries. Clinics in Chest Medicine, 33(4), 649–665. http://doi.org/10.1016/j.ccm.2012.08.003

xi PsychNet ‘Affect and memory: A review. ‘. N.p., 2015. Web. 15 Nov. 2015. http://tinyurl.com/qbmw2sx

xii Eich, James Eric. ‘The Cue-Dependent Nature Of State-Dependent Retrieval’. Mem Cogn 8.2 (1980): 157-173. Web. 15 Nov. 2015.

xiii Buffum, M. D., Hutt, E., Chang, V. T., Craine, M. H., & Snow, A. L. (2007). Cognitive impairment and pain management: Review of issues and challenges. The Journal of Rehabilitation Research and Development, 44(2), 315. http://doi.org/10.1682/JRRD.2006.06.0064

xiv Stewart, S. A. (2005). The effects of benzodiazepines on cognition. The Journal of Clinical Psychiatry, 66 Suppl 2, 9–13.

xv Diamond, D. (2005). Cognitive, Endocrine and Mechanistic Perspectives On Non-linear Relationships Between Arousal and Brain Function. Nonlinearity in Biology, Toxicology, and Medicine, 3(1), 1–7. http://doi.org/10.2201/nonlin.003.01.001

xviii Crean, R. D., Crane, N. A., & Mason, B. J. (2011). An Evidence-Based Review of Acute and Long-Term Effects of Cannabis Use on Executive Cognitive Functions: Journal of Addiction Medicine, 5(1), 1–8. http://doi.org/10.1097/ADM.0b013e31820c23fa

xix Ilieva, I. P., & Farah, M. J. (2013). Enhancement stimulants: perceived motivational and cognitive advantages. Frontiers in Neuroscience, 7. http://doi.org/10.3389/fnins.2013.00198

xx Pringsheim, T., & Steeves, T. (2012). Cochrane Review: Pharmacological treatment for Attention Deficit Hyperactivity Disorder (ADHD) in children with comorbid tic disorders. Evidence-Based Child Health: A Cochrane Review Journal, 7(4), 1196–1230. http://doi.org/10.1002/ebch.1861

xxi Bagot, K. S., & Kaminer, Y. (2014). Efficacy of stimulants for cognitive enhancement in non-attention deficit hyperactivity disorder youth: a systematic review. Addiction (Abingdon, England), 109(4), 547–557.

xxii Mariani, John J., John J. Mariani, and Frances R. Levin. ‘Treatment Strategies For Co-Occurring ADHD And Substance Use Disorders’. Am J Addict 16.s1 (2007): 45-56. Web. 15 Nov. 2015.

xxiii Garnock-Jones, K. P., & Keating, G. M. (2009). Atomoxetine: A Review of its Use in Attention-Deficit Hyperactivity Disorder in Children and Adolescents. Pediatric Drugs, 11(3), 203–226. http://doi.org/10.2165/00148581-200911030-00005

xxiv Hoffman, R., & Al’Absi, M. (2010). Khat use and neurobehavioral functions: Suggestions for future studies. Journal of Ethnopharmacology, 132(3), 554–563. http://doi.org/10.1016/j.jep.2010.05.033

xxv Urban, K. R., & Gao, W.-J. (2014). Performance enhancement at the cost of potential brain plasticity: neural ramifications of nootropic drugs in the healthy developing brain. Frontiers in Systems Neuroscience, 8. http://doi.org/10.3389/fnsys.2014.00038

xxvi Dusan Kolar, Lily Hechtman. ‘Treatment Of Adults With Attention-Deficit/Hyperactivity Disorder’. Neuropsychiatric Disease and Treatment 4.2 (2008): 389. Web. 15 Nov. 2015.

xxvii Urban, K. R., & Gao, W.-J. (2014). Performance enhancement at the cost of potential brain plasticity: neural ramifications of nootropic drugs in the healthy developing brain. Frontiers in Systems Neuroscience, 8. http://doi.org/10.3389/fnsys.2014.00038

xxviii Urban, K. R., & Gao, W.-J. (2014). Performance enhancement at the cost of potential brain plasticity: neural ramifications of nootropic drugs in the healthy developing brain. Frontiers in Systems Neuroscience, 8. http://doi.org/10.3389/fnsys.2014.00038

xxix Gross, M. L., & Carrick, D. (2013). Military medical ethics for the 21st century. Farnham, Surrey, England: Ashgate. Retrieved from http://public.eblib.com/choice/publicfullrecord.aspx?p=1160538

xxx Towards responsible use of cognitive-enhancing drugs by the healthy. Nature 456, 702-705 (11 December 2008) | doi:10.1038/456702a; Published online 10 December doi:10.1038/456702a

xxxi Mehlman, M. J. (2004). Cognition-Enhancing Drugs. The Milbank Quarterly, 82(3), 483–506. http://doi.org/10.1111/j.0887-378X.2004.00319.x

xxxii Adams, Jared. ‘Cochrane For Clinicians: Immediate-Release Methylphenidate For The Treatment Of ADHD In Adults – American Family Physician’. Aafp.org. N.p., 2015. Web. 15 Nov. 2015.

xxxiii van den Ban, Els et al. ‘Less Discontinuation Of ADHD Drug Use Since The Availability Of Long-Acting ADHD Medication In Children, Adolescents And Adults Under The Age Of 45 Years In The Netherlands’. ADHD Attention Deficit and Hyperactivity Disorders 2.4 (2010): 213-220. Web. 15 Nov. 2015.

xxxiv Biederman, J., Monuteaux, M. C., Spencer, T., Wilens, T. E., & Faraone, S. V. (2009). Do Stimulants Protect Against Psychiatric Disorders in Youth With ADHD? A 10-Year Follow-up Study. PEDIATRICS, 124(1), 71–78. http://doi.org/10.1542/peds.2008-3347

xxxvii Castells, Xavier et al. ‘Amphetamines For Attention Deficit Hyperactivity Disorder (ADHD) In Adults’. Cochrane Database of Systematic Reviews (1996): n. pag. Web. 15 Nov. 2015.

xxxviii Wang, G.-J., Volkow, N. D., Wigal, T., Kollins, S. H., Newcorn, J. H., Telang, F., … Swanson, J. M. (2013). Long-Term Stimulant Treatment Affects Brain Dopamine Transporter Level in Patients with Attention Deficit Hyperactive Disorder. PLoS ONE, 8(5), e63023. http://doi.org/10.1371/journal.pone.0063023