Pill wars: debate heats up over 'brain booster' drugs.
Adults are taking stimulants like Ritalin and Adderall, normally used to treat serious medical conditions, to boost their concentration and job performance. Critics ask: Is it making Americans too dependent on their medicine cabinets?
By Gregory M. Lamb | / staff writer
from the May 10, 2009 edition

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Boston - It's a play right out of the Twitter era and the family medicine cabinet. "Distracted," at an off-Broadway theater in New York, examines the ever-shortening attention span of modern life – including the moral conundrum of whether a restive 9-year-old should be given pills to alter his mood.

At one point, an actor breaks from character to address the audience directly and advocate the use of Ritalin and Adderall, two prescription stimulants, which, he says, helped him learn his lines. [Editor's note: The
original version wrongly called Ritalin and Adderall over-the-counter drugs.]

The aside encapsulates a growing debate in scientific circles and living rooms across America: Should adults be using so-called "brain-boosting" drugs – normally intended to treat serious medical conditions – to improve concentration and performance?

College students, of course, have been using stimulants for years: They take such things as modafinil, Adderall, and Ritalin (euphemistically known on campuses as "vitamin R") to enhance their memories for exams or to stay up all night and press out a term paper. By one estimate, at least 10 percent of American college students use prescription drugs as study aids.

Now the general adult population is turning to the pills, too – often illegally – to boost productivity and enhance their mental prowess on the job. Some experts laud the development: They think it's time to consider making the stimulants legal for brain-boosting functions.

But critics worry it will accelerate a slide toward a drugged society. In an era when people take everything from Viagra to enhance their romance to steroids to enhance their baseball statistics, they argue that the addition of so-called "cognitive enhancement" drugs will only make us more dependent on the pill bottle.

Ultimately, it raises the most fundamental questions about identity and what it means to be human: Are we the sum of our experiences or the sum of our pills? As Carl Elliott writes in his book, "Better than Well: American Medicine Meets the American Dream": "Today, enhancement technologies are not just instruments for self-improvement, or even self-transformation – they are tools for working on the soul."

LAST SUMMER, Michael Arrington, the founder of the influential technology blog TechCrunch, wrote a post asking, "How many Silicon Valley start-up executives are hopped up on Provigil?" He was referring to the stimulant, which is the brand name for modafinil, that doctors normally prescribe to treat excessive drowsiness associated with narcolepsy and other sleep disorders. "[T]he buzz lately is that it's the 'entrepreneur's drug of choice' around Silicon Valley," the post said.

In an online poll in the British science journal Nature last year, answered by 1,400 people in 60 countries, 1 in 5 said they had used drugs for nonmedical reasons "to stimulate their focus, concentration, or memory." Only about half had a prescription for the drug they were using. A third had bought the drugs over the Internet. And even though about half reported unpleasant side effects, 4 out of 5 "thought that healthy adults should be able to take the drugs if they want to," Nature reported.

Philip Harvey is one who uses them. A professor of psychiatry and behavioral sciences at Emory University in Atlanta, he regularly flies from Georgia to Europe on business. To prepare for his flight, he takes modafinil. He uses the stimulant to feel alert and rested, despite lost sleep, allowing him to return to his family faster. He has no trouble getting a prescription from his doctor. "From Atlanta, I can get to Europe by 6 a.m. and give a 9 a.m. presentation," he says. "It lets you go and come back the same day, or go over one day and come back the next."

In the current debate over brain boosters, the focal point of much of the discussion has been a commentary in the December issue of Nature. Seven prominent bioethicists noted that the drugs "are 'disruptive technologies' that could have a profound effect on human life in the twenty-first century." While calling for more research to better understand the safety and effectiveness of use in healthy individuals, the piece went on to advocate that "mentally competent adults should be able to engage in cognitive enhancement using drugs."

In the months since, the paper has met with both hearty approval and deep reservations from scientists and other bioethicists. "Anything that can help our brains deal better with the complex challenges of the twenty-first century is to be not only welcomed but actively sought," wrote Nick Bostrom, director of the Future of Humanity Institute at the University of Oxford, in a letter to the journal.

The commentary served its purpose to "kick up" a needed discussion, says Henry Greely, a bioethicist and professor of law at Stanford University and one of the coauthors of the Nature commentary. He received far more e-mails about the article than for any other he's published. The aim, he said, was to argue that "enhancement is not fundamentally a dirty word."

"I think people should think of [drugs] as just one more of many different ways we try to improve our minds," Dr. Greely says. "I'm a teacher. I'm in the enhancement business. I'm trying to enhance my students' brains."

But others were disappointed with the commentary. "It's not really a piece of science. It's an editorial arguing that we should use more drugs," says George Annas, chairman of the department of Health Law, Bioethics, and Human Rights at Boston University. He wonders why an article taking the other side of the debate didn't accompany it, and why the authors called for looser strictures on use of the drugs before more is known about them. "The way you make sure they're not harmful is you do a study before you widely advise people to use them," he says.

Critics argue more time is needed with the petri dishes and field testing before the drugs are used as mind enhancers. "The reality [is] that there is very little research to document whether [these drugs] are universally beneficial, whether they could be detrimental, what are the long-term outcomes, what are the side effects," says Nora Volkow, director of the National Institute on Drug Abuse, a US government agency. "There's really very, very limited knowledge."

What troubles Dr. Volkow is how the commentary dismissed the dangers of these drugs, equating taking them with drinking coffee, "which is, to say the least, an irresponsible way to present it and an inaccurate one," she says.

In March, Volkow published a small preliminary study showing that taking modafinil might be addictive in humans, increasing the levels of dopamine, a neurotransmitter that plays a major role in addiction.

Nearly everyone talking about brain-boosting drugs agrees that they ought to be both safe and effective before being widely used. But some worry about other problems they present. Would workers, for example, feel coerced to use enhancement drugs in order to win promotions or even simply to keep their jobs?

"For example, what if hospitals started to demand that medical residents dose up on methylphenidate, a drug used to improve concentration, as a prerequisite for employment?" asks Jacob Appel in an article last year in the Journal of Medical Ethics called "When the boss turns pusher." Or what if fast-food chains insisted that employees take antidepressants to keep them calm and upbeat when confronted by dissatisfied customers?

Employers may face a dilemma. "Denying some individuals the opportunity to enhance in this way clearly undermines their right to do with their bodies as they choose," he says. "However, to permit some to engage in these enhancements may lead to an inevitable race to the bottom – or top – in which employers and market forces pressure more and more American workers to place their brains at the disposal of their bosses."

More broadly, some worry that as more brain-enhancing drugs come on the market in the next 10 to 15 years, countries may battle for "neuro competitive advantage" in the workforce. If you're a 58-year-old person living in Boston who's competing with a 25-year-old in Mumbai, for instance, you might be tempted to use the drugs – whether or not they're legal in the US, notes Zach Lynch, executive director of the Neurotechnology Industry Organization, a trade group.

Moreover, even if they are illegal, or regulated, enforcing those controls would be difficult. "Living in a global economy, I think it's going to be very hard to regulate the use of these [drugs] in the future, if they're safe and effective," Mr. Lynch says.

Brain-boosting drugs are already being considered for another workplace – the military. The Defense Advanced Research Projects Agency is working on "all kinds of drugs to make you stronger, to make you eat less," says Dr. Annas. "They want soldiers to function for up to five days without sleep. That would certainly require drugs. Whether that would have any long-term consequences, I don't think anybody knows yet."

A drug called donepezil, developed to treat Alzheimer's disease, has been shown to modestly increase memory in healthy people. It may become a Viagra-like hit with baby boomers worried about cognitive decline. Work is also under way to use drugs or other methods to selectively erase memories, something that could be used to ease post-traumatic stress among soldiers returning from war, allowing them to forget what they did on the battlefield. Annas sees problems here. "I think we want to have remorse about killing," he says.

Advocates point out that humans already "enhance" their thinking in a variety of ways, from drinking beverages with caffeine (a known stimulant), to exercising to brighten their mood, to relying on a computer to increase knowledge, to simply getting a good night's sleep before a big test.

But for some, a caution light goes on when we're changing the way the brain works, particularly when so little is known about it. "Not only do we not have a model for how our brains do complex tasks, we can't even imagine one," Dr. Karl Deisseroth, a neuroscientist at Stanford University, told Wired magazine earlier this year.

AT THE MOST FUNDAMENTAL LEVEL, the drugs challenge perceptions of who we are. Some people believe the next big scientific revolution will be turning our technological prowess on the world within, notably our brains, rather than the world around us. Neuroscience, which includes the development of brain enhancers, is part of this "revolution."

In this realm, some experts suggest that using pills to alter thinking or mood comes too close to altering our sense of self. "In seeking by these [biotechnologies] to be better than we are or to like ourselves better than we do, we risk 'turning into someone else,' confounding the identity we have acquired through natural gift cultivated by genuinely lived experiences," wrote Leon Kass in a 2003 report on human enhancement from the President's Council on Bioethics.

Yet others argue the definition of what is one's "real" self will be up to the individual – and should be.

"It's not at all clear that people feel more themselves when they're unmedicated than when they're medicated," says James Hughes, director of the Institute for Ethics and Emerging Technologies in Hartford, Conn. "Some people are going to feel more 'themselves' when they take the drugs, and some are not going to feel more themselves."

As drug and biotechnology companies look to expand their products and markets, more possibilities for illicit use may lie ahead. Cephalon Inc. is planning to launch Nuvigil, a longer-lasting version of Provigil, later this year. The company sold nearly $1 billion of Provigil last year, but the drug is going off patent in 2012. Cephalon says a study shows that Nuvigil works to alleviate jet lag, and it is expected to ask the Food and Drug Administration (FDA) to add jet lag as a new medical condition.

Many argue that more research is needed on existing drugs before we start thinking about new ones. Greely, for one, says we don't have any "real evidence about the effects, short-term or long-term," of Adderall and Ritalin, which are both used to treat attention-deficit hyperactivity disorder, on healthy people. As companies seek approval from the FDA for new drugs, if they seem likely to be used for enhancement, "we should require some research on those off-label uses," he says.

If a drug is truly quite safe, he says, the FDA could make an early decision to permit over-the-counter sales. On the other hand, it also could place tough limits on who could prescribe a particular drug or limit the number of pills per prescription.

In the end, if it's true that we only use a small part of our brain now, people are always going to try to improve on that, Annas says, "and drugs are a way in."

"But we certainly want to think this through and do careful, controlled studies before we move toward over-the-counter sales."

• Sarah More McCann contributed to this story