Experts Clash Over Cognitive Enhancers for Healthy People

Megan Brooks

December 24, 2012

Physicians should "seriously consider" refusing to prescribe medications for cognitive enhancement to healthy individuals, according to a new analysis article.

Dr. Eric Racine

"An emerging discussion in the medical and ethics literature on the acceptability and the responsibility of physicians to prescribe cognitive enhancers to healthy individuals prompted us to reflect on this issue and write this paper," Eric Racine, PhD, from the Neuroethics Research Unit, Clinical Research Institute of Montreal, Quebec, Canada, told Medscape Medical News.

The article was published online December 17 in the Canadian Medical Association Journal.

Research suggests that up to 11% of college students who are without attention deficit disorder (ADD) use stimulants to boost concentration and alertness, Dr. Racine and coauthors note in their article. Research shows that up to 77% of students get these medications from fellow students, but others may ask their doctor to prescribe stimulants.

"We do not have very good data detailing prevalence of use or of requests (or increase in prevalence) in Canada or the United States at this time, but the issue has salience because of the ethical questions associated with it," said Dr. Racine.

"Diverging perspectives on how cognitive enhancement aligns with medical professional integrity indicate that cognitive enhancement is not yet a general or an accepted medical practice," he added.

Opposing Views

In the article, Dr. Racine and coauthors assert that the clinical and social benefits of neuroenhancers for healthy individuals are "not well supported by scientific and professional literature," and in their view, physicians should not prescribe them to healthy people.

But Derryck Smith, MD, clinical professor of psychiatry at the University of British Columbia, Vancouver, Canada, feels differently. He told Medscape Medical News that he "disagrees entirely" with the authors of this article.

Dr. Smith believes psychiatrists should play a central role in discussions about nonmedicinal use of cognitive enhancement drugs.

"These medications are available now — people are buying them online or getting them from their friends, so we can't keep our heads in the sand," he told Medscape Medical News in 2010, after delivering a workshop on the subject at the Canadian Psychiatric Association (CPA) 60th Annual Conference.

R. Scott Benson, MD, child and adolescent psychiatrist in private practice in Pensacola, Florida, who is also a member of the American Psychiatric Association (APA), said research shows that stimulants improve concentration and focus.

"If you are a normal person with a normal attention span and you took one, then your attention span probably will go longer," Dr. Benson told Medscape Medical News.

However, he added that he does not believe this is a huge issue for practicing physicians.

"I don't think physicians are going to be in a position to prescribe [stimulant] medications to healthy people because in order to get paid for it, they have to say that the patient has a condition. I can't see healthy people in my office and treat them for something they don't have."

But Dr. Benson acknowledged that "our society is certainly into all kinds of enhancements." Take the number of commercials shown on nightly television touting treatments for low testosterone levels.

"I wonder," said Dr. Benson, "where did this come from? Why do we suddenly have an epidemic of low testosterone in this country?"

No Official Position

The American Academy of Neurology (AAN) has issued guidance on "neuroenhancement" for healthy individuals (Neurology 2009;73:1406-1412), in essence saying that physicians can but are not obliged to grant requests for cognitive enhancers to healthy individuals.

To date, neither the APA nor the CPA has stated an official position on the issue.

But Dr. Benson told Medscape Medical News that in general, the APA's "position" is that "doctors should always be good doctors."

"We have good evidence that treatment of people who have ADHD [attention-deficit/hyperactivity disorder] with stimulant medication makes a world of difference for them by improving their overall function and adjustment. The APA would never have a position of doing any kind of medical treatment to people who are otherwise healthy, and we certainly have a huge interest in discouraging substance misuse because of the risk that it leads to substance abuse," Dr. Benson said.

In general, healthy people are not going to psychiatrists and asking for stimulants, Dr. Benson noted.

"They may be asking their family physician, and there are family physicians who are more liberal in prescribing medication, and there are those who are more conservative in their prescribing."

Dr. Racine said he hopes the article prompts "reflection and discussion" in the medical community about the use of cognitive enhancers in healthy individuals.

Dr. Racine and coauthor Cynthia Forlini have disclosed no relevant financial relationships. Coauthor Serge Gauthier, MD, has served as a consultant for Lilly, Sanofi, Pfizer, Janssen, and Merck. He has provided expert testimony at a Health Canada meeting on the behalf of Lilly, he has received payment for the development of educational presentations from Merck Canada, and he is a member of the data safety monitoring boards of Bristol-Myers Squibb and Elan. He has also served as scientific advisor for United BioSource and Servier. Dr. Smith has served on advisory boards for Eli Lilly Canada Inc, Janssen-Ortho Inc, Purdue Pharmaceuticals, and Shire Canada Inc. Dr. Benson has disclosed no relevant financial relationships.

CMAJ. Published online December 17, 2012.