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Lloyd I. Sederer, MD Headshot

Paying the Piper: Brain "Neuroenhancers"

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I read recently that the United States Air Force was "making available" the drug modafinil (Provigil®) to pilots on long missions. Modafinil is a type of stimulant approved by the FDA for narcolepsy and sleep apnea (resulting in severe daytime problems staying awake). I knew that stimulants like Ritalin® and Adderall® had extended far beyond their medically recognized use for Attention Deficit Hyperactivity Disorder (ADHD) and, like modafinil, were increasingly used by high school and university students to improve their performance on tests and papers. Those already in highly competitive financial and legal jobs were also discovering these drugs in order to keep up with the pace and productivity that success seemed to demand. It is now a reality that stimulant drugs have developed a role beyond their FDA approvals and become "neuroenhancers" - medications to improve memory, concentration, and mental functioning. They seem to provide an edge, a way of defying fatigue, achieving greater focus, and overcoming the boredom of everyday repetitive tasks. I started to wonder if I could use some modafinil.

In late 2007 the British Medical Association (BMA) took up the medical and moral challenges of neuroenhancers by publishing a "discussion paper" called Boosting your brainpower: ethical aspects of cognitive enhancements. Trying to "encourage debate" on efforts to "improve upon nature" they stressed that enhancers are creating vexing problems about how to balance individual freedom to improve performance with public health and ethical concerns about potential short and long term harm - for adults as well as the children whose parents will see fit to try to add octane to their child's brainpower. A commentary in late 2008 in the prestigious journal Nature called Use of Cognitive Enhancement Drugs implied the inevitability of these agents and that "...Society must respond to the growing demand...by rejecting the idea that 'enhancement' is a dirty word." Their policy recommendations aim to insert some intelligence and control into what appears to be the future of a society built on cognitive enhancers "...increasingly useful for improved quality of life and extended work productivity." But I thought, when they say that something is too good to be true, it usually is too good to be true.

Fortunately, Dr. Nora Volkow, director of the National Institute of Drug Abuse (NIDA), and colleagues have been studying modafinil and in March 2009 published their findings in the Journal of the American Medical Association (JAMA). They were able to show that modafinil exerts its effect by increasing brain dopamine (as do the rest of the stimulant drugs, including cocaine and methamphetamine). What this means is that they have the potential for tolerance and abuse where more of the drug is needed to achieve the same effect and the brain craves for the drug if it is not present. The piper in these drugs may play quite a tune but you will have to pay the piper.

If you, your child or your loved one has a medical condition like ADHD or narcolepsy then the benefit of stimulants is likely to outweigh the risk (especially if combined with cognitive behavioral interventions). But if you do not, you are entering the world of performance enhancement - not the same thing as the treatment of a disorder - where many have tread and paid a great price. Neuroenhancers stand to become yet another cautionary tale in which promise is soon eclipsed by problems. So, I have decided to stick to coffee and tea, nourishing foods, learning a language or doing crosswords, reading and writing more, and getting some needed sleep - all of which ages of experience have shown enable us to think and perform better, safely, the old fashioned way.