During the past few years considerable debate has arisen within academic journals with respect to the use of smart drugs or cognitive enhancement pharmaceuticals. The following paper seeks to examine the foundations of this cognitive enhancement debate using the example of methylphenidate use among college students. The argument taken is that much of the enhancement debate rests upon inflated assumptions about the ability of such drugs to enhance and over-estimations of either the size of the current market for such drugs or the rise in popularity as drugs for enhancing cognitive abilities. This article provides an overview of the empirical evidence that methylphenidate has the ability to significantly improve cognitive abilities in healthy individuals, and examines whether the presumed uptake of the drug is either as socially significant as implied or growing to the extent that it requires urgent regulatory attention. In addition, it reviews the evidence of side-effects for the use of methylphenidate which may be an influential factor in whether an individual decides to use such drugs. The primary conclusions are that neither drug efficacy, nor the benefit-to-risk balance, nor indicators of current or growing demand provide sufficient evidence that methylphenidate is a suitable example of a cognitive enhancer with mass appeal. In light of these empirically based conclusions, the article discusses why methylphenidate might have become seen as a smart drug or cognitive enhancer.
- Biomedical enhancement
- social values
- social control of science/technology
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- Biomedical enhancement
- social values
- social control of science/technology
The new wave of neurological technologies, especially psychotropic drugs, have attracted considerable attention within academic literature. Collectively, the discussion refers to the use of these technologies to improve the lives of people who would be currently be considered neurologically healthy (ie, they are not diagnosed with any form of mental disorder). Bioethicists in particular have become interested in the implications of widespread neurological enhancement for issues of equality, choice, coercion and the ‘authenticity’ of experience.1–6 It is not the place of this paper to rehash these debates. Instead, the approach taken is to focus upon one particular form of neurological enhancement, the use of methylphenidate by college and university students, which has taken up a role as a springboard for these discussions. The intention is use this technological and social focus to provide a critical exploration of basis to these bioethical discussions, and to suggest alternative frames by which to explore cognitive enhancement.
As referred to above, the illicit use of methylphenidate by college students has become integral to the launching of discussions concerned with enhancement. As an example of this framing of methylphenidate in relation to enhancement and college student use, Greeley et al have stated that “many of the medications used to treat psychiatric and neurological conditions also improve the performance of the healthy. The drugs most commonly used for cognitive enhancement at present are stimulants, namely Ritalin (methylphenidate) and Adderall (mixed amphetamine salts).”5 (The first line of the article refers to the illicit trade in methylphenidate among students). A similar case is made for including methylphenidate as an enhancement drug by Sahakian & Morein-Zamir and Farah et al when they explore the illicit use of methylphenidate and ask questions about future regulation of this market. Once again the articles refer to a growing use (in particular among students) of methylphenidate as a cognitive enhancer.4 7 Lastly, Sandel has stated that “since stimulants [such as methylphenidate] work for both medical and non-medical purposes, they raise the same moral questions posed by other technologies of enhancement.”8 Sandel's case is made as part of wider argument concerning how new technologies might be driving us into a culture of pharmaceutically derived perfectionism, based upon the widespread use of such drugs.
The objective of referring to these discussions is not to criticise the articles themselves or become deeply engaged in their content. Indeed such articles are of great interest for exploring the directions where such drug use might take us. However, in order for these deliberations to be relevant beyond narrow academic confines, it argued they need to be grounded in scientific and social realities. Some observers of this literature have challenged bioethicists and philosophers to demonstrate that their concerns have an empirical grounding.9 In addition, they have called on discussants to avoid assuming that the merely possible is somehow inevitable and to reflect upon the potential for the discussion itself to hype the benefits and dangers of such technologies in equal measure.10 11 Taking these arguments into consideration, and basing initial questions upon Williams and Martin's appeal for greater empirical evidence to support claims concerning the future of cognitive enhancement, the first section of this paper will examine the following questions (i) what is the evidence for methylphenidate's efficacy as pharmacological enhancer? (ii) Could side-effects limit the popular desire to take psychotropic enhancers? (iii) What evidence is there of an existing or emerging market for the drug?9 The discussion that follows is based upon this empirical overview; summarising these findings and suggesting alternative ways of understanding and exploring what has come to be seen as cognitive enhancement.
What is the evidence for methylphenidate's efficacy as pharmacological enhancer?
Methylphenidate was first synthesised in 1944 and marketed by Ciba-Geigy Pharmaceutical Company as Ritalin. During the 1950s the product was used in relation to a variety of conditions such as chronic fatigue, depression and narcolepsy.12 However, the current prescription-based use of methylphenidate is primarily for the treatment of attention deficit hyperactivity disorder (ADHD). While the precise pharmakinetic properties of methylphenidate are not under review in this study, it would appear that that the slow-release action of methylphenidate works to improve the concentration abilities of people diagnosed with ADHD, by controlling excessive production of dopamine (hyperactivity) while increasing the rate at which biochemical reward (required for concentration) is achieved by reducing dopamine reuptake.13–15 However, evidence of methylphenidate's pharmaceutical efficacy in improving cognitive ability in individuals without ADHD is equivocal.16 17 Some studies appear to indicate that methylphenidate is able to demonstrate limited cognitive enhancing properties, while others appear to contradict this. For example, Mehta has reported evidence for an improvement in spatial working memory in healthy adults.18 Similar findings concerning spatial working memory improvement have been found by Elliott et al19 However, Mehta's study has suggested that benefits for spatial working memory are proportional to baseline ability. As such, improvements may decrease the higher the existing (non-medicated) spatial working memory functionality is in the individual. Elliot et al also report that “by contrast, there were no significant effects on non-spatial tests”.19 Elliot's findings appear to confirm a previous report by Koelega that there is little evidence to suggest non-spatial task improvement in healthy individuals using methylphenidate.20 Regarding the conclusions to be drawn from these studies (and citing Elliot), Schermer et al report that methylphenidate “does not appear to have effect on concentration or sustained attention in healthy volunteers. Moreover, while methylphenidate enhances executive function on novel tasks, it impairs previously established performance.”21 Finally, studying the effect of methylphenidate on an older, healthy population group, Turner has reported that no improvements in spatial span and spatial working, response inhibition (stop-signal) or sustained attention (rapid visual information processing) were seen in volunteers.22 In summary, problems with compatibility of study outcomes and the limited number of studies on specifically healthy population groups make it difficult to reach conclusions about the enhancing capabilities of this drug in real world situations.
Could side-effects limit mass appeal?
Studies on children and adults using methylphenidate for treatment of ADHD have reported generalised and relatively mild side-effects with respect to the use methylphenidate at regular doses. Some of the most frequently referred to shorter and medium-term side-effects include decreased appetite, dry mouth, sleeping problems, repetitive movements (tics), and mild forms of depression.23 However, few side effects appear to reach a level of statistical significance. In a study conducted by Kooij et al in 45 adults on the efficacy of methylphenidate with ADHD, the only statistically significant adverse effect that occurred more often using methylphenidate than using placebo was loss of appetite (22% vs 4%; p=0.039).24 Similarly, Spencer et al have recorded that “of individual side effects reported, only MPH-associated [methylphenidate-associated] appetite suppression, dry mouth, and mild moodiness reached our threshold for statistical significance”.25 However, in a recent systematic review of the use of methylphenidate in adults, Godfrey found that “across all the studies that reported on the adverse effect in question, the following were reported significantly more often in the methylphenidate arm [compared to placebo arm] of the trial: dry mouth (31% vs 11%); decreased appetite/anorexia (27% vs 9%); moody/mood lability (18% vs 2%); jitteriness/tension (22% vs 5%); depression/sadness (21% vs 9%); weight loss (11% vs 0%); vertigo (12.5% vs 2%).”26 Very little is known about longer term use among healthy users, although there is no reason to suspect that regular use will be accompanied by any fewer incidences of side-effects. More acute side-effects have been found to be associated with irregular forms of usage in adults (irregular tablet use or smoking and/or injecting methylphenidate). In addition to concerns regarding adverse side effects, concerns have also been raised with respect to the addictive qualities of methylphenidate. Kollins' review of published articles referring to the addictive effects of methylphenidate states that in “10 out of 11 studies for which comparative data were reported, the reinforcing effects of methylphenidate were generally similar to those of cocaine and D-amphetamine” and concludes that “the results of the present review suggest that methylphenidate, even in typically administered oral form, is not benign with respect to abuse potential”.27
In summary, although side-effects do not appear to be as acute as for other forms of stimulant abuse there is considerable evidence that methylphenidate is not free of side-effects (along with all forms of drug use) in regular or irregular use, and has the potential to be addictive. It will be difficult to extrapolate what impact this evidence would have upon whether people choose to take methylphenidate (given that people continue to smoke despite evidence of its ill-effects and lack of benefits). However, while evidence of side-effects will not determine the size of the market for methylphenidate, it would be highly surprising if such evidence had no effect on demand.
What evidence is there of an existing or emerging market for the drug?
Measuring the current market for cognitive enhancement by using methylphenidate presents difficulties. Firstly, such a market needs to be distinguished from people using methylphenidate with a diagnosis of ADHD (or other illness associated with methylphenidate prescriptions). Secondly, motivations for use need to be identified (what is it being used for?). This leaves, primarily, a market whereby drugs have been obtained illicitly through friends, purchasing of tablets and/or faking of symptoms. (In certain studies illicit use also includes people with a legitimate diagnosis but using methylphenidate in ways that are deliberately different to intended prescription use—binge tablet use, smoking, snorting or injecting). According to the US Monitoring the Future: National Survey Results on Drug Use 1975–2007, college students' rate of annual use in 2007 was at 3.7% and the non-college group was 2.3%.28 By comparison college marijuana use was 31.8%. Other recorded prevalence rates in the survey included: amphetamines (overall—including methylphenidate) (6.9%), tranquilisers (5.5%), cocaine (5.4%), hallucinogens (4.9%) and heroin (0.2%). Other studies, using differing methodologies and recording prevalence over differing time periods, have indicated a considerably higher use of methylphenidate in the college population (but without comparative figures for other forms of drug use). For example, White et al report that 16.2% for lifetime of the student population in their research self-reported the misuse or abuse of stimulants.29 Of this 16.2%, 96% specified that Ritalin was their stimulant of choice, with 2% reporting that Adderall was the abused drug. The study found that 15.5% of misusers were abusing two or three times a week, 33.9% one or two times per month, and 50.6% two or three times a year. As such, regular abuse of stimulants was relatively rare, amounting to approximately 8% of the student population sampled using illicit stimulants (predominantly methylphenidate) at least once a month. Other studies have reported prevalence figures for lifetime use of 16%,30 14% (11% female and 17% male),31 and 8%32 and annual use at 5.4%.32 Figures are clearly difficult to compare due to the differing methodologies being employed with some referring to lifetime usage (at least once during life) and others referring to specific time periods. These figures are further complicated (with respect to the enhancement debate) by evidence that the motivations for using methylphenidate are diverse and are often strongly connected to recreational drug taking rather than to drug taking for what might be seen as cognitive enhancement. In the White study, of 1025 returned surveys from students of the University of New Hampshire, improving attention was given as the dominant reason for misuse, partying given as relatively close second, improving studying habits and grades were third and fourth respectively, with reduction in hyperactivity given as the fifth reason.29 Meanwhile in the Barrett et al study of McGill University in Canada “70% of those who used MPH [methylphenidate] reported using it for recreational purposes, while the remaining 30% reported using it exclusively as an aid for study”.33 In summation, while it should not be concluded that such figures are trivial, it is also difficult to make informed judgements about the size of the market and the motivations for use.
It could be argued that current figures for illicit use are just the beginning of a newly emerging market. However, statistical trends are, once again, equivocal concerning growth in the methylphenidate market. According to the US National Survey Results on Drug Use, 1975–2008 in Secondary Schools, the illicit use of methylphenidate (recorded as Ritalin use) rose from 0.1% in 1992 to 2.8% in 1997 (recorded as annual use). This remained relatively stable for next five years before jumping to 3.9% in 2004, after which there has been a decline in use.34 Within the college population longer term trends are not available. However, the use of methylphenidate from 2002 to 2007 are indicative of a slight fall in use within college students (down from 5.7% annual prevalence in 2002 to 3.7% in 2007), in (non-college) young adults generally (ages 19–28) (down from 2.9% to 2.4% from 2002 to 2007), and within the 12th grade (4.0% to 3.8% from 2002 to 2007).28 The idea that this is steadily or rapidly growing market is therefore contradicted statistically (at least according to the available records). Finally, it might be argued that and that demand is likely to be significantly suppressed by knowledge that methylphenidate is an illegal drug. However, with respect to the influence of methylphenidate's illicit status, student perceptions that the drug is widely available within some universities29 and the extremely low rate of drug arrests for methylphenidate suggests that the illegal status of the drug has not necessarily suppressed demand.35
While it is difficult to draw firm conclusions from this evidence as to whether the market is socially significant currently, or growing rapidly, it can tentatively be asked whether such empirical evidence is really suggestive of a large or ‘growing demand for cognitive enhancement’ as suggested by commentaries on the implications of cognitive enhancement.5
Williams and Martin have challenged “expert-led deliberations on the prospects and implications of cognitive-enhancing drugs” to become less speculative, stating that that such discussion is “not well grounded in evidence or experience”. Unless these challenges are met, they argue that “the debate, as it stands, will continue to be premised upon unrealistic expectations about either the potential benefits, or the threats, to individuals and society”.9 While the foregoing empirical review cannot conclusively show that these deliberations are entirely speculative, it suggests that greater caution be taken in using methylphenidate as an example of a cognitive enhancer. Thus, the following tentative conclusions might be drawn from the available evidence. Firstly, there is an absence of data to conclude that the drug can significantly improve cognitive abilities in ‘healthy’ individuals. Until more observational studies are carried out concerning improvements in cognitive ability, we must be wary of conflating popular assumptions about cognitive enhancement through methylphenidate and treating this as if it were a reality (thus implicitly adding academic weight to these assumptions). Secondly, although side-effects and the potential for addiction may not deter healthy people from using methylphenidate for enhancement; it may be a significant factor in deciding if and how often individuals feel it can or should be used. We must maintain an awareness that this growing use may level off once evidence emerges about its risks in relation to benefits. Third and finally, assumptions about widespread use, regularity of use and growing usage needs to be reviewed with respect to the statistical data available, especially in relation to other forms of illicit drug use. In the light of this evidence, the example of methylphenidate might be replaced by another drug which does have the ability to neurologically enhance healthy individuals and appears to be more widely used for the purposes of enhancement. However, as yet there appears to be no example of such a drug.
Given these empirical indicators, why might methylphenidate be seen as cognitively enhancing? Below, the author provides three discussion points as to why methylphenidate may have come to been seen as cognitively enhancing and sociologically significant despite the lack of empirical evidence. The first is based upon the critique of the enhancement discussion. The second is that while our futuristic thinking may be misleading, it is indicative of an already established sociological desire to find a pharmacological solution to social problems. And, thirdly, combining both the futuristic and contemporary, an argument is put forward that methylphenidate might be seen as an enhancer because the distinction between treatment for a medical illness and personal enhancement by pharmaceutical means is already breaking down.
Potentially, the simplest answer as to why methylphenidate has become a primary case example for enhancement is the intense academic and media speculation about the new wave of neurological technologies, and their abilities to change our lives. Arguably, this has set up a cycle of expectation about what such drugs can do, or might do. Thus, methylphenidate (a long-established pharmacological technology) appears to have been caught up in wider speculations about enhancement (including very different types of enhancement such as deep brain stimulation that are highly unlikely to be used on widespread basis due to their cost and the high risks of such invasive neurological procedures). Sociologists of science have observed that overestimation of the power of new biotechnologies is common in discussion of both their benefits and the risks, feeding into what has been referred to as the dynamics of expectation.11 36 While these dynamics do not necessarily direct the research itself; they can be observed in the framing of discussions whereby “what looks like an improbable, merely possible future in the first half of the sentence, appears in the second half as something inevitable”.10 Arguably, therefore, it is not the drive of technological development that pushes forward both expectations and concerns, but the framing of the debate itself, especially the implicit or explicit jump between the technologically improbable to the presumed urgency of regulatory frameworks to negotiate the consequences of widespread use.
A second reason as to why methylphenidate might be seen as an enhancer is the possible conceptual link between the treatment of ADHD and the expectation of improved learning abilities. If we are to challenge ourselves to meet Nordmann's critique that ethical concerns should not be squandered on incredible futures, especially when they distract from ongoing developments that demand our attention, then we might find that one such ‘ongoing development’ is the use of methylphenidate to medicate for ADHD. In short, if methylphenidate is seen as being associated with educational success (at least catching-up) for schoolchildren, then it is difficult to prevent this framework of understanding educational success becoming more widely appropriated (even if the reality of educational success is better understood as multi-factorial). Indeed, the assumption that methylphenidate will help to achieve success in competitive learning environments is a strong motivator for the use of this drug. Statistically this is borne out in the use of methylphenidate being greater within the university population than the non-university population, which goes against the standard balance of greater illicit drug use among the non-university population.28 Similarly, expectations of improved academic performance have been reported in studies of motivations behind the use of methylphenidate within universities.29 37 As Steven Rose has argued, we might need to explore “the way we live today in advanced industrial societies that drives people to seek pharmacological fixes?”38 Comparison of the different cultural values which are implicit in the uptake of both ADHD as a form of diagnosis and its associated treatments39 40 may help to illuminate why such pharmacological fixes have become increasingly sought, (but without the necessity for the type of speculation that may feed in to the expectation of neurological enhancement from methylphenidate and similar drugs).
Finally, as Nikolas Rose has argued, we may be witnessing a result of the breaking down of the conceptual barrier between health and illness.41 42 The discussion concerning the use of methylphenidate may be the product not of its future potential as a sociologically significant form of an enhancement, but the product of a changed social context in which the barriers between enhancement and treatment are already breaking down. This re-conceptualisation of methylphenidate as an enhancer does not reflect encroaching medicalisation in the sense of the line between treatment and illness being moved. Instead it is argued that the line is becoming less clear. It could be argued that no definitive line between treatment and enhancement has ever been present, especially in relation to neurological illness and preventive treatments. However, whether the breaking down of the barrier between treatment and enhancement is new (or simply newly-recognised academically), it would be difficult to argue that consumer-culture has not had a significant impact upon medical practice. In summary our individual and collective understanding of neurological pharmaceuticals and other forms of neurological intervention has become one in which “recipients of these interventions are consumers, making access choices on the basis of desires that can appear trivial, narcissistic, or irrational, shaped not by medical necessity but by the market and consumer culture”.42 Debates over enhancement, which often rest tentatively on the presumed emerging pharmacological enhancement market, may be seen as reflective of this already changed cultural context in which the dividing line between enhancement and treatment is unsustainable.
Rather than assuming novel neurotechnologies will be able to achieve substantial cognitive enhancement effects on a mass scale, it might be important to temper such speculation by noting the empirical evidence for efficacy, safety and demand. This is not to say that discussion is futile. Instead, even if methylphenidate and other such drugs do not prove to be the elixir or threat that they promise to be, it may be that the expectation that methylphenidate can be used to enhance is worthy of our attention. It has been suggested that we might study the enhancement debate as outsiders, looking at why methylphenidate, as an example, has become seen as an enhancer within both academic circles and the public sphere. We might need to take a step back to examine academia's role in creating this culture of expectation, as well as closely examining the relationship between the acceptable use for ADHD and the culture of expectation that is growing around methylphenidate and similar drugs. Finally, we might need to explore this culture of expectation within the wider context whereby self-care and pharmaceutical-care have become conflated, breaking down the barriers between treatment and enhancement.
I would like to thank members of the Novel Tech Ethics team for their comments on earlier drafts of this commentary.
Funding Canadian Institutes of Health Research, NNF 80045, States of Mind: Emerging Issues in Neuroethics.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.