Just How Cognitive Is "Cognitive Enhancement"? On the Significance of Emotions in University Students' Experiences with Study Drugs

A comparative review on neuroethical issues in neuroscientific and neuroethical journals

This study is a pilot literature review that compares the interest of neuroethicists and neuroscientists. It aims to determine whether there is a significant gap between the neuroethical issues addressed in philosophical neuroethics journals and neuroscience journals. We retrieved 614 articles from two specialist neuroethics journals (Neuroethics and AJOB Neuroscience) and 82 neuroethics-focused articles from three specialist neuroscience journals (Neuron, Nature Neuroscience, and Nature Reviews Neuroscience). We classified these articles in light of the neuroethical issue in question before we compared the neuroethical issues addressed in philosophical neuroethics with those addressed by neuroscientists. A notable result is a parallelism between them as a general tendency. Neuroscientific articles cover most neuroethical issues discussed by philosophical ethicists and vice versa. Subsequently, there are notable discrepancies between the two bodies of neuroethics literature. For instance, theoretical questions, such as the ethics of moral enhancement and the philosophical implications of neuroscientific findings on our conception of personhood, are more intensely discussed in philosophical-neuroethical articles. Conversely, neuroscientific articles tend to emphasize practical questions, such as how to successfully integrate ethical perspectives into scientific research projects and justifiable practices of animal-involving neuroscientific research. These observations will help us settle the common starting point of the attempt at "ethics integration" in emerging neuroscience, contributing to better governance design and neuroethical practice.

On the psycho-emotional deficitisation of workers in the age of cognitive enhancement

Despite being the subject of public and scholarly debates for some time, the topic of cognitive enhancement remains theoretically under-developed in organisation studies. This is because the ‘dots’ still have to be ‘connected’ between macro-level phenomena (here, the therapeutic ethos and cognitive capitalism), and micro-level phenomena (in this case, cognitive abilities). In this essay, we use Fromm’s notion of social character to theorise dialectally about the interaction between these macro and micro-level phenomena. Doing so enables us to examine how the macro/micro interaction fosters to adoption of cognitive enhancement in the context of work, and what kinds of consequences might emerge from this. We propose the psycho-emotional deficitisation of workers as a central consequence of the aforementioned interaction, and define it as an internalised version of external ideals of what it means to be a productive worker under cognitive capitalism, which over time generates and reinforces the affective experience of being deficient. Our theorising around socially patterned defects of a cognitive kind has crucial ramification for our understanding of technology-mediated affective control at work and how human–technology interactions shape the subjectivities of workers towards greater self-inferiorisation vis-à-vis the perceived superiority of technology. We close by foreshadowing avenues for future research.

Perspectives on Deterrents from Students Who Have Discontinued Prescription Stimulant Misuse and Diversion Behaviors

Although a growing number of studies have sought to understand what motivates the initiation of prescription stimulant misuse and diversion among college students, there has been a lack of studies focused on what motivates behavior cessation. We aimed to explore what motivates prescription stimulant misuse and diversion cessation, from the perspective of college students with a history of having initiated and then discontinued these behaviors. We conducted face-to-face interviews with students who had a history of misuse, diversion, or both, and who had intentionally, either for the short-term or long-term, ceased these behaviors. We audio-recorded, transcribed, and analyzed interviews inductively using a thematic analysis approach. Of the six themes we identified, four applied to both misuse and diversion, while two applied to diversion only. Engaging in related behavior change, seasonality of the behaviors, changes in personal needs, and negative and/or null experiences with the behaviors were themes for both misuse and diversion cessation. Themes that emerged solely for diversion cessation included: moral and legal concerns and not wanting to be perceived as a drug dealer. The information shared by students with first-hand misuse and diversion cessation experience has the potential to guide interventions designed to address prescription stimulant misuse on college campuses.

The Ethics of Motivational Neuro-Doping in Sport: Praiseworthiness and Prizeworthiness

Motivational enhancement in sport – a form of ‘neuro-doping’ – can help athletes attain greater achievements in sport. A key question is whether or not that athlete deserves that achievement. We distinguish three concepts – praiseworthiness (whether the athlete deserves praise), prizeworthiness (whether the athlete deserves the prize), and admiration (pure admiration at the performance) – which are closely related. However, in sport, they can come apart. The most praiseworthy athlete may not be the most prizeworthy, and so on. Using a model of praiseworthiness as costly commitment to a valuable end, and situating prizeworthiness within the boundaries of the sport, we argue that motivational enhancement in some cases can be compatible with desert.

Prescription Stimulant Misuse and Diversion Events Among College Students: A Qualitative Study

Prescription stimulant misuse and diversion are interrelated behaviors: diversion increases the availability of stimulants for misuse, and persons who misuse are also more likely to divert. To date, research has examined these behaviors using a primarily quantitative lens. We led a qualitative investigation to better understand misuse and diversion events. Data are from a diverse southern California campus where we interviewed students who misuse and/or divert prescription stimulants (32 total interviews: 16 interviews with students who had a history of misuse, and 16 different interviews with students who had a history of diversion). We analyzed interview data inductively. We identified the following themes about misuse and diversion events, several of which intersected during interviews: medication surplus, diversion and misuse hubs, ease of behavior performance, academic stress, and other drugs commonly involved. For diversion, altruism and monetary gain were juxtaposed themes. Across themes, friends and family were influential figures. Implications for prevention, intervention, and future research directions are discussed.

The Use and Impact of Cognitive Enhancers among University Students: A Systematic Review

INTRODUCTION

Cognitive enhancers (CEs), also known as "smart drugs", "study aids" or "nootropics" are a cause of concern. Recent research studies investigated the use of CEs being taken as study aids by university students. This manuscript provides an overview of popular CEs, focusing on a range of drugs/substances (e.g., prescription CEs including amphetamine salt mixtures, methylphenidate, modafinil and piracetam; and non-prescription CEs including caffeine, cobalamin (vitamin B12), guarana, pyridoxine (vitamin B6) and vinpocetine) that have emerged as being misused. The diverted non-prescription use of these molecules and the related potential for dependence and/or addiction is being reported. It has been demonstrated that healthy students (i.e., those without any diagnosed mental disorders) are increasingly using drugs such as methylphenidate, a mixture of dextroamphetamine/amphetamine, and modafinil, for the purpose of increasing their alertness, concentration or memory.

AIM

To investigate the level of knowledge, perception and impact of the use of a range of CEs within Higher Education Institutions.

METHODOLOGY

A systematic review was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Whilst 1400 studies were identified within this study through a variety of electronic databases (e.g., 520 through PubMed, 490 through Science Direct and 390 through Scopus), 48 papers were deemed relevant and were included in this review.

RESULTS

The most popular molecules identified here included the stimulant CEs, e.g., methylphenidate, modafinil, amphetamine salt mixtures and caffeine-related compounds; stimulant CEs' intake was more prevalent among males than females; drugs were largely obtained from friends and family, as well as via the Internet. It is therefore suggested that CEs are increasingly being used among healthy individuals, mainly students without any diagnosed cognitive disorders, to increase their alertness, concentration, or memory, in the belief that these CEs will improve their performance during examinations or when studying. The impact of stimulant CEs may include tolerance, dependence and/or somatic (e.g., cardiovascular; neurological) complications.

DISCUSSION

The availability of CEs for non-medical indications in different countries is influenced by a range of factors including legal, social and ethical factors. Considering the risk factors and motivations that encourage university students to use CE drugs, it is essential to raise awareness about CE-related harms, counteract myths regarding "safe" CE use and address cognitive enhancement in an early stage during education as a preventative public health measure.

Cognitive enhancing drug use by students in the context of neoliberalism: cheating? Or, a legitimate expression of competitive entrepreneurialism?

A recurrent theme regarding drug policy and the use of cognitive enhancing drugs (CEDs) by students in higher education (HE), concerns the potential introduction of policy to prohibit the use of CEDs. One of the arguments put forward to support a prohibitive policy framework, is that the use of CEDs by students in HE is a form of academic misconduct; that the use of CEDs constitutes cheating. Now, given that it is widely documented that the use of CEDs by students in HE has been growing steadily over the past decade or more, there is surprisingly, a dearth of in-depth discussion on the topic of whether their use represents academic misconduct and is a form of cheating. Therefore, this commentary will summarise some examples of literature dedicated to the topic, before discussing whether the use of CEDs by students in HE constitutes cheating, when framed contextually, around neoliberalism and the key characteristics of competition and entrepreneurialism. The commentary will propose a potentially useful argument that, given the neoliberal context and those key characteristics, (HE) students could in theory, legitimise their use of CEDs. Consequently, students using CEDs for the purpose of hypothetically increasing academic excellence, would not consider their use of CEDs as a form of academic misconduct, of cheating. Thus, this paper, would in principle, support and endorse a legal, regulatory approach to CED policy and in addition, recommends that individual HE institutions do not prohibit the use of CEDs by students on the grounds of academic misconduct, but instead, advance harm reduction initiatives around their use.

"Study Natural" without Drugs: An Exploratory Study of Theory-Guided and Tailored Health Campaign Interventions to Prevent Nonmedical Use of Prescription Stimulants in College Students

Nonmedical use of prescription stimulants (NMUPS) among college students continues to rise. While some anti-NMUPS campaigns are available, little is known about the campaign development process and how well college students evaluate these messages. To bridge this gap, we developed theory-guided anti-NMUPS campaign interventions that are tailored to college students’ characteristics and evaluated students’ response towards them. A total of 445 college students (74.4% female; Mean_age of 20; 18 to 35 years old) reviewed the campaign interventions and offered their evaluation via an online survey. Findings indicate that students responded to the campaigns positively. Results also indicate that female students are more likely to perceive the campaigns as effective than their male counterparts. Overall, the findings of this study suggest that theory-guided and tailored anti-NMUPS campaigns have great potential in changing students’ attitudes and behavior towards NMUPS. While this study fills critical gaps in the literature, considering the progress needed to strengthen the research field, more research is needed to further identify effective strategies that could prevent college students’ participation in NMUPS activities.

Examining Breaks and Resistance in Medication Adherence Among Adolescents With ADHD as Associated With School Outcomes

Objective: Pharmacological interventions combined with behavioral treatment have been associated with better outcomes for children with ADHD. Yet, as children age into adolescence and gain autonomy, they may choose not to adhere to taking a prescribed medication. The purpose of the current study was to examine school outcomes among adolescents with ADHD who take medication breaks versus resisting medication with respect to grades and school behaviors. Method: We statistically controlled for a variety of variables such as the child's age, sex, the presence of side effects, and parent's relationship with child. Approximately half of the sample of adolescents with ADHD exhibited some form of medication nonadherence. Results: The results of the current study suggest that more positive school outcomes in terms of behaviors and grades are associated with adolescents taking breaks from their ADHD medication rather than resisting their medication. Conclusion: This result would indicate that not all forms of medication nonadherence have the same association with school outcomes in terms of grades and behaviors.

[Circulation of information on drugs and other substances to increase cognitive performance: a study of a Brazilian blog (2015-2017)]

By observing the processes of (bio)medicalization and pharmacologization of society, this article addresses drugs that have been used by healthy individuals to increase cognitive dimensions such as alertness, memory, and concentration. The use of so-called "smart drugs" or "nootropics" has spread among young people, aided by the internet. The circulation of information about such drugs are analyzed using a Brazilian blog called "Cérebro Turbinado," through publications available for public access between 2015 and 2017. The study adopts theoretical and methodological frameworks of the social sciences, including an anthropological perspective. Documental research was conducted on the internet, specifically with scientific dissemination materials and the material available from the aforementioned blog. The results show that the blog acts as a medium for spreading biomedical knowledge among the lay public and indicates the production of new forms of subjectivity by revealing the meanings attributed to these substances in socialization processes.

Networked psychostimulants: a web-based ethnographic study

Purpose

The purpose of this paper is to understand contemporary psychostimulant use among members of online discussion fora. Two objectives are addressed: to describe accounts of practices related to psychostimulant use, and to examine how these pharmaceuticals may shape contemporary subjectivities.

Design/methodology/approach

This paper presents a qualitative analysis of three online discussion fora belonging to Reddit. Drawing on actor-network theory, psychostimulants are envisaged as networked actants to understand the underlying logics related to their use. Non-participant observation of r/Adderall was carried out over an 18-month period. A qualitative analysis of postings on the three selected fora was also performed.

Findings

For each discussion forum, a network comprised of human and non-human actors was observed: members of the forum, psychostimulants as objects and subreddits as agentic spaces. This study reveals the emergence of multiple subjectivities associated with psychostimulant use: productivity, wellness and enhancement‐related.

Practical implications

Findings open to a wider debate regarding public health’s and healthcare professionals’ understanding of psychostimulant use outside of the clinical setting and how this may contrast with how psychostimulant use is practiced in context.

Originality/value

This research shows new online socio-cultural spaces formed around psychostimulant use. Calling upon a web-based ethnographic approach, this research presents a new perspective on the contemporary use of psychostimulants.

Cognitive Enhancing Drugs in Sport: Current and Future Concerns

Sporting authorities and policy makers have warned of a radical increase in the availability and use of so-called 'smart' drugs, which putatively deliver cognitive enhancements in the form of improved focus, concentration, alertness, and rapid decision-making. Although the potential for health risks is well documented when it comes to performance enhancing drugs in sport, the health implications of cognitive enhancing drugs (CEDs) remain unclear. Objectives: This article aims to provide a foundational understanding about CEDs and their application in sport. It considers what little is known about the types, nature, impact, and implications of their use for athletes and sport policy. Method: A narrative literature review was undertaken to ascertain the emerging role of CEDs beyond their clinical use to treat prescribed disorders, including the limited studies in the sporting domain. This review also considered literature pertinent to the impact of CEDs in sport and the challenges for sport policy. Results: Given the prospects of negative health impacts, policy-makers interested in preventing and controlling the use of CEDs, as well as reducing harm to athletes at all levels of performance, need guidance. This article highlights multi-faceted concerns and shines a spotlight on key issues for sporting bodies to consider regarding the critical impact that widespread use and adoption of these substances might entail. Conclusion: While the World Anti-Doping Agency (WADA) is seemingly awake to the threat posed, actions to circumvent the spread of CEDs throughout sport are nascent and require greater understanding and attention.

ESTUDANTES E O DOPING INTELECTUAL: VALE TUDO NA BUSCA DO SUCESSO NO VESTIBULAR?

RESUMO Este artigo apresenta os resultados de uma pesquisa que buscou caracterizar a percepção de estudantes do 3º ano do ensino médio de escolas públicas, privadas e profissionalizantes e de cursinhos públicos e privados sobre o uso de medicamentos para aprimoramento cognitivo. A pesquisa contou com 534 estudantes das cidades de Juazeiro do Norte (CE), Fortaleza (CE) e São Paulo (SP), e utilizou um questionário voltado à percepção desses estudantes sobre o uso de medicamentos que prometiam melhorar o aproveitamento nos estudos, se já tinham ouvido falar deles, se conheciam usuários e se fariam uso deles. A maioria considerou positivo o uso desses medicamentos, mostrou curiosidade em relação à substância e afirmou que faria uso, caso tivesse acesso, para garantir energia e concentração nas atividades. Os resultados deste estudo ressaltam a importância de se compreender a percepção dos jovens sobre este tema para que se possa orientar futuras intervenções.

In search of optimal psychoactivation: stimulants as cognitive performance enhancers

An increasing number of people, students in particular, seek substances that improve their cognitive functioning. The most popular group of pharmacological cognitive enhancers (PCEs) are stimulants. Available studies suggest a small beneficial effect of methylphenidate and amphetamine on memory, executive functions, and processing speed. However small, this effect can make the difference between success and failure. In recent years, research has focused on the additional beneficial effect on the emotional state, increased motivation, and placebo-induced cognitive enhancement. This paper briefly reviews the latest and most important research on the relationship between popular stimulants and cognitive enhancement. One cannot understand this relationship without understanding the Yerkes-Dodson law, which explains the relationship between the degree of arousal and performance. It suggests that the effect of stimulants is a dose-dependent continuum. This law has repeatedly been confirmed by studies in which an optimal level of psychoactivation for cognitive enhancement was obtained with low stimulant doses, whereas exceeding the effective dose resulted in cognitive deficits, psychomotor agitation, and addiction. A separate section has been devoted to modafinil, an increasingly popular stimulant that differs from the rest in neurochemical profile and behavioural effects.

Developing expertise, customising sleep, enhancing study practices: exploring the legitimisation of modafinil use within the accounts of UK undergraduate students

Introduction and aim: Increasing numbers of students are reportedly using prescription medications to enhance cognition. This study aimed to generate qualitative data on UK students' understandings and perspectives of the risks and benefits surrounding so-called 'study drugs' (particularly, modafinil). Design and methods: Fifteen undergraduate students studying biomedical science subjects were interviewed about their perspectives on study drugs. Interviews were recorded and transcribed for thematic analysis. Users and non-users were included in the sample. Results: The prescription status and comparisons to other legal and illicit stimulants informed accounts of the (lack of) risks associated with study drugs, legitimising use. The customisation of sleep(iness) and wakefulness was described as a key benefit of study drug use. Drivers of use related to university pressures and desires to increase productivity. In periods of heightened stress, such as examinations, students reported altered practices and perspectives on risk. Discussion and conclusions: We noted the contextual nature of students' use and risk appraisals, with fluctuating social contexts and pressures over time being capable of altering prior assessments and current practices (including the legitimisation of study drug consumption). Further, we highlighted the degree to which students leveraged their biomedical and experiential expertise to account for drug consumption.

Moral Attitudes Toward Pharmacological Cognitive Enhancement (PCE): Differences and Similarities Among Germans With and Without PCE Experience

Pharmacological cognitive enhancement (PCE), the use of illicit and/or prescription drugs to increase cognitive performance, has spurred controversial discussion in bioethics. In a semi-structured interview study with 60 German university students and employees, differences and similarities in moral attitudes toward PCE among 30 experienced participants (EPs) vs. 30 inexperienced participants (IPs) were investigated. Substances EPs used most often are methylphenidate, amphetamines, tetrahydrocannabinol and modafinil. Both EPs and IPs addressed topics such as autonomous decision making or issues related to fairness such as equality in test evaluation and distortion of competition. While most EPs and IPs were convinced that the decision of whether or not to use PCE is part of their individual freedom, their views varied considerably with regard to fairness. IPs considered issues related to fairness as much more critical than EPs. Thus, a person’s moral attitudes toward PCE may not only depend on moral common sense, but also on whether they have used illegal and/or prescription drugs for PCE before. This points to the importance of including the various relevant stakeholder perspectives in debates on the ethical and social implications of PCE.

Attention, Motivation, and Study Habits in Users of Unprescribed ADHD Medication

OBJECTIVE

Despite the limited effectiveness of ADHD medications on healthy cognition, prescription stimulants' cognitive enhancement use is increasing. This article examines enhancement users' attention, motivation, and study habits.

METHOD

A total of 61 users of unprescribed stimulants and 67 controls (no history of prescription stimulant use) completed tests of objectively measured and subjectively reported attention. Self-reports on study habits, as well as motivation during laboratory attention testing, were also administered.

RESULTS

Our data replicated previous findings of relatively lower self-reported attention functioning in users. Extending past research, we showed that user-control differences in attention were still present but less pronounced on objective measures than on self-report. In addition, we obtained evidence of lower motivation during cognitive testing and less optimal study habits among users, as compared with their non-using peers.

CONCLUSION

Unprescribed stimulant use is more strongly related to compromised study habits, low motivation, and a subjective perception of attention problems than to objective attention performance.

Smarter Than Thou, Holier Than Thou: The Dynamic Interplay Between Cognitive and Moral Enhancement

The debate about the desirability of using drugs to enhance human skills encompasses cognitive abilities such as memory and attention, and moral capacities such as emotional empathy and a sense of fairness. These two strands of literature in bioethics have grown relatively independent from each other, and an implicit framing assumption has emerged suggesting that apparently morally neutral cognitive capacities and paradigmatically moral capacities are distinct and vary independently of each other. Here, we identify key distinctions between competing accounts of cognitive enhancement and moral enhancement and argue that, despite the polarized nature of the bioethical debate, cognitive and moral capacities are intertwined. For example, moral behavior can be improved by enhancing "morally neutral" abilities such as attention span; and cognitive skills can be honed by means of socio-moral interaction. Further, cognitive skill is frequently assigned the abstract status of virtue and treated in the same way as more paradigmatically "moral" traits. We argue that the distinction between moral and cognitive enhancement is more apparent than real, since despite being nominally treated as distinct, cognitive and moral skills are frequently interdependent. As such we present evidence to support the claim that the enhancement of these two kinds of capacities cannot be clearly disaggregated from each other in the way that the theoretical poles of the debate in the literature suggest. We synthesize relevant scientific and bioethical literature and combine it with a line of analysis derived from Peter Hacker to show more clearly the terms of what can be said intelligibly about cognitive and moral skills and their enhancement. As a result of this analysis, we conclude that ethical questions in human bioenhancement are only fully intelligible at the level of persons imbued with feelings, thoughts, intentions, desires, values, and abilities, embedded within a particular social context, rather than at the level of pharmacological modulation of particular cognitive or affective capacities which, though conceptually distinguishable, in the embodied context of moral agency are profoundly intertwined.

Contextualizing study drugs - An exploratory study of perceptions and practices among study counselors, general practitioners, psychiatrists and from student polls

BACKGROUND

Recent decades have revealed a growing use of medicines for non-disease conditions, especially among university students. The prevalence rates for the use of study drugs (SDs), i.e. prescription stimulants and β-blockers, range from 2 to 20% among students worldwide. However, SD use does not take place in a vacuum. Like any other health-related behavior, medicine use takes place in specific social and cultural contexts, and there is very little scholarly work on these contextual aspects of SD use.

OBJECTIVE

This article aims to explore university students' use of SDs through the perceptions and practices of university counselors, general practitioners (GPs), psychiatrists, and from student polls in Denmark, in order to advocate for a contextual approach to SD use.

METHODS

The article relies on data from three different data sets involving a total of 18 semi-structured interviews, seven study counselors, nine GPs, and two psychiatrists, as well as votes from eight in-class polls conducted among approximately 300 university students in total. Data were collected between 2012 and 2017 and analyzed through meaning condensation and categorization.

RESULTS

The study shows that a great variety of perceptions and practices concerning SDs exists. While study counselors generally do not hear much about SDs from students, except for those seeking help with regard to β-blockers, they link the pressure, competition and perfectionism among students to a more general explanation of why some students may feel the need to use SDs. GPs meet students seeking SDs, but differ significantly in how they align their perceptions with their prescribing practices. The psychiatrists who participated in the study expressed widely different perceptions and practices regarding SDs. Finally, student polls indicate that students' opinions on SDs are also highly divided.

CONCLUSION

The lack of consensus on SDs among professionals in health and education may contribute to students' divided opinions about SDs, just as it provides students with an opportunity to legitimize their use of SDs.

On the question of non-medical cognitive enhancers among in-school adolescents: prevalence, predictors and potential health-related harms

Little is known about the use of non-medical cognitive enhancers (NCEs) in the general population, and even less among youth. The study utilises a nationally representative, cross-sectional survey of adolescents attending high schools to provide a comprehensive overview of NCEs and to assess risk factors such as socio-demographics, schooling, mental health and related substance use among French adolescents. A total of 6692 students attending high school (secondary schools) answered an anonymous questionnaire collecting information on demographics, health, psychoactive substance uses (neuroleptics, tobacco, alcohol, cannabis, illicit substances) and patterns of sociability. The use of cognitive enhancers appears to be an underestimated phenomenon among youth. Prevalence of use is heavily gender-influenced, with females twice as likely to use NCEs than males. More than daily school commitments, the use of cognitive enhancers is related to the proximity of the national secondary education examination. Moreover, mental health, use of prescribed anxiolytics and other psychoactive substances are significantly independently associated with the use of cognitive enhancers, particularly among females. The unregulated use of cognitive enhancers is a predictor of potential mental frailty and a substance-based response to stressful events, a behaviour likely to persist during adulthood. The study underpins the lack of contextual and comparable data. Systematic monitoring of younger students in neighbouring countries is required to develop reliable prevention programmes.

Pharmacological cognitive enhancement in pediatrics

PURPOSE OF REVIEW

Given the pervasiveness of psychotropic medication in the youth population and an increasingly competitive culture regarding educational performance, children, teenagers, and/or their parents may increasingly seek psychotropic substances in an effort to enhance a student's cognitive abilities and/or academic performance. Physicians must become aware of this very important and clinically relevant issue and work to ensure that medications remain in the hands of patients seeking wellness and not enhancement.

RECENT FINDINGS

The current article highlights findings on the pervasiveness of stimulant misuse and diversion in youth, the motivations and effects of stimulant use, health and legal consequences associated with use, and physician perceptions and preventive practices. Ethical concerns regarding pharmacological cognitive enhancement in pediatrics are also outlined - including coercion for nonusers, inequities in access, and threats to an individual's sense of self with regard to authenticity and autonomy.

SUMMARY

Pharmacological cognitive enhancement in pediatrics will become a larger, clinically relevant issue in the coming years. Physicians who care for children and adolescents must become more aware of this issue. Given the myriad health, legal, and ethical concerns, clinicians should discourage use of pharmaceuticals for enhancement purposes in the pediatric population.

Mitigating risks of students use of study drugs through understanding motivations for use and applying harm reduction theory: a literature review

As postsecondary students’ use of “study drugs” becomes more popular with increasingly reported negative effects on health and academic performance, failing prohibitionist policies to reduce consumption, and ambiguity in literature towards best practices to address this population, we present a literature review that seeks effective solutions educational institutions can apply to improve outcomes for students who use drugs. Motivations for use, effects of the substances, an analysis of efforts to control use from educational institutions, and suggestions on promoting most effective outcomes based on harm reduction, are described. Theory, quantitative, and qualitative works from systematic reviews, cohort studies, and epidemiological assessments are examined on the “study drugs” methylphenidate, dextroamphetamine, and amphetamine, also known as Adderall, Ritalin, Focalin, and Concerta. There is a focus on postsecondary students ages 18–25 in North America. Results show important risk factors for drug use including low perceived self-efficacy or enjoyment in courses, poor accommodation of special needs, reliance on external validation, having a low GPA, and experiencing a mental health issue. There is much misconception on the health and academic effects of these drugs in literature, among students, and on online knowledge sources. We suggest these drugs do not improve GPA and learning, while they might temporarily increase memory, but with detrimental negative health effects. Campaigns that address underlying factors of use can be most successful in mitigating harms.

Pharmaceutical entanglements: an analysis of the multiple determinants of ADHD medication effects in a Chilean school

This article draws upon findings from ethnographic fieldwork conducted in a Chilean school to explore how the effects of globally circulating ADHD medications emerge within the localized contexts of everyday users. An analysis of observations of children on ADHD medications within classroom settings is developed which challenges the assumption, pervasive within biomedical paradigms, that the effects of such medications can be understood as resulting directly from their chemical properties and biological modes of action. Our case study highlights the significance of multiple, interacting determinants of drug effects in an everyday setting, focusing in particular on classroom dynamics, teacher-student relations, and the agency of children taking the medications. We conclude that while ADHD medications may act in part by altering physiological processes, an adequate account of their effects requires that analytic attention extends to the sociomaterial contexts in which medications and users are embedded.

Lifestyle use of drugs by healthy people for enhancing cognition, creativity, motivation and pleasure

Today, there is continued, and in some cases growing, availability of not only psychoactive substances, including treatments for mental health disorders such as cognitive enhancers, which can enhance or restore brain function, but also 'recreational' drugs such as novel psychoactive substances (NPS). The use of psychoactive drugs has both benefits and risks: whilst new drugs to treat cognitive symptoms in neuropsychiatric or neurodegenerative disorders could have great benefits for many patient groups, the increasing ease of accessibility to recreational NPS and the increasing lifestyle use of cognitive enhancers by healthy people means that the effective management of psychoactive substances will be an issue of increasing importance. Clearly, the potential benefits of cognitive enhancers are large and increasingly relevant, particularly as the population ages, and for this reason, we should continue to devote resources to the development of cognitive enhancers as treatments for neurodegenerative diseases and psychiatric disorders, including Alzheimer's disease, attention deficit hyperactivity disorder and schizophrenia. However, the increasing use of cognitive enhancers by healthy individuals raises safety, ethical and regulatory concerns, which should not be ignored. Similarly, understanding the short- and long-term consequences of the use of NPS, as well as better understanding the motivations and profiles of users could promote more effective prevention and harm reduction measures. Linked Articles This article is part of a themed section on Pharmacology of Cognition: a Panacea for Neuropsychiatric Disease? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.19/issuetoc.

Can Neuromodulation also Enhance Social Inequality? Some Possible Indirect Interventions of the State

There is evidence that noninvasive brain stimulation (NIBS), and especially transcranial direct current stimulation (tDCS), can improve some cognitive functions, at least temporarily. However, as the improvement only applies to some “lucky” people, it may raise ethical, social and legal issues related to fairness in selective contexts (exams, competitions, job interviews). In this regard, an important element tends to be overlooked: the variability in individual response to tDCS in particular. If intensive study or practice and massive doses of chemical enhancers can have slightly different effects over different people, tDCS can sometimes be completely ineffective. The variability in individual response, if tDCS were widely used, could add to the already present natural inequalities between people, or even create new ones, leaving some in a disadvantaged condition. The discussion of the various ethical, social and legal consequences of different individual responses to tDCS might also address a potential indirect intervention by the State. In fact, if NIBS were to be widespread in competitive contexts, those who do not benefit from tDCS would be disadvantaged compared to those able to enhance their skills thanks to neuromodulation technologies. The most disadvantaged people for their lower response to tDCS could then acquire the right to receive and use free and safe cognitive enhancing drugs or other forms of bettering cognitive skills and functions, so as to reduce the gap between them and those who respond well to tDCS, in the light of the principle of equal opportunity.

Exploring the Relationship Between the Misuse of Stimulant Medications and Academic Dishonesty Among a Sample of College Students

The misuse of prescription stimulant medications (MPS) and academic dishonesty (AD) are both problematic behaviors among college students. Although both behaviors are linked to a student's desire to succeed academically, little research has been conducted to examine the relationship between these behaviors. The purpose of this study was to determine if students who engaged in past-year MPS committed acts of AD more frequently than those who do not engage in MPS. We collected our data from a sample of undergraduates (n = 974) between the ages of 18 and 25 enrolled at one of three universities in the US who completed an online questionnaire to assess AD and MPS. Results indicated that 18.2 % of the sample engaged in MPS in the past year and 65 % committed one or more acts of AD during the past year. An increased frequency of AD increased the odds of reporting MPS when controlling for known covariates (e.g., gender, stimulant prescription status, and energy drink consumption). In addition, higher rates of MPS were identified in students affiliated with a Greek organization, those with a current stimulant prescription, those who consume energy drinks, and those who misuse other prescriptions. Concerning specific AD-types, misusers reported copying off someone else's homework, having someone copy of their homework, and using the internet to commit acts of dishonesty more frequently than those who do not engage in MPS. This study adds to the MPS college student literature by highlighting the relationship between MPS and AD.

Not Just "Study Drugs" for the Rich: Stimulants as Moral Tools for Creating Opportunities for Socially Disadvantaged Students

An argument in the cognitive enhancement literature is that using stimulants in populations of healthy but socially disadvantaged individuals mistakenly attributes pathology to nonpathological individuals who experience social inequalities. As the argument goes, using stimulants as cognitive-enhancing drugs to solve the social problem of poorly educated students in inadequate schools misattributes the problem as an individual medical problem, when it is really a collective sociopolitical problem. I challenge this argument on the grounds that not all types of enhancement have to be explained in medical terms, but rather at least one conception of enhancement can be explained in social terms-opportunity maintenance. Therefore, I propose that as a moral requirement we ought to explore whether stimulants could be a means of remedying underprivileged children's experiences of social inequalities that are borne from inadequate schools for the sake of increasing their chances for opportunities and well-being.

"It Was Me on a Good Day": Exploring the Smart Drug Use Phenomenon in England

The non-medical use of prescription medication for the pursuit of increasing cognitive and intellectual capacities (defined neuroenhancement) has received growing attention from the scientific community and policymakers alike. To date, limited qualitative data exist exploring the nature of the phenomenon, especially as a potentially emerging trend among university students in England. Existing American literature suggests that students believe that neuroenhancement helps the individual to maximize his/her time, consenting a suitable balance between work and leisure. Students' motivation to experiment with neuroenhancement appears to be more in line with a need to regulate emotions surrounding study/work settings than to actually improve cognitive abilities beyond normal levels. This study aimed to qualitatively explore representations, motivations, beliefs, and consumption styles of a cohort of university student users residing in England. Through snowball sampling, 13 informants were contacted and interviewed regarding their experience with neuroenhancers. Narrations were analyzed and interpreted using qualitative analysis software and Grounded Theory methodology. Participants belonged to a broad variety of university courses and were predominantly habitual consumers of modafinil. Neuroenhancers were acquired either through friends or via the Internet. Motivations regarded the need to "catch up" and be on par with high achieving students. The entire cohort had previously experimented with other psychotropic substances. Synthetic compounds in particular were believed to be "gateway" drugs to using neuroenhancers. Experimentation with neuroenhancement can be seen as a self-governing strategy aimed at achieving continued focused productivity. Participants acknowledged sustainable benefits in neuroenhancement as it optimized work performance. The majority of the cohort also contemplated the possibility of using these drugs in the future once they entered the workforce. Neuroenhancing drug users expressed "situated morality," differentiating between using these substances for assessments (exams) or during revisions, finding only the former as an immoral conduct. In the present scenario, it appears that neuroenhancement is practiced by small numbers of students. Nonetheless, the instrumental views of psychotropic substances held by many young adults and the globalization of these practices make the normalization of neuroenhancement a plausible possibility of the future.

Drugs, games, and devices for enhancing cognition: implications for work and society

As work environments change, the demands on working people change. Cognitive abilities in particular are becoming progressively more important for work performance and successful competition in a global environment. However, work-related stress, performance over long hours, lack of sleep, shift work, and jet lag affect cognitive functions. Therefore, an increasing number of healthy people are reported to use cognitive-enhancing drugs, as well as other interventions, such as noninvasive brain stimulation, to maintain or improve work performance. This review summarizes research on pharmacological and technical methods as well as cognitive training, including game apps for the brain, in healthy people. In neuropsychiatric disorders, impairments in cognitive functions can drastically reduce the chances of returning to work; therefore, this review also summarizes findings from pharmacological and cognitive-training studies in neuropsychiatric disorders.

Moral and social reasons to acknowledge the use of cognitive enhancers in competitive-selective contexts

BACKGROUND

Although some of the most radical hypothesis related to the practical implementations of human enhancement have yet to become even close to reality, the use of cognitive enhancers is a very tangible phenomenon occurring with increasing popularity in university campuses as well as in other contexts. It is now well documented that the use of cognitive enhancers is not only increasingly common in Western countries, but also gradually accepted as a normal procedure by the media as well. In fact, its implementation is not unusual in various professional contexts and it has its peak in colleges (where the trend has been characterized as "academic doping"). Even when certain restrictions in the legislation of a country are indeed in place (i.e. through prescriptions requirements), they are without doubts easy to overcome. The legitimacy and appropriateness of such restrictions will not be the focus of our investigation.

DISCUSSION

Our concern is instead related to the moral and social reasons to publicly acknowledge the use of cognitive enhancers in competitive-selective contexts. These reasons are linked to a more neutral analysis of contemporary Western society: it is a fact that an increasing number of competitive-selective contexts have a substantial number of contenders using cognitive enhancers. Through the use of five explicative examples, in this paper we want to analyse the problems related to its use. In particular, it will be our aim to show the tension between one of the main argument used by bio-liberals (the use of cognitive enhancers is an eligible procedure that society does not impose on anyone) and the actual implementation of the drugs in competitive, or semi-competitive contexts.

Australian University Students' Coping Strategies and Use of Pharmaceutical Stimulants as Cognitive Enhancers

BACKGROUND

There are reports that some university students are using prescription stimulants for non-medical 'pharmaceutical cognitive enhancement (PCE)' to improve alertness, focus, memory, and mood in an attempt to manage the demands of study at university. Purported demand for PCEs in academic contexts have been based on incomplete understandings of student motivations, and often based on untested assumptions about the context within which stimulants are used. They may represent attempts to cope with biopsychosocial stressors in university life by offsetting students' inadequate coping responses, which in turn may affect their cognitive performance. This study aimed to identify (a) what strategies students adopted to cope with the stress of university life and, (b) to assess whether students who have used stimulants for PCE exhibit particular stress or coping patterns.

METHODS

We interviewed 38 university students (with and without PCE experience) about their experience of managing student life, specifically their: educational values; study habits; achievement; stress management; getting assistance; competing activities and demands; health habits; and cognitive enhancement practices. All interview transcripts were coded into themes and analyzed.

RESULTS

Our thematic analysis revealed that, generally, self-rated coping ability decreased as students' self-rated stress level increased. Students used emotion- and problem-focused coping for the most part and adjustment-focused coping to a lesser extent. Avoidance, an emotion-focused coping strategy, was the most common, followed by problem-focused coping strategies, the use of cognition on enhancing substances, and planning and monitoring of workload. PCE users predominantly used avoidant emotion-focused coping strategies until they no longer mitigated the distress of approaching deadlines resulting in the use of prescription stimulants as a substance-based problem-focused coping strategy.

CONCLUSION

Our study suggests that students who choose coping responses that do not moderate stress where possible, may cause themselves additional distress and avoid learning more effective coping responses. Helping students to understand stress and coping, and develop realistic stress appraisal techniques, may assist students in general to maintain manageable distress levels and functioning. Furthermore, assisting students who may be inclined to use prescription stimulants for cognitive enhancement may reduce possible drug-related harms.

Prescription Psychostimulant Use Among Young Adults: A Narrative Review of Qualitative Studies

BACKGROUND

Within the last decade, the nonmedical use of prescription drugs has raised concern, particularly among young adults. Psychostimulants, that is to say amphetamine and its derivatives, are pharmaceuticals, which contribute to what has come to be known in Canada and the United States as the "prescription drug crisis." Research in the fields of public health, addiction studies, and neuroethics has attempted to further understand this mounting issue; however, there is a paucity of data concerning the underlying social logics related to the use of these substances.

OBJECTIVES

The objective of this article is to provide an overview of the current literature related to the social context of prescription psychostimulant use among young adults, and to discuss theoretical considerations as well as implications for future research.

METHODS

A narrative review of the literature was performed.

RESULTS

We found that research efforts have chiefly targeted college students, yet there is a lack of knowledge concerning other social groups likely to use these pharmaceuticals nonmedically, such as persons with high strain employment. Three main emerging patterns related to prescription psychostimulant use were identified: (1) control of external stressors, (2) strategic use toward the making of the self, and (3) increasing one's performance.

CONCLUSIONS

Prescription psychostimulant use among young adults is anchored in contemporary normativity and cannot be separated from the developing performance ethic within North-American and other Western societies. We suggest that pharmaceuticalization and Actor-Network Theory are useful conceptual tools to frame future research efforts.

Pursuing Pleasures of Productivity: University Students' Use of Prescription Stimulants for Enhancement and the Moral Uncertainty of Making Work Fun

This article presents ethnographic data on the use of prescription stimulants for enhancement purposes by university students in New York City. The study shows that students find stimulants a helpful tool in preventing procrastination, particularly in relation to feeling disinterested, overloaded, or insecure. Using stimulants, students seek pleasure in the study situation, for example, to get rid of unpleasant states of mind or intensify an already existing excitement. The article illustrates the notion that enhancement strategies do not only concern productivity in the quantitative sense of bettering results, performances, and opportunities. Students also measure their own success in terms of the qualitative experience of working hard. The article further argues that taking an ethnographic approach facilitates the study of norms in the making, as students experience moral uncertainty-not because they improve study skills and results-but because they enhance the study experience, making work fun. The article thereby seeks to nuance simplistic neoliberal ideas of personhood.

Enhancement, ethics and society: towards an empirical research agenda for the medical humanities and social sciences

For some time now, bioethicists have paid close attention to issues associated with 'enhancement'; specifically, the appropriate use and regulation of substances and artefacts understood by some to improve the functioning of human bodies beyond that associated with 'normal' function. Medical humanities scholars (aside from philosophers and lawyers) and social scientists have not been frequent participants in debates around enhancement, but could shine a bright light on the range of dilemmas and opportunities techniques of enhancement are purported to introduce. In this paper, we argue that empirical research into the notion and practice of enhancement is necessary and timely. Such work could fruitfully engage with-and further develop-existing conceptual repertoires within the medical humanities and social sciences in ways that would afford benefit to scholars in those disciplines. We maintain that empirical engagements could also provide important resources to bioethicists seeking to regulate new enhancements in ways that are sensitive to societal context and cultural difference. To this end, we outline an empirical agenda for the medical humanities and social sciences around enhancement, emphasising especially how science and technology studies could bring benefits to-and be benefitted by-research in this area. We also use the example of (pharmaceutical) cognitive enhancement to show how empirical studies of actual and likely enhancement practices can nuance resonant bioethical debates.

The importance of stress, self-efficacy, and self-medication for pharmacological neuroenhancement among employees and students

OBJECTIVES

This study examined the relationship between stress, self-efficacy, self-medication, and pharmacological neuroenhancement (PNE) in the Swiss general population.

METHODS

Using the largest Swiss Internet panel, a sample of 10,171 employees and students (unweighted N=10,084) aged 15-74 years was recruited and asked to complete a self-administered online survey. The data were weighted for age, sex, and language region to provide results that were representative of the Swiss population. Multinomial logistic regression models were conducted to identify predictors of pharmacological cognitive enhancement (PCE) and pharmacological mood enhancement (PME) over the past year. Two self-medication models and an overall model were determined.

RESULTS

Current medical treatment for a mental disorder was the best predictor of both PCE and PME use as serious self-medication. The overall model revealed that cannabis use, frequent stress, and long-term stress were predictors of both PCE and PME, whereas negative stressors and time pressure at work did not remain in the final model. Furthermore, past-year PCE with and without PME was associated with being male, being a student, and using illegal drugs other than cannabis, whereas being female and having low self-efficacy predicted past-year PME only.

CONCLUSIONS

Consideration of the predictor variables identified in this study may help to identify the potential PCE and PME users for whom measures to prevent drug abuse and manage stress are most appropriate. More specifically, the use of PCE and PME as self-medication to enhance performance at work or while studying needs further consideration in the neuroenhancement debate.

The Use of Prescription Drugs, Recreational Drugs, and "Soft Enhancers" for Cognitive Enhancement among Swiss Secondary School Students

The use of prescription or recreational drugs for cognitive enhancement (CE) is prevalent among students. However, the prevalence of CE among Swiss school students is unknown. We therefore performed a cross-sectional online survey including ≥ 16-year-old students from bridge-year schools (10^th grade), vocational schools, and upper secondary schools (10^th-12^th grade) in the Canton of Zurich to investigate the prevalence of and motives for the use of prescription drugs, recreational drugs, and/or freely available soft enhancers for CE. A total of 1,139 students were included. Of these, 54.5% reported the use of prescription drugs (9.2%), recreational drugs including alcohol (6.2%), or soft enhancers (51.3%) explicitly for CE at least once in their lives. The last-year and last-month prevalence for CE considering all substances was 45.5% and 39.5%, respectively. Soft enhancers were the substances that were most commonly used (ever, last-year, and last-month, respectively), including energy drinks (33.3%, 28.4%, and 24.6%), coffee (29.8%, 25.1%, and 21.9%), and tobacco (12.6%, 9.3%, and 8.3%). CE with methylphenidate was less prevalent (4.0%, 2.8%, and 2.0%). However, the use of prescription drugs, alcohol, or illegal drugs for CE was reported by 13.3% of the participants. The most common motives for use were to stay awake and improve concentration. CE was more prevalent among students who reported higher levels of stress or performance pressure and students with psychiatric disorders. In conclusion, half of the school students had used a substance at least once in their lives to improve school performance. Soft enhancers were most commonly used. Prevalence rates were similar to those reported by Swiss university students, indicating that the use of prescription or recreational drugs for CE already occurs before starting higher education. Performance pressure, stress, and psychiatric disorders may be associated with CE.

The Use of Prescription Drugs and Drugs of Abuse for Neuroenhancement in Europe

Abstract. Pharmacological neuroenhancement, defined as the misuse of prescription drugs, illicit drugs, or alcohol for the purpose of enhancing cognition, mood, or prosocial behavior, is not widespread in Europe – nevertheless, it does occur. Thus far, no drug has been proven as safe and effective for cognitive enhancement in otherwise healthy individuals. European studies have investigated the misuse of prescription and illicit stimulants to increase cognitive performance as well as the use of tranquilizers, alcohol, and cannabis to cope with stress related to work or education. Young people in educational settings report pharmacological neuroenhancement more frequently than those in other settings. Although the regular use of drugs for neuroenhancement is not common in Europe, the irregular and low-dose usage of neuroenhancers might cause adverse reactions. Previous studies have revealed that obtaining adequate amounts of sleep and using successful learning techniques effectively improve mental performance, whereas pharmacological neuroenhancement is associated with ambiguous effects. Therefore, non-substance-related alternatives should be promoted to cope with stressful situations. This paper reviews the recent research on pharmacological neuroenhancement in Europe, develops a clear definition of the substances used, and formulates recommendations for practitioners regarding how to react to requests for neuroenhancement drug prescriptions. We conclude that monitoring the future development of pharmacological neuroenhancement in Europe is important to provide effective preventive measures when required. Furthermore, substance use to cope with stress related to work or education should be studied in depth because it is likely more prevalent and dangerous than direct neuroenhancement.