Use of Cognitive Enhancement Medication Among Northern Italian University Students

The relevance of pharmacological neuroenhancement for stress and resilience-A multistudy report

Background

Pharmacological neuroenhancement (PNE) is discussed as coping strategy in academic and work-related contexts. Depending on the definition of PNE and sample population, different prevalence rates for various groups have been reported. In the three parts of the study, prevalence rates for work and student populations in Germany are detected and the reasons for PNE and possible causal associations between PNE, stress and resilience are investigated.

Methods

In part 1 of the study, 152 occupational physicians (OPs) were surveyed about prevalence rates and reasons for PNE. In part 2 of the study, 1,077 German students reported on their PNE behavior. 704 students were then longitudinally considered to draw conclusions on causal associations between PNE, stress, and resilience.

Results

The OPs' estimated prevalence rate of 10.9% in a working population is higher than the prevalence rate of 5.4% for prescription and illicit substances found in the student sample in part 2 of the study. The reason suspected by OPs to be most important for PNE with prescription drugs were performance pressure and long working hours. Using soft enhancers, such as caffeine, is most common with a prevalence rate of 76.8% in the student sample. Stress predicts a higher (β = 0.179, p < 0.001) and resilience a lower use of PNE (β = -0.13, p = 0.001). Resilience predicts a lower (β = -0.35, p < 0.001) and PNE a higher level of stress (β = 0.11, p < 0.001).

Conclusion

OPs suspect a prevalence rate of 10.9% among the working population, while we found a prevalence rate of 5.4% among students. Caffeine is the most used substance for PNE, while the use of prescription and illicit substances remains low. Higher levels of stress and lower levels of resilience result in a higher use of PNE. Universities should therefore include the promotion of resilience and methods for dealing with study stress in health programs to reduce PNE.

Assessing prevalence, knowledge and use of cognitive enhancers among university students in the United Arab Emirates: A quantitative study

BACKGROUND

Cognitive enhancers (CE) are often used to improve memory, alertness and cognitive capacity. These products are commercially and pharmaceutically available. Due to high academic pressure, university students are at risk of CE misuse. However, data regarding this issue are limited, especially in the United Arab Emirates (UAE).

AIMS

To assess the prevalence of CE intake; evaluate students' knowledge of these substances; and identify student characteristics associated with CE usage.

METHOD

A cross sectional study based on a validated online survey that was distributed using university-licensed software (Qualtrics) as a direct web link via email and social media to all Medical, Pharmacy, Dentistry, Nursing and Engineering students enrolled in six UAE universities. Associations between student characteristics and CE use were investigated using the chi-squared test and multiple logistic regression. Reasons for CE use, temporal patterns of use, details regarding purchase and types of CE used were compared by gender.

RESULTS

One quarter of students had used CEs. There was a clear difference between users and non-users in terms of gender (p<0.001). CE users were disproportionately represented by students from either UAE or other Arab countries (p<0.001), and by students of Medicine, followed by Pharmacy, Dentistry, and Engineering (p<0.001). CE use increased with year of study, reaching the highest level in the fourth year (p<0.001), which for most programmes is the final year. Modafinil was self-administered, especially in males, for concentration and alertness; B12 was typically taken by female students for academic performance and concentration; and high-dosage caffeine compounds were ingested to improve alertness levels. Use of the internet for both obtaining information and purchasing CEs was frequently reported. Multiple logistic regression analysis showed that gender, nationality, and year of study were associated with CE use among UAE university students.

CONCLUSIONS

Universities need to address the prevalence of CE use amongst their students by providing effective support programs.

Potential risk groups and psychological, psychosocial, and health behavioral predictors of pharmacological neuroenhancement among university students in Germany

Aiming to develop and implement intervention strategies targeting pharmacological neuroenhancement (PN) among university students more specifically, we (1) assessed the prevalence of PN among German university students, (2) identified potential sociodemographic and study-related risk groups, and (3) investigated sociodemographic, psychological, study-related psychosocial, general psychosocial and health behavior related factors predicting the 12-month prevalence of PN. Therefore, a cross-sectional online survey was administered to students of the University of Mainz, Germany. A binary logistic regression with stepwise inclusion of the five variable groups was performed to predict PN. A total number of 4351 students out of 31,213 registered students (13.9%) participated in the survey, of which N = 3984 answered the question concerning PN. Of these, 10.4% had used one substance for PN at least once in the past 12 months. The regression analysis revealed 13 variables that were significantly related to the 12-month prevalence of PN. Specifically, the group of health behavior related variables showed the strongest relationship with PN. Therefore, an approach to the prevention of PN should be multifactorial so that it addresses social conditions, as well as education on substance use and healthy behaviors in terms of non-pharmacological strategies as alternatives of PN.

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.

Understanding the relationship between safety beliefs and knowledge for cognitive enhancers in UK university students

BACKGROUND

Cognitive enhancers (CE) are prescription drugs taken, either without a prescription or at a dose exceeding that which is prescribed, to improve cognitive functions such as concentration, vigilance or memory. Previous research suggests that users believe the drugs to be safer than non-users and that they have sufficient knowledge to judge safety. However, to date no research has compared the information sources used and safety knowledge of users and non-users.

OBJECTIVES

This study compared users and non-users of CE in terms of i) their sources of knowledge about the safety of CE and ii) the accuracy of their knowledge of possible adverse effects of a typical cognitive enhancer (modafinil); and iii) how the accuracy of knowledge relates to their safety beliefs.

METHODS

Students (N = 148) from King's College London (UK) completed an anonymous online survey assessing safety beliefs, sources of knowledge and knowledge of the safety of modafinil; and indicated whether they used CE, and, if so, which drug(s).

RESULTS

The belief that the drugs are safe was greater in users than non-users. However, both groups used comparable information sources and have similar, relatively poor drug safety knowledge. Furthermore, despite users more strongly believing in the safety of CE there was no relationship between their beliefs and knowledge, in contrast to non-users who did show correlations between beliefs and knowledge.

CONCLUSION

These data suggest that the differences in safety beliefs about CE between users and non-users do not stem from use of different information sources or more accurate safety knowledge.

Pharmacokinetic and pharmacodynamic of the cognitive enhancer modafinil: Relevant clinical and forensic aspects

Modafinil is a nonamphetamine nootropic drug with an increasingly therapeutic interest due to its different sites of action and behavioral effects in comparison to cocaine or amphetamine. A review of modafinil (and of its prodrug adrafinil and its R-enantiomer armodafinil) chemical, pharmacokinetic, pharmacodynamic, toxicological, clinical and forensic aspects was performed, aiming to better understand possible health problems associated to its unconscious and unruled use. Modafinil is a racemate metabolized mainly in the liver into its inactive acid and sulfone metabolites, which undergo primarily renal excretion. Although not fully clarified, major effects seem to be associated to inhibition of dopamine reuptake and modulation of several other neurochemical pathways, namely noradrenergic, serotoninergic, orexinergic, histaminergic, glutamatergic and GABAergic. Due its wake-promoting effects, modafinil is used for the treatment of daily sleepiness associated to narcolepsy, obstructive sleep apnea and shift work sleep disorder. Its psychotropic and cognitive effects are also attractive in several other pathologies and conditions that affect sleep structure, induce fatigue and lethargy, and impair cognitive abilities. Additionally, in health subjects, including students, modafinil is being used off-label to overcome sleepiness, increase concentration and improve cognitive potential. The most common adverse effects associated to modafinil intake are headache, insomnia, anxiety, diarrhea, dry mouth and raise in blood pressure and heart rate. Infrequently, severe dermatologic effects in children, including maculopapular and morbilliform rash, erythema multiforme and Stevens-Johnson Syndrome have been reported. Intoxication and dependence associated to modafinil are uncommon. Further research on effects and health implications of modafinil and its analogs is steel needed to create evidence-based policies.

University students with attention deficit hyperactivity disorder (ADHD): a literature review

OBJECTIVES

To review existing literature about university students with Attention Deficit Hyperactivity Disorder (ADHD).

METHODS

A framework for scoping studies and content analysis were used to source and review selected publications from PubMed, ScienceDirect, Google Scholar and relevant bibliographies.

RESULTS

Seventy-four publications were reviewed and key findings were categorised under six core themes that represent the issues germane to university students with ADHD. These themes are: academic, social and psychological functioning, giftedness, new media technologies, treatment, substance misuse and the non-medical use of prescription stimulants, and malingering.

CONCLUSION

In Ireland and the United Kingdom (UK) young people with ADHD are unlikely to enrol into further education, and of those who do go to university, few will graduate at the same time as their non-ADHD peers. ADHD is associated with poor educational outcomes and it may be a hidden disability within institutions of higher education (e.g. universities). Surprisingly, in this topic area, there is a paucity of research in Ireland and the UK. Most studies originate from North America were research activity in the field has been ongoing since the 1990s. These studies however, tend to use relatively small samples of college (university) students recruited at a single institution. It is difficult to generalise the findings of these studies to student populations in North America, let alone in Ireland and the UK. At the very least, these North American studies provide insights into key areas of concern. This topic area straddles education and psychiatry. This means an inter-disciplinary approach is required to examine, better understand and address the impact of ADHD on the educational outcomes of university students. The philosophies of difference, equity and self-realisation can offer a conceptual framework for conducting further research and/or developing services to deliver more personalised learning support for university students with ADHD.

Modelling predictors of UK undergraduates' attitudes towards smart drugs

BACKGROUND

Smart drug use is increasing but we have little insight into their use. We hypothesized that use is predicted by attitudes and various factors including incremental morality and entity intelligence beliefs would be associated with positive attitudes, whilst perception of unfairness would be associated with negative attitudes.

METHODS

UK undergraduates completed an online survey to establish attitudes towards smart drugs, previous use and likely future use as well as measures of several factors hypothesized to predict attitudes.

RESULTS

Attitudes were found to predict previous and likely future use. Attitudes were more positive in those who believed that smart drugs were harmless and those who felt they knew enough to use them safely. By contrast, perceived unfairness was associated with negative attitudes.

CONCLUSIONS

Interventions to reduce smart drug use should focus on attitudinal beliefs around potential harm and safety, as well as emphasizing the debate around unfairness.

Use and Propensity to Use Substances as Cognitive Enhancers in Italian Medical Students

International media has paid attention to the use of substances by healthy subjects to enhance cognitive performance. Medical students are liable to use cognitive enhancers (CE) with the aim of improving academic performance. The study explored use and attitudes toward the use of CE in Italian medical students. The authors anonymously surveyed 433 medical students of the University of Modena and Reggio Emilia with an ad hoc 36-items questionnaire. CE were broadly defined as any substance taken with the purpose of improving cognitive functions, from readily available beverages and substances, such as coffee, tea, energy drinks, and supplements to prescription only medication, such as psychostimulants and modafinil. Response rate was 83.8% (n = 363). While the majority of the students (74.7%; n = 271) said that they had used substances to improve cognitive functions, only 2 students (0.6%) reported the use of prescription-only medications in the last 30 days. Main reasons for not taking prescription-only drugs were concerns about safety and side effects, reported by 83.3% of students (n = 295). A positive attitude toward use was held by 60.3% (n = 219) subjects. The surveyed Italian medical students used many substances as CE, but this did not seem to apply significantly to psychostimulants. A multivariable analysis showed that the following variables were related to the propensity to use substances as CE: male gender, self-reported memory impairment, concerns about worsening of cognitive performance, lifetime use of at least one illegal substance, use of any substance (both legal or illegal) in the last 30 days.

Pharmacological neuroenhancement and the ability to recover from stress - a representative cross-sectional survey among the German population

BACKGROUND

Pharmacological neuroenhancement (PNE) refers to the use of psychoactive substances without doctor's prescription to enhance cognitive performance or to improve mood. Although some studies have reported that drugs for PNE are also being used to cope with stressful life situations, nothing is known about the relationship of PNE and resilience, i.e. the ability to recover from stress. This study aimed at investigating the relationship of PNE and resilience in the first representative population sample.

METHODS

A cross-sectional survey in a representative sample of 1128 adults (age ≥ 18 yrs.) living in Germany was conducted. The use of PNE and related attitudes, perceptions and behaviours were assessed by structured interviews and self-report questionnaires. Stepwise logistic regression with backward elimination was conducted to identify potential risk factors for PNE use.

RESULTS

Lifetime prevalence for the use of stimulating prescription drugs without medical indication was 4.3%, 10.2% for stimulating illicit drugs, 20.3% for mood modulating prescription drugs, and 23.4% for cannabis. Coping with stressful situations was more frequently reported as underlying motive for using stimulant or mood modulating prescription drugs than stimulating illicit drugs or cannabis. The individual perceived stress increased the risk of using stimulating prescription drugs (OR: 2.86; 95% Cl: 1.49-5.46) and the individual ability to recover from stress decreased the risk of using any substance for PNE and especially mood modulating prescription drugs (OR: .62; 95% Cl: .47-.81).

CONCLUSIONS

The non-medical use of prescription drugs for PNE appears to be more prevalent in subjects who are less resilient to stress. Tailored resilience interventions that improve the ability to adapt to and recover from stressors may prevent the use of prescription medication for PNE. Further research should disentangle the association between psychological resilience and PNE as well as examine the efficacy of resilience interventions in the prevention of PNE.

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.

Prevalence Estimates for Pharmacological Neuroenhancement in Austrian University Students: Its Relation to Health-Related Risk Attitude and the Framing Effect of Caffeine Tablets

Background: Pharmacological neuroenhancement (PN) is defined as the use of illicit or prescription drugs by healthy individuals for cognitive-enhancing purposes. The present study aimed (i) to investigate whether including caffeine tablets in the definition of PN within a questionnaire increases the PN prevalence estimate (framing effect), (ii) to investigate whether the health-related risk attitude is increased in students who use PN. Materials and methods: Two versions of a paper-and-pencil questionnaire (first version included caffeine tablets in the definition of PN, the second excluded caffeine tablets) were distributed among university students at the University of Graz, Austria. The unrelated question model (UQM) was used to estimate the 12-month PN prevalence and the German version of the 30-item Domain-Specific Risk-Taking (DOSPERT) scale to assess the health-related risk attitude. Moreover, large-sample z-tests (α = 0.05) were performed for comparing the PN prevalence estimates of two groups. Results: Two thousand four hundred and eighty-nine questionnaires were distributed and 2,284 (91.8%) questionnaires were included in analysis. The overall PN prevalence estimate for all students was 11.9%. One-tailed large-sample z-tests revealed that the PN estimate for students with higher health-related risk attitude was significantly higher compared to students with lower health-related risk attitude (15.6 vs. 8.5%; z = 2.65, p = 0.004). Furthermore, when caffeine tablets were included into the example of PN, the prevalence estimate of PN was significantly higher compared to the version without caffeine tablets (14.9 vs. 9.0%; z = 2.20, p = 0.014). Discussion: This study revealed that the PN prevalence estimate increases when caffeine tablets are included in the definition of PN. Therefore, future studies investigating the prevalence of, and predictors for, PN should be performed and interpreted with respect to potential framing effects. This study further revealed that the PN prevalence estimate is increased in students with a higher health-related risk attitude compared to students with a lower one. Therefore, future education and prevention programs addressing PN in the collective of students should not only inform about potential side effects of its use but also address the limited effects on cognition and potential alternatives of PN.

Use of cognitive enhancers among medical students in Lithuania

Aims

The purpose of this study is to analyse the use of cognitive enhancers among medical students in Lithuania, determine the reasons for usage and evaluate the contributing factors such as socio-demographic characteristics, stress levels, sleep quality and knowing somebody who has used a neuro-enhancing drug.

Design

A cross-sectional survey study was performed by analysing a convenience sample of n=579 in the two universities offering medical education in Lithuania, Vilnius University and the Lithuanian University of Health Sciences. In 2014, students were asked to fill in anonymous paper questionnaires consisting of 13 items on prevalence of substance use to enhance cognitive performance, and on reasons and correlates (response rate 95%) during lecture time.

Results

Of the respondents, 8.1% indicated that they had used cognitive enhancers. Among those who had used these drugs, nootropics were the most frequently mentioned (59.6%), while psychostimulants, such as modafinil, methylphenidate and amphetamine-derived drugs were mentioned less frequently (38.3%). Other substances were indicated by 23.4% of the respondents. Improvement of concentration and increased studying time were predominant purposes (55.3% and 48.9% of users, respectively). Male students reported three times higher prevalence rates than females (14.6% vs. 5.1%, p<0.05). Prevalence was also higher in students who knew someone using these substances than among those who did not know such persons (17.3% vs. 5.1%, p< 0.05). This was the most associated factor with cognitive-enhancing drug-taking behaviour. No correlation between cognitive enhancement usage and sleep quality or stress levels was found, nor between usage and belonging to a student organisation or having a job.

Conclusions

In Lithuania, 1 of 12 medical students admits to having used neuro-enhancing drugs. Our study results provide an overview of the actual situation on correlates and reasons for taking performance-enhancing substances.

Prevalence of and motives for pharmacological neuroenhancement in Switzerland--results from a national Internet panel

AIMS

To estimate the prevalence of self-reported pharmacological neuroenhancement (PNE) with prescription or recreational drugs among the Swiss general population and correlates of PNE.

DESIGN

A population-based cross-sectional study using a self-administered online survey.

SETTING

A telephone-recruited highly representative internet panel in Switzerland.

PARTICIPANTS

A total of 10,171 Swiss employees and students (unweighted n = 10,084) aged 15-74 years (mean age: 39.1 ± 13.3; 46.6% female).

MEASUREMENTS

Self-reported life-time, past-year and past-month use of prescription or recreational drugs for PNE, motives for use and correlates of PNE, including socio-demographic, health and recreational drug use characteristics.

FINDINGS

The life-time prevalence of PNE was 4.0% [95% confidence interval (CI) = 3.62, 4.38], and the past-year prevalence was 2.1% (95% CI = 1.82, 2.38). Life-time pharmacological mood enhancement (3.1%; 95% CI = 2.76, 3.44) was more prevalent than pharmacological cognitive enhancement (1.4%; 95% CI = 1.17, 1.63). Fifty-four participants reported both (0.5%; 95% CI = 0.36, 0.64). PNE was associated with studying rather than full-time [odds ratio (OR) = 0.35; 95% CI = 0.21, 0.57] or part-time employment (OR = 0.39; 95% CI = 0.23, 0.67), stress (OR = 1.51 95% CI = 1.31, 1.75), cocaine (OR = 2.40; 95% CI = 1.51, 3.82) and amphetamine use (OR = 2.44; CI 95% = 1.37, 4.33), diagnosis of a mental disorder (OR = 4.26; 95% CI = 3.14, 5.80), and perceived poor health (OR = 0.76; 95% CI = 0.64, 0.90).

CONCLUSIONS

Taking prescription or recreational drugs for pharmacological neuroenhancement is rare among Swiss employees and students (4.0%). Pharmacological mood enhancement (3.1%) is more prevalent than direct pharmacological cognitive enhancement (1.4%).

Associations Between the Big Five Personality Traits and the Non-Medical Use of Prescription Drugs for Cognitive Enhancement

While the number of studies of the non-medical use of prescription drugs to augment cognitive functions is growing steadily, psychological factors that can potentially help explain variance in such pharmaceutical cognitive enhancement (CE) behavior are often neglected in research. This study investigates the association between the Big Five personality traits and a retrospective (prior CE-drug use) as well as a prospective (willingness to use CE drugs) measure of taking prescription drugs with the purpose of augmenting one's cognitive functions (e.g., concentration, memory, or vigilance) without medical necessity. We use data from a large representative survey of German employees (N = 6454, response rate = 29.8%). The Five Factor Model (FFM) of Personality was measured with a short version of the Big Five Personality Traits Inventory (BFI-S), which includes: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Together with this, demographic variables such as gender, age, education, and income were used as potential confounders in multiple logistic regression models. Our results show a 2.96% lifetime prevalence of CE-drug use and a 10.45% willingness to (re)use such drugs in the future. We found that less conscientious and more neurotic respondents have a higher probability of prior CE-drug use and a greater willingness to use CE drugs in the future. No significant effects were found for openness, extraversion, or agreeableness. Prior CE-drug use was strongly associated with a greater willingness to take such drugs in the future. This study shows that specific personality traits are not only associated with prior enhancement behavior, but also affect the willingness to (re)use such drugs. It helps increase understanding of the risk factors of CE-drug use, which is a health-related behavior that can entail severe side-effects for consumers. The knowledge gathered can thus help improve interventions aimed at minimizing health problems.

The Complexity of Neuroenhancement and the Adoption of a Social Cognitive Perspective

This contribution attempts to provide a broad perspective to the psychological study of neuroenhancement (NE). It departs from the assumption that, as the use of performance enhancing substances in sport, the use of substances with the aim of improving one's cognitive, motivational and affective functioning in academic domains is a goal-directed behavior. As such, its scientific study may very well benefit from an analysis taking into account the psychological processes regulating people's behavioral intentions and decisions. Within this broad framework, this contribution addresses several issues that currently seem to characterize the debate in the literature on neuroenhancement substances (NES) use. The first conceptual issue seeks to determine and define the "boundaries" of the phenomenon. The second issue concerns the empirical evidence on the prevalence of using certain substances for the purpose of NE. Finally, there is a debate around the ethical and moral implications of NE. Along these lines, the existing psychological research on NE has adopted mainly sociological and economic decision-making perspectives, greatly contributing to the psychological discourse about the phenomenon of NE. However, we argue that the existing psychological literature does not offer a common, explicit and integrated theoretical framework. Borrowing from the framework of doping research, we recommend the adoption of a social cognitive model for pursuing a systematic analysis of the psychological processes that dynamically regulate students' use of NES over time.

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.

Work-related stress and cognitive enhancement among university teachers

BACKGROUND

Working conditions of academic staff have become increasingly complex and occupational exposure has risen. This study investigates whether work-related stress is associated with the use of prescription drugs for cognitive enhancement (CE).

METHODS

The study was designed around three web-based surveys (n1 = 1131; n2 = 936; n3 = 906) to which university teachers at four German universities were asked to respond. It assessed past CE-drug use and the willingness to use CE-drugs as factors influencing future use. Overlap among participants across the surveys allowed for analyses of stability of the results across time.

RESULTS

Our study suggests a currently very low prevalence of CE-drug use as well as a low willingness to use such drugs. The results showed a strong association between perceptions of work-related stress and all measures of CE-drug use (when controlling for potential confounding factors). They also showed that past use of CE-drugs increased participants' willingness to use them again in the future, as did lower levels of social support. Two different measures showed that participants' moral qualms against the use of CE-drugs decreased their probability of using them.

CONCLUSIONS

The results increase our knowledge about the prevalence of CE-drug use and our understanding of what motivates and inhibits the use of CE-drug.

A survey of substance use for cognitive enhancement by university students in the Netherlands

Background: Pharmacological cognitive enhancement, using chemicals to change cellular processes in the brain in order to enhance one's cognitive capacities, is an often discussed phenomenon. The prevalence among Dutch university students is unknown.

Methods: The study set out to achieve the following goals: (1) give an overview of different methods in order to assess the prevalence of use of prescription, illicit and lifestyle drugs for cognitive enhancement (2) investigate whether polydrug use and stress have a relationship with cognitive enhancement substance use (3) assessing opinions about cognitive enhancement prescription drug use. A nationwide survey was conducted among 1572 student respondents of all government supported Dutch universities.

Results: The most detailed level of analysis—use of specific substances without a prescription and with the intention of cognitive enhancement—shows that prescription drugs, illicit drugs and lifestyle drugs are respectively used by 1.7, 1.3, and 45.6% of the sample. The use of prescription drugs and illicit drugs is low compared to other countries. We have found evidence of polydrug use in relation to cognitive enhancement. A relation between stress and the use of lifestyle drugs for cognitive enhancement was observed. We report the findings of several operationalizations of cognitive enhancement drug use to enable comparison with a wider variety of previous and upcoming research.

Conclusions: Results of this first study among university students in the Netherlands revealed a low prevalence of cognitive enhancement drug use compared to other countries. Multiple explanations, such as a difference in awareness of pharmacological cognitive enhancement among students, accessibility of drugs in the student population and inclusion criteria of enhancement substances are discussed. We urge enhancement researchers to take the different operationalizations and their effects on the prevalence numbers into account.

Robust resilience and substantial interest: a survey of pharmacological cognitive enhancement among university students in the UK and Ireland

Use of 'smart drugs' among UK students is described in frequent media reports as a rapidly increasing phenomenon. This article reports findings from the first large-scale survey of pharmacological cognitive enhancement (PCE) among students in the UK and Ireland. Conducted from February to September 2012, a survey of a convenience sample of 877 students measured PCE prevalence, attitudes, sources, purposes and ethics. Descriptive and logistic regression statistical methods were used to analyse the data. Lifetime prevalence of PCE using modafinil, methylphenidate or Adderall was under 10%, while past regular and current PCE users of these substances made up between 0.3%-4% of the survey population. A substantial majority of students was unaware of and/or uninterested in PCE; however about one third of students were interested in PCE. PCE users were more likely to be male, British and older students; predictors of PCE use included awareness of other students using PCEs, ADHD symptomatology, ethical concerns, and alcohol and cannabis use. The survey addresses the need for better evidence about PCE prevalence and practices among university students in the UK. We recommend PCE-related strategies for universities based on the survey findings.

Modeling students' instrumental (mis-) use of substances to enhance cognitive performance: Neuroenhancement in the light of job demands-resources theory

Background

Healthy university students have been shown to use psychoactive substances, expecting them to be functional means for enhancing their cognitive capacity, sometimes over and above an essentially proficient level. This behavior called Neuroenhancement (NE) has not yet been integrated into a behavioral theory that is able to predict performance. Job Demands Resources (JD-R) Theory for example assumes that strain (e.g. burnout) will occur and influence performance when job demands are high and job resources are limited at the same time. The aim of this study is to investigate whether or not university students’ self-reported NE can be integrated into JD-R Theory’s comprehensive approach to psychological health and performance.

Methods

1,007 students (23.56 ± 3.83 years old, 637 female) participated in an online survey. Lifestyle drug, prescription drug, and illicit substance NE together with the complete set of JD-R variables (demands, burnout, resources, motivation, and performance) were measured. Path models were used in order to test our data’s fit to hypothesized main effects and interactions.

Results

JD-R Theory could successfully be applied to describe the situation of university students. NE was mainly associated with the JD-R Theory’s health impairment process: Lifestyle drug NE (p < .05) as well as prescription drug NE (p < .001) is associated with higher burnout scores, and lifestyle drug NE aggravates the study demands-burnout interaction. In addition, prescription drug NE mitigates the protective influence of resources on burnout and on motivation.

Conclusion

According to our results, the uninformed trying of NE (i.e., without medical supervision) might result in strain. Increased strain is related to decreased performance. From a public health perspective, intervention strategies should address these costs of non-supervised NE. With regard to future research we propose to model NE as a means to reach an end (i.e. performance enhancement) rather than a target behavior itself. This is necessary to provide a deeper understanding of the behavioral roots and consequences of the phenomenon.

Life context of pharmacological academic performance enhancement among university students--a qualitative approach

Background

Academic performance enhancement or cognitive enhancement (CE) via stimulant drug use has received increasing attention. The question remains, however, whether CE solely represents the use of drugs for achieving better academic or workplace results or whether CE also serves various other purposes. The aim of this study was to put the phenomenon of pharmacological academic performance enhancement via prescription and illicit (psycho-) stimulant use (Amphetamines, Methylphenidate) among university students into a broader context. Specifically, we wanted to further understand students’ experiences, the effects of use on students and other factors, such as pressure to perform in their academic and private lives.

Methods

A sample of 18 healthy university students reporting the non-medical use of prescription and illicit stimulants for academic performance enhancement was interviewed in a face-to-face setting. The leading questions were related to the situations and context in which the students considered the non-medical use of stimulants.

Results

Based on the resultant transcript, two independent raters identified six categories relating to the life context of stimulant use for academic performance enhancement: Context of stimulant use beyond academic performance enhancement, Subjective experience of enhancement, Timing of consumption, Objective academic results, Side effects, Pressure to perform.

Conclusions

The answers reveal that academic performance enhancement through the use of stimulants is not an isolated phenomenon that solely aims at enhancing cognition to achieve better academic results but that the multifaceted life context in which it is embedded is of crucial relevance. The participants not only considered the stimulants advantageous for enhancing academic performance, but also for leading an active life with a suitable balance between studying and time off. The most common reasons given for stimulant use were to maximize time, to increase motivation and to cope with memorizing. According to the interviews, there is a considerable discrepancy between subjective experiences and objective academic results achieved.

Evaluating the drivers of and obstacles to the willingness to use cognitive enhancement drugs: the influence of drug characteristics, social environment, and personal characteristics

BACKGROUND

The use of cognitive enhancement (CE) by means of pharmaceutical agents has been the subject of intense debate both among scientists and in the media. This study investigates several drivers of and obstacles to the willingness to use prescription drugs non-medically for augmenting brain capacity.

METHODS

We conducted a web-based study among 2,877 students from randomly selected disciplines at German universities. Using a factorial survey, respondents expressed their willingness to take various hypothetical CE-drugs; the drugs were described by five experimentally varied characteristics and the social environment by three varied characteristics. Personal characteristics and demographic controls were also measured.

RESULTS

We found that 65.3% of the respondents staunchly refused to use CE-drugs. The results of a multivariate negative binomial regression indicated that respondents' willingness to use CE-drugs increased if the potential drugs promised a significant augmentation of mental capacity and a high probability of achieving this augmentation. Willingness decreased when there was a high probability of side effects and a high price. Prevalent CE-drug use among peers increased willingness, whereas a social environment that strongly disapproved of these drugs decreased it. Regarding the respondents' characteristics, pronounced academic procrastination, high cognitive test anxiety, low intrinsic motivation, low internalization of social norms against CE-drug use, and past experiences with CE-drugs increased willingness. The potential severity of side effects, social recommendations about using CE-drugs, risk preferences, and competencies had no measured effects upon willingness.

CONCLUSIONS

These findings contribute to understanding factors that influence the willingness to use CE-drugs. They support the assumption of instrumental drug use and may contribute to the development of prevention, policy, and educational strategies.

Attitudes towards prescribing cognitive enhancers among primary care physicians in Germany

BACKGROUND

Primary care physicians are gate keepers to the medical system having a key role in giving information and prescribing drugs to their patients. In this respect they are involved in claims of patients/clients for pharmacological Cognitive Enhancement (CE). Therefore, we studied the knowledge of primary care physicians about CE and their attitudes toward prescribing CE drugs to healthy subjects.

METHODS

A self-report paper-and-pencil questionnaire and case vignettes describing a hypothetical CE drug were sent out to all 2,753 registered primary care physicians in Rhineland Palatine, Germany. 832, i.e. 30.2% filled in the questionnaire anonymously.

RESULTS

96.0% of all participating physicians had already heard about CE. However, only 5.3% stated to be very familiar with this subject and 43.5% judged themselves as being not familiar with CE. 7.0% had been asked by their clients to prescribe a drug for CE during the last week, 19.0% during the last month, and 40.8% during the last year. The comfort level to prescribe CE drugs was very low and significantly lower than to prescribe sildenafil (Viagra®). Comfort level was mainly affected by the age of the client asking for prescription of CE drugs, followed by the availability of non-pharmacological alternatives, fear of misuse of the prescribed drug by the client and the missing indication of prescribing a drug.

CONCLUSIONS

Although a relatively high proportion of primary care physicians have been asked by their clients to prescribe CE drugs, only a small proportion are well informed about the possibilities of CE. Since physicians are gate keepers to the medical system and have a key role regarding a drugs' prescription, objective information should be made available to physicians about biological, ethical and social consequences of CE use.

Associations between physical and cognitive doping--a cross-sectional study in 2.997 triathletes

Purpose

This study assessed, for the first time, prevalence estimates for physical and cognitive doping within a single collective of athletes using the randomized response technique (RRT). Furthermore, associations between the use of legal and freely available substances to improve physical and cognitive performance (enhancement) and illicit or banned substances to improve physical and cognitive performance (doping) were examined.

Methods

An anonymous questionnaire using the unrelated question RRT was used to survey 2,997 recreational triathletes in three sports events (Frankfurt, Regensburg, and Wiesbaden) in Germany. Prior to the survey, statistical power analyses were performed to determine sample size. Logistic regression was used to predict physical and cognitive enhancement and the bootstrap method was used to evaluate differences between the estimated prevalences of physical and cognitive doping.

Results

2,987 questionnaires were returned (99.7%). 12-month prevalences for physical and cognitive doping were 13.0% and 15.1%, respectively. The prevalence estimate for physical doping was significantly higher in athletes who also used physical enhancers, as well as in athletes who took part in the European Championship in Frankfurt compared to those who did not. The prevalence estimate for cognitive doping was significantly higher in athletes who also used physical and cognitive enhancers. Moreover, the use of physical and cognitive enhancers were significantly associated and also the use of physical and cognitive doping.

Discussion

The use of substances to improve physical and cognitive performance was associated on both levels of legality (enhancement vs. doping) suggesting that athletes do not use substances for a specific goal but may have a general propensity to enhance. This finding is important for understanding why people use such substances. Consequently, more effective prevention programs against substance abuse and doping could be developed.

Enhancement stimulants: perceived motivational and cognitive advantages

Psychostimulants like Adderall and Ritalin are widely used for cognitive enhancement by people without ADHD, although the empirical literature has shown little conclusive evidence for effectiveness in this population. This paper explores one potential explanation of this discrepancy: the possibility that the benefit from enhancement stimulants is at least in part motivational, rather than purely cognitive. We review relevant laboratory, survey, and interview research and present the results of a new survey of enhancement users with the goal of comparing perceived cognitive and motivational effects. These users perceived stimulant effects on motivationally-related factors, especially "energy" and "motivation," and reported motivational effects to be at least as pronounced as cognitive effects, including the effects on "attention."

Impact of contextual factors and substance characteristics on perspectives toward cognitive enhancement

Enhancing cognitive performance with substances–especially prescription drugs–is a fiercely debated topic among scholars and in the media. The empirical basis for these discussions is limited, given that the actual nature of factors that influence the acceptability of and willingness to use cognitive enhancement substances remains unclear. In an online factorial survey, contextual and substance-specific characteristics of substances that improve academic performance were varied experimentally and presented to respondents. Students in four German universities rated their willingness to use and moral acceptance of different substances for cognitive enhancement. We found that the overall willingness to use performance enhancing substances is low. Most respondents considered the use of these substances as morally unacceptable. Situational influences such as peer pressure, policies concerning substance use, relative performance level of peers, but also characteristics of the substance, such as perceptions of substance safety, shape the willingness and acceptability of using a substance to enhance academic performance. Among the findings is evidence of a contagion effect meaning that the willingness was higher when the respondents have more CE drug users in their social network. We also found deterrence effects from strong side effects of using the substance, as well as from policy regulations and sanctions. Regulations might activate social norms against usage and sanctions can be seen as costly to users. Moreover, enhancement substances seem to be most tempting to low performers to catch up with others compared to high performers. By identifying contextual factors and substance characteristics influencing the willingness and acceptability of cognitive enhancers, policy approaches could consider these insights to better manage the use of such substances.

Use of illicit and prescription drugs for cognitive or mood enhancement among surgeons

BACKGROUND

Surgeons are usually exposed to high workloads leading to fatigue and stress. This not only increases the likelihood of mistakes during surgery but also puts pressure on surgeons to use drugs to counteract fatigue, distress, concentration deficits, burnout or symptoms of depression. The prevalence of surgeons taking pharmacological cognitive enhancement (CE) or mood enhancement (ME) drugs has not been systematically assessed so far.

METHODS

Surgeons who attended five international conferences in 2011 were surveyed with an anonymous self-report questionnaire (AQ) regarding the use of prescription or illicit drugs for CE and ME and factors associated with their use. The Randomized Response Technique (RRT) was used in addition. The RRT guarantees a high degree of anonymity and confidentiality when a person is asked about stigmatizing issues, such as drug abuse.

RESULTS

A total of 3,306 questionnaires were distributed and 1,145 entered statistical analysis (response rate: 36.4%). According to the AQ, 8.9% of all surveyed surgeons confessed to having used a prescription or illicit drug exclusively for CE at least once during lifetime. As one would expect, the prevalence rate assessed by RRT was approximately 2.5-fold higher than that of the AQ (19.9%; 95% confidence interval (CI), 15.9% to 23.9%, N = 1,105). An even larger discrepancy between the RRT and AQ was observed for the use of antidepressants with a 6-fold higher prevalence (15.1%; 95% CI, 11.3% to 19.0%, N = 1,099) as compared to 2.4% with the AQ. Finally, logistic regression analysis revealed that pressure to perform at work (odds ratio (OR): 1.290; 95% CI, 1.000 to 1.666; P = 0.05) or in private life (OR: 1.266; 95% CI, 1.038 to 1.543; P = 0.02), and gross income (OR: 1.337; 95% CI, 1.091 to 1.640; P = 0.005), were positively associated with the use of drugs for CE or ME.

CONCLUSIONS

The use of illicit and prescription drugs for CE or ME is an underestimated phenomenon among surgeons which is generally attributable to high workload, perceived workload, and private stress. Such intake of drugs is associated with attempts to counteract fatigue and loss of concentration. However, drug use for CE may lead to addiction and to overestimation of one's own capabilities, which can put patients at risk. Coping strategies should be taught during medical education.