Five Unapproved Drugs Found in Cognitive Enhancement Supplements

Phenibut: A drug with one too many "buts"

Phenibut is a gamma aminobutyric acid derivative with activity at γ-aminobutyric acid (GABA)B, A and β-phenethylamine receptors. It was developed as a drug in the former Soviet Union to overcome anxiety and improve cognitive function in military personnel. In the last decade, it has made inroads into the European and U.S. markets, being marketed for purported nootropic properties. Here, we summarize the current knowledge on phenibut, its toxicology, pharmacology, adverse health effects, and patterns of use. Publications in peer-reviewed journals were searched in PubMed, Web of Science, and Google Scholar databases. Available literature points to adverse side effects associated with intoxication, withdrawal, and addiction to phenibut. Some of these effects can be life-threatening, requiring hospitalization and therapeutic interventions. Supportive efforts are often complicated by a lack of knowledge regarding phenibut's toxicology and pharmacology. Ingestion of phenibut was often associated with concomitant use of other substances of abuse. As control over its online marketing seems unrealistic, current efforts need to be focused on the addition of phenibut to current drug screening tests and the development of generally accepted treatment strategies for phenibut-associated toxicities.

General practitioners' role in safeguarding patients with dementia in their use of dietary supplements. A qualitative study

OBJECTIVE

The use of dietary supplements (DS) may cause harm through direct and indirect effects. Patients with dementia may be particularly vulnerable. This study aims to explore general practitioners' (GPs') experiences with DS use by these patients, the GPs perceived responsibilities, obstacles in taking on this responsibility, their attitudes toward DS, and suggestions for improvements to safeguard the use of DS in this patient group.

DESIGN

Qualitative individual interview study conducted February - December 2019. Data were analysed using systematic text condensation.

SETTING

Primary healthcare clinics in Norway.

SUBJECTS

Fourteen Norwegian GPs.

FINDINGS

None of the informants were dismissive of patients using DS. They were aware of the possible direct risks and had observed them in patients. Most GPs showed little awareness of potential indirect risks to patients with dementia who use DS. They acknowledged the need for caretaking of these patients. Although there were differences in practice styles, most of the GPs wished to help their patients safeguarding DS use but found it difficult due to the lack of quality assurance of product information. Furthermore, there were no effective ways for the GPs to document DS use in the patients' records. Several suggestions for improvement were given by the GPs, such as increased attention from GPs, inclusion of DS in the prescription software, and stricter regulatory systems for DS from the authorities.

CONCLUSION

The GPs had initially little awareness of this safety risk, but there were differences in practice style and attitudes towards DS. The GPs did not perceive themselves as main responsible for safe use of DS in patient with dementia. The most important reason to disclaim responsibility was lack of information about the products. One suggestion for improvement was better integration of DS in patients' medical record.

Prevalence of adulteration in dietary supplements and recommendations for safe supplement practices in sport

The prevalence of dietary supplement use among athletes continues to rise with 60-80% of athletes often reporting current or previous use of dietary supplements. While select dietary ingredients have been shown to improve acute performance and enhance training adaptations over time, it is important to still consider the risk vs. reward for athletes before opting to consume a dietary supplement. Previous work has indicated that certain dietary supplements may pose risks for inadvertent doping, may be susceptible to mislabelling, could be banned by certain governing bodies of sport, or pose health risks for certain populations. The purpose of the current narrative review is to summarize the prevalence of adulteration in dietary sport supplement products, outline the risks of inadvertent doping for athletes, and highlight best practices regarding safe supplementation strategies. Analytical studies have found anywhere from 14 to 50% of samples analyzed from dietary supplement products have tested positive for anabolic agents or other prohibited substances. It is important for the consumer to adhere to safe supplementation strategies, which include following serving size recommendations, cross-referencing ingredient profiles with the list of prohibited substances, choosing quality products that have been verified by a third-party certification program, and being cognizant of consuming multiple dietary supplement products with overlapping ingredient profiles. Once these practices have been considered, it is reasonable for an athlete to utilize dietary supplements as a strategy to optimize performance and health, with a low risk of failing a drug test (adverse analytical finding) and experiencing adverse events.

Unauthorized ingredients in "nootropic" dietary supplements: A review of the history, pharmacology, prevalence, international regulations, and potential as doping agents

The first nootropic prohibited in sport was fonturacetam (4-phenylpiracetam, carphedon) in 1998. Presented here 25 years later is a broad-scale consideration of the history, pharmacology, prevalence, regulations, and doping potential of nootropics viewed through a lens of 50 selected dietary supplements (DS) marketed as "cognitive enhancement," "brain health," "brain boosters," or "nootropics," with a focus on unauthorized ingredients. Nootropic DS have risen to prominence over the last decade often as multicomponent formulations of bioactive ingredients presenting compelling pharmacological questions and potential public health concerns. Many popular nootropics are unauthorized food or DS ingredients according to the European Commission including huperzine A, yohimbine, and dimethylaminoethanol; unapproved pharmaceuticals like phenibut or emoxypine (mexidol); previously registered drugs like meclofenoxate or reserpine; EU authorized pharmaceuticals like piracetam or vinpocetine; infamous doping agents like methylhexaneamine or dimethylbutylamine; and other investigational substances and peptides. Several are authorized DS ingredients in the United States resulting in significant global variability as to what qualifies as a legal nootropic. Prohibited stimulants or ß2-agonists commonly used in "pre-workout," "weight loss," or "thermogenic" DS such as octodrine, hordenine, or higenamine are often stacked with nootropic substances. While stimulants and ß2-agonists are defined as doping agents by the World Anti-Doping Agency (WADA), many nootropics are not, although some may qualify as non-approved substances or related substances under catch-all language in the WADA Prohibited List. Synergistic combinations, excessive dosing, or recently researched pharmacology may justify listing certain nootropics as doping agents or warrant additional attention in future regulations.

Picamilon, a γ-aminobutyric acid (GABA) analogue and marketed nootropic, is inactive against 50 biological targets

Picamilon is an analogue of the neurotransmitter γ-aminobutyric acid (GABA), which is marketed as a nootropic claiming to enhance cognition. There is a lack of in silico, in vitro and in vivo data on the safety of picamilon. Therefore, to ascertain potential physiological effects of picamilon, it was screened against 50 safety-related biological targets (receptors, ion channels, enzymes and transporters) by in silico and in vitro methods. Using two in silico tools, picamilon was not predicted to bind to the targets. Similarly, picamilon exhibited weak or no binding to the targets when measured in vitro at 10 μM. Overall, this data shows that picamilon, although structurally similar to other GABA analogues, has a different biological target binding profile. Picamilon's lack of binding to the 50 targets fills important data gaps among GABA analogues, a group of structurally related substances found in drugs and other consumer products.

Mental Health Implications for Aviators from COVID-19

Mental Health Implications for Aviators from COVID-19

Objective

The authors present aeromedical implications from COVID-19 disruptions on the civil aviation sector, consider mental health impacts on pilots, and discuss possible helpful responses to support pilot mental health.

Methods

A multiple database review investigated articles from January 2002 to May 2021 on severe commercial aviation disruptions impacting pilot mental health and on pilot mental health coping or treatment. Fifteen papers were identified.

Results

During the COVID-19 pandemic, airline flights were severely reduced. By January 2021, airlines shed thousands of jobs and 24 airlines no longer existed. General population surveys found 13% of individuals had “serious distress” from the pandemic. In two aviation focused surveys, 40-66% of pilots agreed or strongly agreed that their mental health worsened since the COVID-19 pandemic. Compared to past Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) patients, more COVID-19 patients have mental health symptoms in the acute phase of illness; while about 10% of COVID-19 patients appear to have chronic or “long haul” symptoms. Mental Health treatment and coping strategies found helpful to pilots are discussed.

Conclusions

Pilots remain at risk for mental health symptoms and illness due to the COVID-19 pandemic. For those who develop severe distress or mental illness from the effects of the pandemic (or COVID-19 infection), early treatment with psychotherapy and/or approved medications may be warranted. This may decrease the likelihood of persistent physical or cognitive or mental health symptoms that would delay a return to flying status.

The unapproved drug centrophenoxine (meclofenoxate) in cognitive enhancement dietary supplements

INTRODUCTION

Centrophenoxine (meclofenoxate) is prescribed in China and elsewhere to treat a variety of conditions including alcoholism and dementia, but the US Food and Drug Administration has not approved the drug for any indication. We designed our study to determine the presence and quantity of centrophenoxine in dietary supplements sold over-the-counter in the US.

METHODS

Supplements were included in our study if the label included (a) the term "dietary supplement" and (b) "centrophenoxine" as a declared ingredient. Supplements were purchased online, and powder from each dietary supplement product was reconstituted in methanol and analyzed using ultra high-performance liquid chromatography.

RESULTS

Seven products were analyzed. Centrophenoxine was present in all products in dosages ranging from 79 to 251 mg per serving. Consumers following the maximum recommended daily intake on the label would be exposed to 237 to 752 mg of centrophenoxine per day. Only 1 of 7 products (14%) listed a quantity of centrophenoxine on the label within ±10% of the actual amount.

CONCLUSION

Clinicians should be aware and advise patients that cognitive enhancement supplements may contain unapproved and prohibited drugs.

Dietary Supplement Use in Middle-aged and Older Adults

OBJECTIVES

Despite limited evidence of clinical benefits, dietary supplement use is increasingly common among older adults. The aim of this study was to characterise the prevalence of dietary supplement use in a national sample of community-dwelling middle-aged and older adults and investigate factors associated with its use.

DESIGN/SETTING/PARTICIPANTS

This was a cross-sectional study using data from the Health and Retirement Study (HRS), a biennial, nationally representative survey of individuals aged 50 years and older in the United States. This study combined data from the 2013/14 Health Care and Nutrition Survey (HCNS) and 2012 Core Survey.

MEASUREMENTS

The primary outcome was the use of any dietary supplement at least once a week. Secondary outcomes were the use of multivitamins and specific vitamin and supplement types. Multivariable regression models were used to identify factors associated with any dietary supplement use.

RESULTS

A total of 6045 participants (weighted n = 71,268,015) were included in the final analytical sample (mean age 67.7 years, 59.3% female). Of these, 84.6% (n=60,292,704) were regular dietary supplement users, with participants taking a mean of 3.2±0.1 different dietary supplements and 41.9% taking four or more. Multivitamins were the most common, used by 57.5% (n=41,147,146) of participants. Other commonly used dietary supplements were vitamin D, fish oil, calcium, vitamin C, and vitamin B12. Older age (75+ years), female sex, higher education, daily alcohol use, vigorous physical activity, regular medication use, and arthritis were associated with higher odds of dietary supplement use.

CONCLUSIONS

In this sample of middle-aged and older Americans, more than 4 out of 5 used a dietary supplement. Certain demographic, behavioural, and clinical factors were associated with their use. Given the lack of evidence for improving health outcomes, our findings suggest potential overuse of dietary supplements in people over the age of 50.

Home care service employees' contribution to patient safety in clients with dementia who use dietary supplements: a Norwegian survey

OBJECTIVE

To explore home care services (HCS) employees' professional experiences with the use of dietary supplements (DSs) in their clients with dementia. We also investigated their attributed professional responsibility concerning this use and their attitudes toward DSs in general. Differences between nurses and nurse assistants were investigated.

DESIGN

A cross-sectional survey with self-administered questionnaires.

SETTING

Home care services in six Norwegian municipalities in the period August-December 2016.

SUBJECTS

A total of 231 (64% response rate) HCS employees; 78 nurses and 153 nurse assistants (auxiliary nurses and employees without formal education).Main outcome measures: Health care employees' experiences with patient safety in clients with dementia who use DSs.

RESULTS

Fifty per cent were concerned that clients with dementia might harm their health due to DS use. Thirty-one per cent reported having intervened in order to reduce the risk. Seventy-one per cent preferred to administer DSs to clients with dementia rather than leaving this responsibility to the clients. The respondents placed the responsibility for patient safety in clients with dementia using DSs mainly with the general practitioners, while they ascribed themselves and pharmacies a medium level of responsibility. There were only minor difference between nurses and nurse assistants, and no difference in attitudes towards DSs.

CONCLUSION

Employees in HCS were concerned about the DS use in clients with dementia. Moreover, almost one-third had intervened to improve clients' patient safety. The majority indicated that HCS should administer DSs rather than the clients with dementia themselves.KEY POINTSTo our knowledge, this is the first study investigating the role of home care services with regard to patient safety in clients with dementia who use dietary supplements (DSs).•Home care service employees worried about patient safety related to DS use in clients with dementia.•Home care service employees attributed to themselves medium responsibility to ensure the safe use of DSs in these clients.•Lack of knowledge was the most important reason why home care service employees did not recommend DSs to clients.

Concept generation of cognitive enhancement: healthcare professionals' approach towards the impact and utilization of cognitive enhancers in academic context

Cognitive enhancers (CEs) encompass a wide range of drugs, including prescription medications for attention deficit disorders and pharmacological compounds for cognitive enhancement. It is well-documented that the students are the leading cohort of CEs users. Exploring how healthcare professionals perceive the use of CEs for academic accomplishments is significant to understand their encouragement of CE use. Hence, the purpose of the current study was to look at healthcare professionals' attitudes and perceived understanding about the usage of CEs in academic contexts. The study was a quantitative cross-sectional research design conducted in different healthcare and academic settings of Karachi. The respondents were approached either through social media platforms or the official email addresses of their working organizations. Data were collected through a web link of an online questionnaire that included four sections; inquiring about the respondents' demographics characteristics, their knowledge about CEs, their attitudes towards the use and impact of CEs, and their inclination to use a hypothetical prescription-only CE. The response rate of the study was 73.3%. The majority of the respondents negated to permit university students to using CEs for cognitive boost (n = 360, 67.1%), to concentrate (n = 406, 75.7%), to increase vigilance (n = 394, 73.5%) or to mitigate the effects of other medicines (n = 312, 58.2%). The pharmacists were more likely to refute that using CEs by the students is safe (pharmacists 10.8% vs. physicians 8.3%, p=<0.001), beneficial (pharmacists 12.7% vs. physicians 5.3%, p=<0.001), or necessary (pharmacists 17.6% vs. physicians 12.8%, p=<0.001). The major reasons for not encouraging the use of CEs were fear of misuse (n = 510, 95.1%), safety concerns (n = 495, 92.3%), and their consideration for CE as unnecessary medical intervention (n = 441, 82.2%). The findings indicated that overall, respondents have a clear consensus of not letting university students use CEs for cognitive improvement or any other purpose implying that cognitive enhancement is not yet a common or approved medical practice by the healthcare professionals in Pakistan.

Quantity of phenibut in dietary supplements before and after FDA warnings

INTRODUCTION

Phenibut is used to treat anxiety, insomnia, alcohol withdrawal and other conditions in Russia. The drug, however, has abuse potential and may cause lethargy, delirium, psychosis and coma. In the United States (US), the US Food and Drug Administration (FDA) has never approved the use of phenibut as a prescription medication, but the drug is available over-the-counter in dietary supplements. More than 80 cases of coma and death have been associated with phenibut consumption and withdrawal, and the FDA recently warned that the drug is not permitted in over-the-counter supplements. We designed our study to determine the presence and quantity of phenibut in over-the-counter supplements before and after the FDA warnings.

METHODS

Phenibut products were included if they (a) listed phenibut or a synonym as an ingredient on the label, (b) were labeled as a dietary supplement, and (c) were available for sale both before and after the FDA warning. Supplements were analyzed by liquid chromatography time-of-flight mass spectrometry; quantification was performed by isotope dilution method.

RESULTS

Four brands of dietary supplements labeled as containing phenibut met the inclusion criteria. Prior to the FDA warnings, two of the four brands contained phenibut, at dosages of 484 mg and 487 mg per serving. After the FDA warning, all four products contained phenibut, ranging in dosages from 21 mg to 1,164 mg per serving. Phenibut was first detected only after the FDA warnings in two brands, and the quantity of phenibut increased in three of four products after the FDA warnings. Quantities detected per dose were as much as 450% greater than a typical 250 mg pharmaceutical tablet manufactured in Russia.

CONCLUSION

Following FDA issuing an advisory that phenibut is not permitted in dietary supplements, the quantity of phenibut increased in 3 of 4 brands of over-the-counter phenibut supplements.