Professor Barbara Sahakian, Professor of Clinical Neuropsychology at the University of Cambridge, has been researching cognitive enhancers for over a decade. Here she discusses the emergence of ‘smart drugs’ and the ethical and practical issues they raise.

If long-term safety and efficacy are proven in healthy people, it may well be, at least for certain segments of the population, these drugs will prove life-savers.

Professor Barbara Sahakian, Professor of Clinical Neuropsychology at the University of Cambridge

There is an increasing lifestyle use of cognitive enhancing drugs, or smart drugs by healthy people. Why might this be? And how will it change our society? Are people using these drugs just realize their potential, or is it that pressures to perform in a globally competitive environment means that individuals’ feel that they cannot afford an ‘off day’ due to lack of sleep or stress?  This is perhaps particularly true of certain professions, where there are issues of safety to oneself or others, such as the military, doctors, etc.

Caffeine is the current stimulant of use for many people, as it is widely available, and effective: however, its wakefulness-promoting effects are transient. For doctors there is the undesirable side-effect of tremors at the dose required for maximum effects (600mg), which is common.

Therefore, it is useful to examine whether there are more effective cognitive enhancers, with fewer detrimental side effects, for those whose failures in attention, concentration and problem solving may lead to deleterious effects, including jeopardy of safety in the military arena, or serious adverse events during operations.

Although measures to reduce doctors’ working hours have been implemented in both the United Sates and Europe, surgeons performing long, arduous operations remain susceptible to the effects of fatigue, and frequent transitions from day to night work expose junior doctors to the risk of impaired psychomotor performance.

Indeed, fatigued doctors risk making poor judgements and committing serious medical errors. Given the continued need for innovation in this area, pharmacological methods could conceivably be used to combat fatigue at some time in the future.

In an exciting collaboration between the University of Cambridge, Department of Psychiatry and the Imperial College London, Division of Surgery, it has recently been discovered that the ‘smart drug’ Modafinil improves cognitive flexibility and reduces impulsivity in sleep deprived doctors. These results have just been published in the journal Annals of Surgery.

In a proof of concept randomized placebo controlled study, run by Charlotte Housden (Cambridge) and Dr Colin Sugden (Imperial), 39 doctors were deprived of sleep overnight and given a dose of 200mg of Modafinil or placebo. The doctors taking Modafinil had cognitive improvements, including flexibility of thinking, and reduced impulsivity.

These executive functions are clearly important for conducting surgical operations under stress and time pressure. However, there was no change on their clinical psychomotor performance on a laparoscopic task, which mimics and measures the dexterity necessary to perform surgery.

While a chronic Modafinil study is required to determine the long term effects of the drug as a safe and effective means of improving cognitive impairment due to sleep deprivation, this acute study has demonstrated that benefits are obvious on at least the first occasion.

Given these important findings, it is possible to speculate that doctors who take these drugs may be able to plan an intervention more effectively or show greater cognitive flexibility when approaching a challenging clinical problem.  However, it is critical that the long-term safety of the use of these drugs in healthy people remains to be determined.

The many ethical discussions that I and Charlotte Housden have had with the public on the use of cognitive enhancing drugs by healthy people have been revealing.  A variety of views have emerged, ranging from ‘These drugs should only be used by people with neuropsychiatric disorders such as Attention Deficit Hyperactivity disorder, or Alzheimer’s Disease’, to ‘If they are safe, why not use them, to make up for fatigue, to improve memory or other forms of cognition?’, and ‘Why not use them to get in an especially productive working day?’.

This increasing lifestyle use has to be balanced against other important facets of life, such as a good work/life balance. The possibility to accelerate into a 24/7 society for many people is a serious concern, as are issues of cheating and coercion.

As a society, we certainly need to be concerned about the use of these drugs by healthy children and adolescents where their brains are still in development. Furthermore, the purchasing of prescription medication over the internet is dangerous. However, if long-term safety and efficacy are proven in healthy people, it may well be, at least for certain segments of the population, these drugs will prove life-savers.

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