Thursday, July 2, 2009

Experts Debate Benefits and Risks of Stimulants for Healthy People

Two new editorials debate the question of whether healthy people should take stimulants, especially methylphenidate, to enhance cognitive performance.

John Harris, DPhil, from the school of law at the University of Manchester, in the United Kingdom, argues that it is unethical to stop healthy adults from taking methylphenidate to enhance cognitive performance and asserts that chemical cognitive enhancers should be freely available to those who choose to use them.

Anjan Chatterjee, MD, from the Center for Cognitive Neuroscience at the University of Pennsylvania, in Philadelphia, disagrees, maintaining that making methylphenidate freely available to those who want to enhance performance would cause undue medical risk and that these drugs should be reserved for those who suffer from attention-deficit/hyperactivity disorder (ADHD). The risks of methylphenidate include potential for abuse and dependence and risk for sudden death and serious cardiovascular events, he points out.

Their discussion is published online June 18 in BMJ.

Risk for Sudden Death

Methylphenidate was also the subject of a recent case-control study published in the American Journal of Psychiatry that showed an increased risk for sudden death in healthy children and adolescents who take the medication (Gould MS et al. Am J Psychiatry. 2009;AIA:1-10). In response, however, the US Food and Drug Administration (FDA) issued an advisory noting that children with ADHD should not stop stimulants based on this study, because its conclusions were limited by several flaws.

Dr. Harris argues that methylphenidate is safe enough to be used widely in children and adults with ADHD, and its significant advantages for healthy adults include improved executive function, study skills, and the ability to focus. In an interview, he noted that access to methylphenidate could be improved by taking it off prescription or allowing it with a pharmacist consultation.

Methylphenidate's health risks should be dealt with in the same way as are those of cigarettes; while adults who use the drug should be warned of its potential for abuse and cardiac risks, sale should not be prohibited. "We should not police healthy adults," he said. "We can issue them a warning as we do on other dangerous products."

Social Coercion?

Dr. Chatterjee, however, warns of the public-health risks that could occur should methylphenidate be freely available. He notes that the risks for serious cardiovascular events with methylphenidate are likely to be higher in older people with undetected cardiac disease — 1 group that might be likely to use the drug if it were sold over the counter.

He also said that expanding access to methylphenidate would invite subtle societal coercion to use the drug to enhance performance in school or in the workplace. "We live in a very competitive society, where people think that every little bit that gets you ahead is advantageous," he said in an interview. Were methylphenidate freely available, there might be implicit pressures to use the drug to improve school grades or cognitive abilities during long working hours, he writes in his editorial.

Dr. Chatterjee also argues that the use of methylphenidate might pose another risk for society that is rarely considered in debates about the subject. He notes that enhancing focus with methylphenidate might mean sacrificing creativity. "Most models of creativity suggest that you have to have some down time in order to have the leaps of imagination that end up being creative insights; it requires not being focused," he said.

Dr. Harris, however, equated methylphenidate with electric light — a valuable technology that may also have the adverse effect of potential overuse. "With the advent of synthetic sunshine, work and social life could continue into and through the night, creating competitive pressures and incentives for those able or willing to use it to their advantage," he writes in his editorial.

"The solution, however, was not to outlaw synthetic sunshine but to regulate working hours and improve access," he adds. "The same is or will be true of chemical cognitive enhancers."

Source : http://www.medscape.com/viewarticle/705057?sssdmh=dm1.492967&src=nldne

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