The Dark Side of "Smart Drugs": Cognitive Enhancement vs. Clinical Concerns

The European Union Drugs Agency has emphasized the increasing difficulty in monitoring the drug market due to the emergence of new psychoactive substances, often marketed as legal highs. The proliferation of fake pharmacies, drugstores, and e-commerce platforms has made access to illicit substances alarmingly rapid and inexpensive. These substances are readily available without medical prescriptions, lacking proper risk assessments or monitoring of potential adverse effects, raising significant public health concerns. Today, the relentless pursuit of validation and success-often, at any cost-has led to an exponential rise in the use of cognitive and mood enhancers. Such substances are frequently consumed to manage demands related to work, diet, sexuality, sleep, achievement, and interpersonal relationships. Consequently, investigating these phenomena is critically important for institutions, as they represent a serious threat to individual development and health. Developing effective preventive and protective systems is essential. This review provides an overview of currently available smart drugs, discussing their desired and adverse neuropharmacological effects, psychological implications, and cognitive decline resulting from their excessive and unregulated use. This review concludes that a multidisciplinary approach combining molecular identification, micro-morphological analysis, and chemical characterization is crucial for the accurate detection, monitoring, and risk mitigation of new psychoactive substances.

Cognitive Enhancers Consumption: Prevalence, Knowledge, and Determinants of Use Among Medical Students in Egypt, Sudan, and Jordan

BACKGROUND

Cognitive Enhancers (CE) are central nervous system stimulant substances known to improve cognitive functions. Due to high-perceived stress and academic pressure, CEs are becoming increasingly popular among medical students. As a result, they are more likely to misuse these substances.

OBJECTIVES

This study aims to estimate the prevalence of CE consumption, compare the prevalence between countries and genders, and identify characteristics associated with CE consumption among students at medical schools in Egypt, Sudan, and Jordan.

METHOD

A population-based survey study was conducted among medical students from Egypt, Sudan, and Jordan. An online self-reported questionnaire was used to collect data. Frequencies and percentages were calculated to represent participant distribution across categories. Chi-square was used for categorical variables comparisons. All tests were two-tailed, considering p < 0.05 statistically significant. Demographic characteristics, reasons for use, types of CE used, and side effects were compared by country and gender.

RESULTS

A total sample of 1399 participated in the questionnaire, most of whom were females 824 (58.9%). Overall, 1236 (88.3%) were CE consumers, and 163 (11.7%) were non-consumers. Of the respondents who used CE, 814 (58.2%) reported using them daily. There was a statistically significant difference between the consumption of CE and the source of acquisition, nationality, and residence status regarding gender.

CONCLUSIONS

Our findings suggest that CE use is increasing among medical students in Egypt, Sudan, and Jordan. Efficient support, stress management programs, and awareness symposia may help reduce the misuse of these substances. Future longitudinal studies are still required.

The rising use of cognitive enhancement drugs and predictors of use during COVID-19: findings from a cross-sectional survey of students and university staff in the UK

Background

The use of psychoactive substances to increase cognitive performance while studying has been termed 'pharmacological cognitive enhancement' (PCE). In previous years, several large-scale national surveys have focused on their use by students at university, including drug types, prevalence rates, and predictive factors. The recent coronavirus pandemic brought about widespread structural changes for UK universities, as students were forced to adapt to home-based learning and in many cases reduced academic support. No study has yet focused primarily on the impact of pandemic social restrictions on PCE in students and academic staff, and whether personality and demographic factors reveal user profiles that predict use during the pandemic period.

Method

A convenience sample of 736 UK students and staff aged 18-54 (M = 22.2, SD = 5.2) completed a cross-sectional survey assessing PCE prevalence rates, polydrug use, perceived effects, academic self-efficacy and personality during the first year of social restrictions (March 2020 - February 2021) compared with the previous year (March 2019 - February 2020).

Results

There was a significant self-reported rise in the use of all drug types (all ps < 0.001) during social restrictions, particularly with Modafinil (+42%), nutraceuticals (+30.2%) and microdose LSD (+22.2%). Respondents also indicated stronger PCE effects for all substances, except alcohol, in comparison to the previous year. Polydrug use with modafinil and other prescription stimulants increased the most during social restrictions. Personality factors and gender identity reliably predicted PCE use and lower agreeableness was often the strongest predictor, followed by identifying as male and lower conscientiousness. Academic self-efficacy and student/academic staff status were not consistent predictors.

Conclusion

This is the first survey of UK students to investigate PCE during coronavirus social restrictions and to assess predictive factors. Findings reveal a rise in PCE use and polydrug use which we suggest is because of increased pressures on students created by the lockdown and reduced access to university resources.

Nonmedical Use of Stimulants Among Students in Jordan: A Nationwide Study

OBJECTIVES

Nonmedical use (NMU) of stimulants is an increasingly common phenomenon worldwide. Motivated by enhancing academic performance, peer pressure, and seeking pleasure, students in the Middle East are thought to be a high-risk population. This is especially important in times when the political instability in the region facilitates the production and trafficking of such substances. This study aimed to unveil the burden of NMU of stimulants and examine associated correlates among senior high school and university students in Jordan.

METHODS

We describe a cross-sectional study of senior high school and university students in Jordan assessing NMU of stimulants. Data were collected between January and April of 2022 through a survey, which was distributed online leading to a google forms page. The survey queried sociodemographic characteristics, history of NMU of stimulants, use of other illicit substances, attitudes toward NMU of stimulants, as well as a mental health assessment.

RESULTS

A total of 8739 students completed the survey (mean age of 20.40 ± 2.45 years), of which 5.1% reported a lifetime NMU of stimulants. Fenethylline (Captagon) was the most widely reported stimulant (2.6%). Living in the southern region, being diagnosed with a personality disorder, and using concomitant illicit substances were associated with the NMU of stimulants.

CONCLUSIONS

The NMU of CNS stimulants, especially fenethylline, is prevalent in Jordan. More surveillance ought to be heeded toward the southern borders of Jordan. Students who use stimulants for academic reasons must be made aware of the potential consequences of the NMU of stimulants.

Do Medical Universities Students Use Cognitive Enhancers while Learning?—Conclusions from the Study in Poland

Background: Stress and everyday problems may impact memory and cognition. Therefore, many people use cognitive enhancers (CEs), sold for prescription, as over-the-counter drugs, or dietary supplements, believing they may help with everyday functioning. Our study was designed to answer whether taking CEs is common among Medical University students and to identify which substances are mainly used. Methods and Results: An anonymous online questionnaire was answered by 479 students of Medical (88%) and Dentistry (12%) Faculties in Poland. Women constituted the majority of respondents (63%). CEs were used by 53% of respondents, with the most frequent being caffeine, ginseng, nicotine, theanine, ginkgo, and lecithin. Some persons used CEs that are available only with a prescription. The most important reasons for the use of CEs were to increase arousal and improve concentration (mentioned by 81% and 73%, respectively). Over 65% of students experienced some undesired/adverse effects after taking CEs, with tachycardia being the most common, followed by sleep disturbances (reported by 51% and 40%, respectively). Conclusions: More than half of the respondents from the Medical and Dentistry Faculties reported using CEs, despite their unproven efficacy and not-well-established safety. This raises significant concern about the knowledge of young persons regarding CEs and should encourage universities to undertake educational actions.

Assessment of knowledge, perception, attitude, and use of performance-enhancing substances among students of Faculty of Medicine, Alexandria University, Egypt: a pilot study

Background

The market for performance enhancement substances (PESs) is currently one of the fastest expanding sectors. Most studies have always concentrated on athletes in terms of PESs’ misuse, ignoring a critical segment of the community: the future health-care workers. Thus, the aim of the study was to probe the knowledge, perception, and attitude of medical students regarding the misuse of PESs in sports and medical academic study. A cross-sectional study was conducted among students of Alexandria Faculty of Medicine, Egypt. Data were collected via self-administered electronic survey from 208 students of both sexes (aged from 18 to 26 years old). Analysis of factors affecting the consumption of PESs like gender differences, and their prior knowledge and perception was performed using logistic regression models.

Results

More than half of the participants have no idea about law concerning the use of doping substances. There were no significant disparities in knowledge and perception between males and females. Female students, on the other hand, consistently reported having a better understanding of the negative impacts of PESs’ misuse. Surprisingly, females are more prone to consume PESs for cognitive enhancement rather than the physical performance.

Conclusions

The study is the first to explore the awareness of the medical students, their attitude, and perception towards different ethical scenarios confronted in the daily practice. This finding pinpoints that the common trend of striving for fitness and an ideal body shape and weight has produced a shift in the prevalence of the PESs use according to gender in Egypt. Moreover, females in medicine academics are more prone to use PESs to improve the cognitive functions albeit it is nonsignificant statistically. Therefore, efforts should be directed to raise the awareness of medical practitioners of diverse categories of these substances, health hazards, laws, and penalties. More importantly, policy measures for their production, marketing, and misuse among university students should be reconsidered by the government.

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.

Attitudes of medicine, pharmacy, and dentistry students about psychostimulant use to enhance cognition

INTRODUCTION

The use of psychostimulant drugs to increase academic success is common among young people. There is no study examining this issue in Turkish population. In this study, the prevalence, attitudes, knowledge, and ethical evaluations of Pharmacological Cognitive Enhancement (PCE) in university students were investigated.

METHOD

A structured online survey was carried out with 1148 undergraduate and postgraduate (master, PhD and residency) students in different faculties of Medicine, Dentistry and Pharmacy in Turkey. Comparisons between groups, correlation and regression analysis about associated variables were made.

RESULTS

The general prevalence of PCE in our study was found to be 7.4%. The highest prevalence was seen in the faculty of medicine (8.4%), among the residency students (15.5%). There was no significant difference prevalence of PCE between the faculties. Education level, smoking, study performance satisfaction, and knowledge level were found to be factors associated with PCE. Around 40% of PCE users stated that they used it with the recommendation of their friends. PCE users had a lower perception of harm and risk, and rated the use of it as more acceptable and normal behaviour.

CONCLUSION

PCE is a method used by young with high knowledge, low study performance satisfaction, to increase their academic success, especially during exam periods. Peer effect is an important factor in increasing prevalence.

Non-medical use of methylphenidate by medical students: prevalence and motivations. Integrative review

Objective: This study performed a literature review evaluating aspects of prevalence and motivations on the non-medical use of methylphenidate by medical students. Methods: We searched the Scopus, PubMed, SciELO, and Web of Science databases and the Google Scholar search tool using the keywords "Methylphenidate" and "Medical Student" and their correlates in Portuguese. A total of 472 articles were recovered, of which 24 were included for full reading and discussion after the application of the pre-established inclusion and exclusion criteria. Results: It was observed that the prevalence of non-prescribed use of methylphenidate ranged from 0.51% in Lithuania to 35% in Colombia. The main motivations reported for using the drug were academic outcomes improvement and increase in concentration during studies, although research shows no significant improvement in academic performance with the use of medication by healthy individuals. Conclusion: The non-prescribed use of methylphenidate presents a high and worrying frequency. Also, scientific studies questioning the use of psychostimulant medications for cognitive improvement by healthy students make the practice illegal and unfounded.

Neuroenhancement: State of the Art and Future Perspectives

Pharmacological neuroenhancement refers to the non-medical use of prescription drugs, alcohol, illegal drugs, or the so-called soft enhancers for the purpose of improving cognition, mood, pro-social behavior, or work and academic performance. This phenomenon is undoubtedly more frequent than previously supposed especially amongst university students. The aim of the present paper was to carefully review and comment on the available literature on neuroenhancement, according to Prisma guidelines. The results showed a great use of all prescribed drugs (benzodiazepines, antidepressants, antipsychotics, nootropic compounds, and especially stimulants) as neuroenhancers amongst healthy subjects, although probably the real prevalence is underestimated. The use of illicit drugs and soft enhancers is similarly quite common. Data on the improvement of cognition by other compounds, such as oxytocin and pheromones, or non-pharmacological techniques, specifically deep brain stimulation and transcranial magnetic stimulation, are still limited. In any case, if it is true that human beings are embedded by the desire to overcome the limits of their intrinsic nature, neuroenhancement practices put into question the concept of authenticity. Therefore, the problem appears quite complex and requires to be deepened and analyzed with no prejudice, although within an ethical conceptual frame.

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.

Effects of Appearance- and Performance-Enhancing Drugs on Personality Traits

Appearance- and performance-enhancing drugs (APEDs) are commonly used by adolescents and young adults in an effort to improve not only athletic performance but also physical and mental efficiency and sexual appearance. The rationale for using these drugs is grounded in the perceived importance of external appearance, the quest for health and youth, and the urge to boost one's sexual performances. Although APED users tend to be quite moderate overall, some specific subpopulations can display pathological use associated with high-risk behaviors. A wide and diverse range of APEDs is now easily accessible to almost anyone through backdoor online avenues. Common APEDs include anabolic-androgenic steroids, non-steroidal anabolics, anorectics, diuretics and ergo/thermogenics, nootropics or "cognition enhancers," licit and illicit psychostimulants, and finally, sexual enhancers. The use of APEDs appears linked to several psychopathological disorders of unclear prevalence, e.g., body image disorders and eating disorders, perfectionism, but also depression and loneliness. The role of personality traits related to APED use has been investigated in adolescents and young adults, in elite and amateur athletes, and in chemsexers and associated with the above-reported personality traits. The studies herein analyzed show that APED consumption in the general population is quickly growing into a public health concern. It is therefore essential to launch prevention and intervention projects aimed at promoting safe instrumental use of the body, not only in sports disciplines but also among the general population, and to promote psychological aid procedures for people with substance use issues, depression and anxiety, and body image disorders.

Professionals' attitudes towards the use of cognitive enhancers in academic settings

INTRODUCTION AND AIMS

The non-medical use of prescription stimulants such as methylphenidate, dexamphetamine and modafinil is increasing in popularity within tertiary academic settings. There is a paucity of information on awareness, attitudes, and acceptability by professionals of use in this context. This study aimed to investigate professionals' knowledge of and attitudes towards the use of cognitive enhancers (CEs) in academic settings, and their willingness to use a hypothetical CE.

DESIGN AND METHODS

A mail survey was sent to doctors, pharmacists, nurses, accountants and lawyers in New Zealand. These disciplines were chosen as they require professional registration to practice. The questionnaire comprised four sections: (1) demographics, (2) knowledge of CEs, (3) attitudes towards the use of CEs, and (4) willingness to use hypothetical CEs.

RESULTS

The response rate was 34.5% (414/1200). Overall, participants strongly disagreed that it was fair to allow university students to use CEs for cognitive enhancement (Mdn = 1, IQR: 1,3), or that it is ethical for students without a prescription to use cognitive enhancers for any reason (Mdn = 1, IQR: 1,2). Professions differed in their attitudes towards whether it is ethical for students without a prescription to use CEs for any reason (p = 0.001, H 31.527).

DISCUSSION AND CONCLUSION

Divergent views and lack of clear consensus within professions and between professionals on the use of CEs have the potential to influence both professionals and students as future professionals. These divergent views may stem from differences in the core values of self-identity as well as extrinsic factors of acceptability within the profession in balancing the elements of opportunity, fairness and authenticity in cognitive enhancement. Further research is required to inform the development of policy and guidelines that are congruent with all professions.

Beyond Treatment Versus Enhancement: A Qualitative Study of Pharmacological Neuro-Enhancement Among Dutch and Lithuanian University Students

This article examines the ambiguous relationship between treating illness and enhancing normalcy through the use of “cognitive enhancement” drugs. Although the literature on pharmacological neuro-enhancement generally differentiates between the “licit/therapeutic” and “illicit/enhancement” use of substances, in-depth interviews with 35 university students in the Netherlands and Lithuania—both with and without formal medical diagnoses of (mainly) Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder—reveal the fluidity of these categories. Our study of the perceptions and experiences of people who use such drugs further suggests a much broader range of substances, motives, and sought-after effects than are commonly acknowledged in the “cognitive enhancement” literature. We need a more inclusive and context-sensitive approach to study pharmacological neuro-enhancement, for instance, by approaching both licit and illicit drugs as tools or instruments.

Nootropic drugs: Methylphenidate, modafinil and piracetam - Population use trends, occurrence in the environment, ecotoxicity and removal methods - A review

Pharmaceuticals which originally were designed to treat people with neurological and psychiatric conditions, e.g. Alzheimer's disease or attention deficit hyperactivity disorder (ADHD), are nowadays often misused by students as a 'brain doping' substances. These substances are known as nootropic drugs, smart drugs or cognitive enhancers, as they increase memory, attention and concentration of healthy individuals. Since they are easily available illicitly, their consumption is observed to be growing. Currently, these pharmaceuticals started gaining researchers' attention, especially since they have been recently detected in wastewater, surface water and even drinking water. This review summarises the current state of knowledge on nootropic drugs in terms of their population use trends and ethics, occurrence in the environment and detection techniques, toxicity and removal methods, in example of methylphenidate, modafinil and piracetam - three most popular nootropics. It points out that the main sources of knowledge on cognitive enhancers illicit use are often inconsistent questionnaires, which are not supported by wastewater analysis to become more veracious. Simultaneously, the studies concerning toxicity and removal methods of nootropic drugs are still limited and in many cases environmentally irrelevant. Although the prescription rules has been subjected to more strict control in developed countries, regulatory frameworks with regard to their ecosystem occurrence are still lacking and should be introduced. Moreover, the use of environmentally relevant concentrations in toxicity studies should be a standard, leading to proper ecotoxicity risk assessment. Based on this review, it is recommended to routinely monitor nootropics and their metabolites in waste- and surface waters.

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.

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.