Ritalin for everyone!

There was a scandal in my small town several years ago when a respected couple was arrested for hosting an alcohol soaked party for middle school students at their home. I don’t remember the details, but I do remember the parents’ defense. They claimed that young teens were going to use alcohol anyway; therefore, it was better if parents provided it and supervised its use.

I was reminded of that case by a controversial commentary, Toward responsible use of cognitive-enhancing drugs by the healthy, published yesterday in the scientific journal Nature. The opinion piece is sure to provoke a firestorm of protest. The authors argue that everyone, healthy people included, should have easy access to cognition-enhancing drugs like Ritalin because, in the words of author Martha J. Farah, “Almost everybody is going to want to use it.” Indeed, the use of Ritalin and other stimulants by healthy college students ranges from 4% to as high as 25% on some campuses. According to Farah, “It’s a felony, but it’s being done.”

This piece makes no sense to me. The authors publish a call for universal access to brain stimulants in the absence of sound scientific research, in the absence of evidence that this is a problem worthy of societal attention, and based on an inane defense that it should be allowed because people are going to use them illegally any way. As Leigh Turner of the University of Minnesota Center for Bioethics said, when asked to evaluate the commentary: “It’s a nice puff piece for selling medications for people who don’t have an illness of any kind,” Turner said.

What does the piece say?

Today, on university campuses around the world, students are striking deals to buy and sell prescription drugs such as Adderall and Ritalin — not to get high, but to get higher grades, to provide an edge over their fellow students or to increase in some measurable way their capacity for learning. These transactions are crimes in the United States, punishable by prison…

 In this article, we propose actions that will help society accept the benefits of enhancement, given appropriate research and evolved regulation. Prescription drugs are regulated as such not for their enhancing properties but primarily for considerations of safety and potential abuse. Still, cognitive enhancement has much to offer individuals and society, and a proper societal response will involve making enhancements available while managing their risks.

In the opening paragraphs, the authors make several bizarre claims. In addition to the claim that everyone is doing it, the authors insist that cognitive enhancement offers many benefits, and that the only role of regulation is safety. Therefore, we, as a society, should figure out how to provide these “benefits” in a safe manner, while presumably decriminalizing the trade of these drugs by individuals.

Drugs like Ritalin have been used successfully to treat attention deficit disorder with and without hyperactivity (ADD/ADHD). There are also reports of therapeutic benefits in cognition in patients with brain tumors, strokes and traumatic brain injuries. However, when it comes to the use of stimulants among healthy young adults, there is surprisingly little scientific information available.

In discussing safety, the authors mention three issues, long term risks, pressure to self medicate, and fairness, but, surprisingly fail to discuss the most important issue, the fact that stimulants like Ritalin are drugs of abuse. We do not have a clear idea of the long term effects of using Ritalin. The information we have at present suggest that stimulants can be safe for long term use in therapeutic settings, allowing us to balance the known benefits of stimulants in therapeutic settings against the unknown, though probably small risks.

There is no reason to assume that the same calculus applies to using stimulants in healthy individuals. Consider a different class of drugs that may offer a useful parallel, opiates. Opiates are extremely beneficial in a therapeutic setting, and although they have both short and long term risks, those risks are usually justified by the benefits. When opiates are used in non-therapeutic situations, to create a “high,” the benefit risk calculus is very different. The “benefit” is not necessarily beneficial, and the long term risk of addiction is far greater. Stimulants, like opiates, are known to be drugs of abuse and addiction even in therapeutic settings. It is quite possible that they are more likely to lead to abuse and addiction when used by healthy people.

The authors devote far more attention to ethical issues of fairness than to the currently more pressing issues of benefits and risk. Their answers to their own ethical questions are hardly better than the inadequate answers to the empirical issue of safety.

Addressing the issue of the morality of using cognitive-enhancing drugs, the authors say:

Human ingenuity has given us means of enhancing our brains through inventions such as written language, printing and the Internet…The drugs just reviewed, along with newer technologies such as brain stimulation and prosthetic brain chips, should be viewed in the same general category as education, good health habits, and information technology — ways that our uniquely innovative species tries to improve itself.

Are these people serious? Brain stimulation and prosthetic brain chips should be viewed in the same category as education? That is a claim that begs for ethical justification and the authors don’t bother to provide any. Blithely assuming that their claim is self-evident, they proceed to two other ethical concerns.

The authors clearly assume that stimulants for cognitition-enhancement in healthy people can and will be widely available. However, they are concerned that when that great day comes, some people will be left out, either because they don’t wish to self-medicate or because they can’t pay for the drugs.

Those concerns are, not surprisingly, similar to issues raised by performance enhancing drugs in sports. If everyone is using steroids, what happens to those who refuse to self-medicate with steroids or can’t afford steroids? Interestingly, we, as a society, have not chosen to make steroid use legal in athletics, nor are we insisting that athletes must use steroids, and we are not offering free steroids to promising high school athletic stars. Nonetheless, this is the direction that the authors of the commentary are pushing us toward in regard to stimulant use.

Who wrote this commentary, and how did it get published in the prestigious and highly respected journal Nature? Of the seven authors, two are consultants for drug companies and one is an editor of Nature. The other four claim to have no conflicts of interest. However, it is a matter of public record that some of their affiliated institutions have financial relationships with drug companies.

At a minimum, it is distressing that Nature has published an article where three of the authors have a clear conflict of interest, including one of their own editors. I want to emphasize that I have no information that the other four authors have any financial ties to the pharmaceutical industry. However, in light of multiple scandals in which authors of papers in both The New England Journal of Medicine and The Journal of the American Medical Association (JAMA) were subsequently revealed to have concealed financial ties to industry, I can only hope that the editors of Nature did more than simply take the authors’ word on potential conflicts of interest.

This commentary is inexplicable. There is no good science to back up its assertions; it ignores the principle risk of drug abuse; and it encourages us to take action on an issue that should be very far down our agenda. And like the parents who were arrested for providing alcohol to minors, its principle justification is that everyone is going to do it anyway. That’s not even a remotely reasonable defense for providing alcohol to minors, and it is not a remotely reasonable defense for providing cognitive-enhancing stimulants to healthy people