Prescribing ADHD "Study Drugs" to Healthy Patients Poses Ethical Questions
Prescribing stimulants to healthy patients comes with significant risks.
--by Alexia Severson
Prescribing cognitive enhancement medications to healthy people may do more harm than good, according to an analysis published this week in the Canadian Medical Association Journal (CMAJ).
This type of medication is often used to treat attention deficit hyperactivity disorder (ADHD). And while prescription stimulants, such as methylphenidate and dextroamphetamine, are available in Canada by prescription only, they are often given to patients without ADHD to increase focus, concentration, and memory. But there is little evidence of the cognitive benefits of these drugs on healthy individuals, while the risks include cardiovascular harm, dependence, and psychosis.
According to researchers, people usually request prescription stimulants in order to perform better in school or at work, and previous studies have shown that rates of cognitive enhancer use among university students ranges from one percent to 11 percent. But the possibility of harm and the professional integrity of physicians should prevent these drugs from being distributed so freely.
The Expert Take
This study poses three ethical questions about prescribing stimulants to patients: Are there benefits for patients? What is the effect on health care resources? And is cognitive enhancement consistent with medical professional integrity?
According to the authors, physicians play a significant role in this debate.
"I think it’s a question of considering what is the value of using medications like this to enhance performance—asking not only can we do this, but should this be a practice that belongs to the medical profession," said Cynthia Forlini, co-author of the analysis.
From an ethical standpoint, it’s important to understand why doctors choose to prescribe these drugs in the first place, and the impact this decision has on their role as physicians, on healthcare systems, and on society in general, Forlini said. At a time when some physicians are prescribing stimulants to healthy, low-income patients to "level the playing field," careful consideration of the consequences has never been more important.
"I hope our analysis sparks additional reflection in health care providers to carefully think about the way they approach any request for enhancements," she said.
Source and Method
For this analysis researchers referenced The American Academy of Neurology, the first professional association to issue specific guidance for physicians on the subject of cognitive enhancement, in order to further discussion of the physician–patient relationship.
The analysis was also based on The Canadian Medical Association’s Code of Ethics, previous studies, and polls and other available data, serving as landmarks in the ethics debate on cognitive enhancement prescriptions.
This analysis poses several important ethical questions about the misuse of cognitive enhancers by patients; a debate that has been a hot topic for several years.
This issue deserves equal attention in both America and Canada, where prescribing cognitive enhancers may not always be an appropriate use of resources due to expanding demands for care. This analysis also sheds light on the risks that come with taking ADD drugs when they are not necessary. Researchers note that these risks may in fact be worse for individuals who are unaware of the correct doses and that there be other risks that have yet to be studied and documented.
Regardless of whether new guidelines are established in the future, it's important that physicians take the time to consider whether a patient is truly in need of cognitive enhancers and to reflect on the reasons behind their decision to prescribe such medications.
Several other studies and polls have addressed this issue. According to the CMAJ analysis, in a poll published in 2008 in Nature, “20 percent of respondents reported using a medication for cognitive enhancement.” And one in five respondents said they had used drugs for non-medical reasons to stimulate their focus, concentration, or memory.
An article published in Neurology in 2004 also discussed ethical concerns about drugs that might improve brain function. The author stated that “neurologists and other clinicians are likely to encounter patient-consumers who view physicians as gatekeepers in their own pursuit of happiness.”
A study published in the Journal of American College Health in 2006 investigated the medical use, illicit use, and diversion of four distinct classes of prescription medication, including stimulants. In a random sample of undergraduate students, researchers found that “the prevalence rate for illicit use within the past year was highest for pain medication, followed by stimulant medication, sedative or anxiety medication, and sleeping medication.” They also found that medical users of stimulants for ADD were the most likely to be approached to divert their medication.