Is it clever to take smart drugs?
What drives medical students to take smart drugs and what are the risks?
“I tried smart drugs because I was struggling with medicine,” says Laura (NB: all student names in this article are pseudonyms). “I didn’t feel academic enough to keep up on the course.” She is not alone. A small online survey of 1122 Student BMJ readers in 2015 found that 8.3% of medical students in the United Kingdom claimed to have used cognitive enhancing drugs to help them study.
Although the number of self selecting respondents represents only around 2% of the medical student population in the UK, this snapshot suggests that some medical students resort to cognitive enhancing drugs to keep up with the demands of their medical degrees. These are often prescription drugs such as modafinil and methylphenidate (marketed as Ritalin), which are used “off licence,” and obtained through unregulated and illegal channels. So, what drives students to use cognitive enhancing drugs? Do they offer an unfair advantage and do the benefits outweigh the risks?
Experiences of taking cognitive enhancing drugs
Laura says she was drawn to cognitive enhancing drugs because she was depressed: “I noticed other medical students using modafinil and wanted to experiment. I didn’t feel like revising and hoped it would keep me interested. It made the boring stuff more interesting.” Laura noticed that “things were ‘sticking’ more,” but wasn’t sure if this was a placebo effect.
Mark, another medical student, says his partner had been prescribed modafinil to help him cope with his shift patterns, and he suggested that Mark should try a pill to help him concentrate on his studies.
Mark claims that modafinil helped him focus, but that his learning experience was superficial. “In some respects, having that degree of focus might have detracted from the learning experience, because I was just ploughing through words, rather than trying to interact with the text and test my understanding,” he adds.
“I first tried modafinil because I was curious,” says final year student, Hannah. “Initially I got modafinil through my non-medic friends, and then I bought it online. I have taken it during exam periods over the past four years. I usually took one pill per week, and never more than three, because it affected my sleep,” she says.
Her experience of using modafinil has been mixed. “It was good for essay writing and made work seem more interesting. It didn’t help me remember complex topics or form links between them, however; it didn’t improve my long term memory.”
Laura says that one of the side effects of modafinil was that it made her impatient. “You don’t have time for your friends. I was definitely more volatile the week after taking it.” Hannah also noticed a difference in how she responded to friends. “I became more emotionally labile. The mood I was in when taking modafinil affected the way I reacted to it.”
Mark says: “The side effects of modafinil included dry mucous membranes to the point where my nose would bleed. This was relatively unpleasant and would prevent me from using it regularly. I also found that I was antisocial if someone distracted me.”
Little is known about the long term safety of taking cognitive enhancing drugs off licence. In a statement to Student BMJ, King’s College London warned students that they risk their health by abusing prescription drugs such as modafinil, which has a long half life and can severely disrupt normal sleep patterns.
Laura’s experience reflects this: “The main negative for me was sleep. I’m normally a good sleeper, but with modafinil I wasn’t in bed until 4 am and it took me an hour to fall asleep. Some of my friends even took diazepam to counteract this effect.”
Box 1: Modafinil
Modafinil is a drug that promotes wakefulness. It upregulates serotonin, glutamate, and histamine levels and downregulates γ-aminobutyric acid. Licensed as a treatment for narcolepsy, modafinil has also been used to prevent sleepiness in healthy individuals, including US long range pilots during the Iraq war.
A systematic review in 2015 concluded that modafinil results in small, but measurable, improvements in cognitive performance—specifically attention and learning. It helped more during complex tasks, particularly in individuals with lower IQs. Adverse effects include insomnia, headaches, depression, and less commonly, psychosis and dermatological emergencies.
A form of cheating?
Although some students may take cognitive enhancing drugs just to keep up with the rigours of medical school, it is possible that others use them to gain an advantage over their peers. This raises the question of whether use of cognitive enhancing drugs offers students an unfair advantage and should be regarded as a form of cheating.
Cheating in exams threatens the accuracy of assessments on an individual level and also skews the results, affecting other students in the process. In the United States, Duke University School of Medicine has banned smart drugs, stating that “the unauthorised use of prescription medication to enhance academic performance constitutes a form of cheating.”  Advice on cognitive enhancing drug use at universities in the UK, however, is less clear and institutions tend not to monitor its use.
Tim Lancaster, director of clinical studies at the University of Oxford Medical School, says its drug and alcohol policy does not focus specifically on cognitive enhancement drugs, and the university does not monitor students’ use of such drugs. Its policy focuses on substance misuse as a factor in poor performance, ill health, or behavioural problems, he explains. But cognitive enhancing drugs present “a paradigm shift” because of their use to boost performance. Oxford is yet to formulate a policy on whether this constitutes cheating.
Hannah says that clarity is needed, adding: “I wish it was more openly discussed by medical schools. I was aware of an advantage, but it never felt like cheating to me, as it was still my brain—me doing the work. I am a mid-grade student and there was no discernible improvement in my exam performance.”
Academics cannot agree on whether taking cognitive enhancing drugs is a form of cheating. Vince Cakic, a psychologist at the University of Sydney, says underperforming students might benefit from cognitive enhancing drugs by improving their academic performance. But Simone Schnall, a psychologist at the University of Cambridge believes their use could skew academic results, because more affluent students can afford cognitive enhancing drugs, giving a further advantage to those already most privileged. In contrast, Steven Rose, professor of biology and neurobiology at the Open University, argues that a private education offers students a bigger advantage than the use of cognitive enhancing drugs.
While it remains ambiguous whether taking cognitive enhancing drugs is a form of cheating, the impact of taking cognitive enhancing drugs on professional reputation is more clear cut.
A spokesperson from the General Medical Council told Student BMJ that use of cognitive enhancing drugs “raises concerns about the individual’s probity, which is one of the fundamental values we expect of all doctors.”
A 2015 survey of 2500 UK medical students by the Medical Schools Council and GMC, as part of a review of their guidance for students, asked whether it was acceptable for medical students to buy prescription only, cognitive enhancing drugs online to help them study. Most respondents (70%) identified the behaviour as “unacceptable.” A further 22% identified it as “mostly unacceptable.”
In their statement to Student BMJ, the GMC says it views the procurement of cognitive enhancing drugs through illegal means to enhance performance as “extremely concerning.” They say it raises questions about an individual’s “insight, judgment, appetite for risk taking, and quality of personal decision making—which is a dangerous precedent for someone who will, in due course, potentially be required to make prescribing decisions for patients under their care.”
A spokesperson at the Medical Schools Council says: “The use of cognitive enhancing drugs can take many forms, both legal and illegal. Misuse of drugs, including prescription medications, can be identified as unprofessional behaviour and lead to fitness to practise proceedings.”
For students who are tempted to take cognitive enhancing drugs, the Medical Schools Council say that medical schools are keen to support students and “urge students who feel the need to use drugs to seek support from staff.” A spokesperson for King’s College London says that if students need drug related support or advice, “they should contact the university health centre or counselling service.”
The use of cognitive enhancing drugs at UK medical schools persists, and it is clear that students need clearer guidance on the implications of taking these drugs, as well as alternatives, to cope with pressure.
Twishaa Sheth, deputy chair and welfare lead for the BMA’s Medical Students Committee says that the numbers of students turning to cognitive enhancing drugs is “really concerning,” and a better understanding of the root causes behind the behaviour is needed. “In the meantime, it is important for medical schools to broach this topic and develop medical student-specific, transparent policies on cognitive enhancing drugs and cheating,” Sheth adds.
The GMC states that cognitive enhancing drug use is unacceptable behaviour and may result in fitness to practise proceedings. The regulator encourages medical students to seek support when needed and to develop healthy ways to face future challenges. University support services, general practitioners, and the BMA Doctors for Doctors service are all free ways that students can seek non-judgmental, practical methods of support.
Box 2: Alternatives to smart drugs
● The GMC’s Achieving good medical practice: guidance for medical students highlights that professionalism involves learning to develop healthy ways to cope with stress, along with resilience in the face of challenges. This can include seeking independent medical advice, as well as support at medical school.
● Given that the pressures of a career in medicine do not end at graduation, long term coping strategies are needed. “Learning new things is great for your brain,” says Barbara Sahakian, professor of clinical neuropsychology at the University of Cambridge. “Exercise is proven to be good for cognition … and people need to get their sleep.”
● Mindfulness meditation training may improve working memory and attention, although further research is required. Pilot studies have found that doctors who participated in mindfulness sessions reported lower levels of stress and burnout.
● “In my day, medical students took Pro Plus,” says Cyrus Abbasian, consultant psychiatrist and honorary senior lecturer at St George’s, University of London. “Things have moved on since then.” Most students have used caffeine as a study aid. High doses do enhance cognition, but side effects include palpitations, headache, and tremor.
St George’s, University of London, UK
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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