Nature editorial

[swanny]

The current issue of Nature includes this editorial:

http://www.nature.com/nature/journal/vaop/ncurrent/full/456702a.html

This seems to me to be the next big ethical issue that we'll be dealing with in the field. It is interesting to me that the article is written primarily by educators...

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[DrJosephKim]

Where do we draw the line? caffeine? Prescription stimulants vs. illegal 'street' stimulants?

 

[whopper]

Some ethical & legal issues I think in addition to the above that need to be tackled, but currently aren't...

1) use of psychotropic medications on children where the parents are urging the doctor to do it, & the parents show some questionable behavior (e.g. they want a kid dx'd with ADHD because he only has a 3.5 GPA).

2) psychiatric patients who attack other people, the police show up the situation, find out the guy is a psychiatric patient, & instead of having the guy arrested, they drop the patient off to a psyche facility.
-Turns out the guy did the crime & knew the police were not going to charge him. Also turns out the guy is completely compliant on his medications & stable.

Or similarly a forensic psychiatric patient who when cleared up of his psychosis or mania turns out to be a complete antisocial type--he attacks someone due to his antisocial traits (not his Axis I traits) then because he's in a psychiatric facility-the authorities will do nothing legally against this person. I've actually seen a forensic psychiatrist use this as a defense for a client. He mentioned that bad behavior can be handled "in house" when the guy damn well knew that the client had no Axis I.

3) use of psychotropics on mentally ******ed people. I've seen several cases where a group home taking care of the MR clients want the person zonked on meds because that person acted out in a manner not indicative of an Axis I illness.

4) antisocial criminal ends up on in a forensic psychiatric facility because the person faked mental illness. Then because this guy is so dangerous (due to completely antisocial reasons) & because calling the psychiatrist on night duty in to administer meds takes too long (up to 20 minutes), the treatment team want the guy zonked out on meds. Seroquel 1000mg/day, Thorzine 600mg/day, Zyprexa 40mg/day, Depakote 2000mg/day--to the point where the guy's CNS is so depresed that he needes a CPAP to breathe while he sleeps.

 

[BobA]

Where do we draw the line? caffeine? Prescription stimulants vs. illegal 'street' stimulants?

I agree that a line has to be drawn somewhere. I think the lack of equitable distribution, coupled with side effects, places stimulants on the wrong side of the line. The article address these issues, but I think it's too quick to downplay them.

1) equitable distribution (anyone can buy a red bull, but only those with access can have a doc prescribe adderrall)
2) side effects - anxiety/aggression produced by stimulants might limit the areas where they increase performance. In fact, not properly monitored stimulants could decrease effectiveness in certain domains. It becomes robbing Peter to pay Paul.

Tangentially, a few years ago wasn't there talk that Paxil increased cooperation and group performance and somewhat humorous speculation that corporations would encourage it's use?

 

[Faebinder]

I dont see why we can't help people become better cognitively as long as no side effects are exhibited. Of course if we observe bad side effects they should be stopped.

 

[masterofmonkeys]

Oh competitive nerds have been abusing substances for their (often over-emphasized) nootropic abilities forever. Back in the high stakes world of nerd competitions, there were high schoolers using everything from cocaine, to crushed and snorted adderall, to nicorette gum (one guy I know ended up becoming a smoker because he got addicted to nicorette and smoking was cheaper lol). This was 10 years ago.

Our 'drug of choice' was a pot of green tea apiece (ergogenic agents like EGCG provide a much 'cleaner' and less jittery stimulant effect than caffeine), high dose B-vitamins, and a hit of coffee or no-doz just before the event . (the coach insisted on the b vitamins and probably had no idea how amped up we were on camelia sinensis and coffea arabica).

These days modafinil is gaining in popularity, along with a few abusing namenda (no joke). There are calls for various competitive nerdery organizations to start piss testing competitors. Again, no joke.

The use of psychotropic agents of any kind for anyone is an ethical morasse and it's hard to find right answers. The state of psychiatric diagnosis is such that almost anyone can be prescribed almost any medication on the basis of demonstrable 'symptoms' of psychiatric illness. From stimulants to mood enhancers to anxiolytics to antipsychotics. The use of these agents can be justified on any number of grounds for almost anyone alive. Every one of us has *some* symptom of depression, anxiety, cyclothymic propensities, or attention problems. Between the four categories, you can justify the use of almost any psychotropic medication under the sun.

And with that said, many self-medicate with broadly biologically similar substances to what doctors prescribe for people in similar circumstances. Should it really be considered a crime to 'treat' yourself?

Why is it ok for a doctor to say 'you're anxious, here's benzo.' But illegal for someone to say 'I'm anxious, I'm gonna buy a benzo from my dealer'. Or for a 15 year old to self-medicate his/her anxiety with alcohol while his neighbor gets xanax from his friendly GP?

And, well, pretty much all child psychiatric medication. Many hot topics in child from ADHD, to IED, to 'pediatric bipolar' are fraught with problems in that the primary basis for diagnosis is the child's effect on parents/teachers/caregivers rather than any level of discomfort in the child themself. Many of these issues are setting specific (ADHD), are due to poor relationships with parents/teachers, due to lack of skilled parenting, or simple immaturity.

Yeah I know, all I brought up was questions, not answers. Sorry, don't have any.

 

[BobA]

I dont see why we can't help people become better cognitively as long as no side effects are exhibited. Of course if we observe bad side effects they should be stopped.

In one sense I think we're saying the same thing.

In the world of ideas, I have no problem with cognitive enhancement on principal. However, in the real world of adderall/ritalin/focalin there are *some* factors that limit the drugs usefulness - whether that be unfairness due to lack of access, or unwanted side effects.

I think moral issues are usually more shades of grey than black and white.

 

[wolfvgang22]

Adrafinil is not even scheduled in the U.S.

 

[whopper]

I agree that a line has to be drawn somewhere. I think the lack of equitable distribution, coupled with side effects, places stimulants on the wrong side of the line. The article address these issues, but I think it's too quick to downplay them.

I read a statistic somewhere about 5-10 years ago mentioning how many law & medical students who were taking ADHD meds. I forgot the figure. I do know that a lot of people who weren't diagnosed with it that I knew in med & lawschool were taking them or buying them off of someone diagnosed with ADHD.

As a doctor I worked with once mentioned--they'll help anyone, whether you have ADHD or not. So just because a guy tells you he works better on stimulants, doesn't prove he has ADHD.

I had some educational materials on ADHD that I tossed into the recycling so I can't cite the specific source; I've actually seen psychiatric educational materials suggesting to psychiatrists that we should be more open minded to prescribe ADHD meds because several people go into adulthood undiagnosed with this disorder. They brought in examples of people who took stimulants, then performed better at work, & tried to use that alone as a proof that the person had ADHD.

Does ADHD go undiagnosed into adulthood? I'm sure there are some cases of it. I also know that I'm not going to prescribe any ADHD meds with an addiction/absue potential to an adult trying me to convince me he/she has it without some testing that strongly suggests it. Even then I'd probably reccomend fish oil, Wellbutrin, Effexor or Strattera, and would still harbor a grudge against using an ADHD med of possible abuse.

Add to the problem, most of the tests for ADHD that are commonly used require the person to be tested in school. Most adults are past schooling.

Would I give it out for performance enhancement? I know some doctors that admitted they would. I wouldn't. For that patient to get billed, I'd have to write some kind of diagnosis that justified an ADHD med. I'm not going to fake an illness on documentation.