Patients who take nootropics

[Unico]

Last year I stumbled upon the world of nootropics and biohacking. I've been lurking on the reddit forum for r/nootropics, r/stackadvice, and on a facebook group called nootropics. The things these people are taking and their reasons for doing so ... it's nuts. As an MS3, the topic both fascinates and frightens me. I've gotten to the point where *I think* I'd like to write about the topic to help educate others about the world of nootropics, specifically the implications of having a patient population who might not be completely forthcoming about their current supplement/medication regimens which may include MOAIs ordered from overseas, NMDA agonists, cholinergics, etc. To that end I'm trying to avoid the "mental enhancement" claims in lieu of providing education to physicians on the common reasons and substances people are using (surprisingly, it's not all about "being smarter"), addressing how physicians can openly discuss this topic with patients, and what are the implications for psychiatrists and the mental health field in general.

I was curious if anyone has had any experience with patients (or anecdotally themselves) with the topic and substances? Are there any questions you think I should address? Any and all help would be greatly appreciated. If by chance anyone knows of anyone who is already writing/talking about this from a psychiatric perspective, please let me know. Or, better still, if you think this topic is career suicide please don't let me shoot myself in the foot before my career even gets started 😉

Thanks!

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[Fan_of_Meehl]

I don't know anything about the actual scientific/empirical and clinical literature on this class of medications. However, given the well-understood phenomena of homeostasis, tolerance, up/down regulation (on the backdrop of millions of years of evolutionary optimization of nervous system functioning)...I would think that any short-term 'juicing'/optimization of nervous system functioning via pharmacological means would run into problems in the long run. Though, in the instant case, I would admit that this is all a priori speculation.

 

[WisNeuro]

What FoM said. I'd keep my feedback to patients at the "we really don't know much about the effects of these supplements" level. Additionally, I would also urge caution about buying **** from shady companies overseas as you really have no idea if that substance is what they say it is. I generally defer most med questions to PCP, but will comment on some glaring things (e.g., maintenance benzos bad for dementia patients, talk to your doctor about the **** ton of diphenhydramine you are taking throughout the day because it's possible you are in a constant state of almost delirium, donepezil doesn't do dick to help with memory).

 

[clausewitz2]

I don't know anything about the actual scientific/empirical and clinical literature on this class of medications. However, given the well-understood phenomena of homeostasis, tolerance, up/down regulation (on the backdrop of millions of years of evolutionary optimization of nervous system functioning)...I would think that any short-term 'juicing'/optimization of nervous system functioning via pharmacological means would run into problems in the long run. Though, in the instant case, I would admit that this is all a priori speculation.

Not to get pedantic or anything, but evolution is in no sense of the word an optimizing process, rhetoric of some over-enthusiastic biologists aside. It is full of organisms stuck in local fitness maxima where a much higher level of functioning would be possible but is not achievable along a continuous fitness growth curve.

Evolution is strictly a sufficing process. It produces good-enough solutions.

To answer your question, OP, I have seen a number of people on phenabut and a couple instances of daily piracetam. They might have been stacking more but this is what they were willing to disclose. True to form they had moved quickly to requiring multiple grams of phenabut a day. One guy was trying to come off benzodiazepenes with it, which is clever but also didn't work very well.

 

[Unico]

Thank you all for the feedback. I should have been more specific in my original post as my focus for the research is not on the cognitive enhancement aspects (and frankly I don't want to touch that with the preverbal ten-foot pole at this moment). The nootropic community has broadened the definition of "cognitive enhancement" to include substance which simply enhance people's lives, which includes supplements for chronic conditions (both mental and physical). Nuances such as the seemingly simple definition of what a nootropic is are a large part of of why I felt the topic was relevant for the medical community.

With that, my focus would be more on patient populations who are looking to self medicate for a variety of psychiatric conditions: addiction and withdrawal (as clausewitz2 mentioned), depression, anxiety (this is pretty big on the forums), personality disorders, somatic symptom disorders, etc. Certainly we could include the juicers/cognitive enhancement crowd for population sake, but I am guessing these populations wouldn't present to a psychiatrist until after the damage is done and their pathology would be more distinguishable after CC, HPI, and psychosocial analysis.

From the posts so far, it would seem that the topic is not as fringe as I had anticipated. However, I still get the sense that a large subset of nootropic users might be going unnoticed. Admittedly, my naivety most likely helps fuel my a priori (in love with this, thanks FoM). Perhaps more exposure with patients during residency will provide more insight with regards to patients who self medicate and their motives for doing so.

Just for completion sake, here is one of the more poignant examples of what I'm talking about: cerebrolysin. It is BDGF, GDNF, NGF, CNFT (ciliary neurotropic factor) purified from pig brains which is administered IM or taken nasally. All cognitive enhancement discussion aside, my goal is elucidate the population of users and signs/symptoms of use. In this case the population for expected abuse would be chronically depressed patients, those with TBI, and recovering addicts who present with sudden worsening of symptoms and a decline in everyday functioning. Simply reminding patients to avoid buying substances from unscrupulous sources in this case seems a bit underwhelming in the face of possible prion toxicity (hyperbole? I don't think anyone knows right now). Again, I don't care to delve into the ethics or evidence of cognitive enhancement, this is purely an information session on demographics.

Thoughts? Is this just new to me?


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[smalltownpsych]

A quick search of pubmed shows that cerebrolysin has been used for stroke and TBI and it seems that it has demonstrated some efficacy and safety. I'm sure some of the neurologists or neuropsychiatrists might be more familiar with that. For myself, I have not heard of depressed patients or addicts taking it. Of course, we're a bit behind the times out here in the rural west. Is there really a significant abuse potential? What I mean by that is does it get you high (like a good drug) or does it produce noticeable results (like anabolic steroids). If not, then I wouldn't really worry too much about it. The internet is a great repository for people who do weird things. I remember the whole toad licking thing. It never really caught on. For performance enhancing that can also get you high, we already have adderall so why inject distilled pig brains?

 

[WisNeuro]

A quick search of pubmed shows that cerebrolysin has been used for stroke and TBI and it seems that it has demonstrated some efficacy and safety. I'm sure some of the neurologists or neuropsychiatrists might be more familiar with that. For myself, I have not heard of depressed patients or addicts taking it. Of course, we're a bit behind the times out here in the rural west. Is there really a significant abuse potential? What I mean by that is does it get you high (like a good drug) or does it produce noticeable results (like anabolic steroids). If not, then I wouldn't really worry too much about it. The internet is a great repository for people who do weird things. I remember the whole toad licking thing. It never really caught on. For performance enhancing that can also get you high, we already have adderall so why inject distilled pig brains?

I haven't seen much in the way of high quality research showing that. Huge conflicts of interest and some questionable methodology, not too mention no real examination of long-term effects or outcomes. Not saying there isn't anything there, just that we still appear to be miles away from a point where we should be advocating for its use in general settings. Needs more research before prime time use.

 

[smalltownpsych]

I haven't seen much in the way of high quality research showing that. Huge conflicts of interest and some questionable methodology, not too mention no real examination of long-term effects or outcomes. Not saying there isn't anything there, just that we still appear to be miles away from a point where we should be advocating for its use in general settings. Needs more research before prime time use.

I figured you would be more familiar with that. Is it one of those things that is being sold as a supplement as opposed to a pharmaceutical to avoid the more stringent requirements to demonstrate efficacy and safety?

 

[Unico]

I figured you would be more familiar with that. Is it one of those things that is being sold as a supplement as opposed to a pharmaceutical to avoid the more stringent requirements to demonstrate efficacy and safety?

Yes. It is being sold in vials online and users are both injecting and snorting up to 50mL of this stuff at a time.


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[WisNeuro]

What SMG said. While I am not a huge fan of some FDA hurdles. I am less a fan of the almost completely hands off approach to supplements due to the industry lining the pockets of certain influential politicians over the years. If people spent the billions of dollars that they waste on useless supplements each year on retirement and health, we'd have a much different situation in this country.

 

[Unico]

Is there really a significant abuse potential? What I mean by that is does it get you high (like a good drug) or does it produce noticeable results (like anabolic steroids). If not, then I wouldn't really worry too much about it. The internet is a great repository for people who do weird things. I remember the whole toad licking thing. It never really caught on. For performance enhancing that can also get you high, we already have adderall so why inject distilled pig brains?

Ironically, amphetamines are not considered nootropics because their effects do not produce changes in the brain -- not my words, just the definition that has become widely accepted.

Abuse potential for this substance seems low due to the MOA and cost ($500 for 5 vials). Psychological addiction is never out of the realm of possibility IMHO. I have not seen any reports of getting high, but with this crowd I feel that term might be subjective and require additional research.

Anecdotal reports from healthy individuals range from increased focus, memory, verbal fluency, clarity of thought, and overall sense of wellbeing. A report I recently read had an arbitrary 10-20% increase in baseline functioning (whatever that is). Similarly, reports of no effect have been seen and are often attributed to a bad source of the product. Adverse effects, again self reported and non-verifiable, have included two cases of EBV, severe brain fog, and derealization. This is not by any means exhaustive, it's just what I remember off the top of my head for this particular substance.

https://m.reddit.com/r/Nootropics/c...ce=amp&utm_medium=comment_header&compact=true

http://www.longecity.org/forum/topic/65682-cerebrolysin-adverse-effects-advice/undefined

Inquires for the substance have included people who are indicted for its use, TBI and cognitive decline as mentioned previously. Additionally, those who feel that they have cognitive decline due to drug abuse, being alive, etc. have expressed interest in its ability to reverse cognitive deficits.

If I do end up writing a poster or something, I will certainly consider calling it the toad licking experiments


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[smalltownpsych]

What SMG said. While I am not a huge fan of some FDA hurdles. I am less a fan of the almost completely hands off approach to supplements due to the industry lining the pockets of certain influential politicians over the years. If people spent the billions of dollars that they waste on useless supplements each year on retirement and health, we'd have a much different situation in this country.

You mean eat healthy food, engage in healthy enjoyable activities, work hard and invest wisely, and have good communication in healthy relationships?

Do you have any idea how many sessions it takes to get someone to agree that is what they need to do and then how many more to get them to start doing it?

Man, I really need that week off next week. 🙂

 

[clausewitz2]

Now that I think about it, two more possible cases that might count as nootropic use, or at least involve similar safety issues:

1) patient from a Middle Eastern country, moves here for school, has a bad depressive episode, wants to go back on Valdoxan (agomelatine) because it worked back in his home country. Too bad, not approved here, no one can prescribe it. One visit to an Internet pharmacy site later, he's back on it.

2) previously high functioning guy has a rather public incident of very poor judgment that ruins his professional and personal life. Gets very depressed, nothing seems to help, doesn't tolerate ECT even. Finds a cowboy ketamine clinic, gets infusions, does better, but doesn't want to keep going back. One order to a Chinese compounding pharmacy later, he has his own supply of intranasal ketamine spray that he uses BID.


So both of these are compounds with real-no-fooling scientific evidence for efficacy, but also are clearly being used in a DIY manner with sourcing from uncertain provenance that I think typifies some of the issues with nootropic.

 

[WisNeuro]

Yeah, I am sure that these substances do you have good therapuetic uses. But, if I'm ordering it from some no-name source overseas, I really have no idea what the hell is in that stuff. Who knows what you're putting into your system. Heck, who knows if the dosing is anywhere near consistent from dose to dose. Caveat emptor on any of these things.

 

[clausewitz2]

Yeah, I am sure that these substances do you have good therapuetic uses. But, if I'm ordering it from some no-name source overseas, I really have no idea what the hell is in that stuff. Who knows what you're putting into your system. Heck, who knows if the dosing is anywhere near consistent from dose to dose. Caveat emptor on any of these things.

Yeah. That's the thing that is my biggest concern with most nootropics. What you are getting from a random Chinese lab is probably fine until it is notm

 

[birchswing]

Yeah. That's the thing that is my biggest concern with most nootropics. What you are getting from a random Chinese lab is probably fine until it is notm

This is a problem with our prescription drug supply as well. The FDA only very recently started doing chemical analysis of drugs, and even that is through very small grant programs to universities. The testing is very limited. Everything to this point has been them looking at manufacturers' self-generated reports showing effectiveness in a clinical trial—no actual testing of the pills themselves.

It was actually a consumer group that tests supplements (ConsumerLab) that first was able to verify that Wellbutrin XL generics were not equivalent to the brand name and were subsequently taken off the market.

Most of the APIs for prescription drugs come from China. They're then manufactured into tablets all over the world, often in China or India. We have just a few people from the FDA monitoring hundreds of factories in India and thousands in China, and they're not testing the end product. All the can do is write up notices for violations (usually dealing with sanitation). They send a letter, the company responds, the FDA re-checks, sends another letter, etc. They have almost no authority to make changes, and even if they did, what would happen to our drug supply if we were to shut down all the out of compliance manufacturers?

Everyone I know who works for or is a contractor for a federal government agency is terrified of losing their job right now. The FDA has been chronically underfunded throughout many administrations. I don't see that improving in the next four years.

 

[nitemagi]

I have gotten a bit into ayurvedic herbs, many of which fall into this category. There's a broad range of papers on some of them, from animal to human. I'm most cautious about cytochrome interactions and very careful about recommending it for patients.

 

[Unico]

I have gotten a bit into ayurvedic herbs, many of which fall into this category. There's a broad range of papers on some of them, from animal to human. I'm most cautious about cytochrome interactions and very careful about recommending it for patients.

I hadn't heard of this term before, thanks for sharing.


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[SeniorWrangler]

In my state, there are lots of naturopaths who make a practice of prescribing really complex combinations of herbs and supplements for various medical conditions. I usually discuss with people all the issues mentioned about bad quality control, lack of evidence, and total unknowns about interactions with medical conditions, medications, and other supplements.

In addition, I would never tell anybody to take a (mainland) Chinese supplement. The Chinese consumer market is notoriously risky and fraudulent and people have gotten seriously ill from basic products like baby formula and menstrual pads. If people can afford it, I encourage them to try pharmaceutical-grade supplements from Europe.

 

[thoffen]

If a psychiatrist has a patient who is taking a substance in order to affect their mental functioning, of course they ought to be involved. This doesn't mean they ought to confront a patient about it, but it is impossible that such a thing would not be biologically and dynamically important to the psychiatric care you provide.

 

[DD214_DOC]

If I discover a patient I have on meds is taking random junk like this, I have an educational session as well as a come to Jesus. They need to decide which they want to take and if they want to continue care with me. Seems harsh, but if something bad happens the cause will always be the useless psych meds greedy shrinks and evil pharma tricked them into taking, and never the different colored mix of pills in an unlabeled bottle found inside a box that appeared on their doorstep.


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[clausewitz2]

If I discover a patient I have on meds is taking random junk like this, I have an educational session as well as a come to Jesus. They need to decide which they want to take and if they want to continue care with me. Seems harsh, but if something bad happens the cause will always be the useless psych meds greedy shrinks and evil pharma tricked them into taking, and never the different colored mix of pills in an unlabeled bottle found inside a box that appeared on their doorstep.


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I can respect that, but I wonder where you would draw the line. Is someone religiously taking fish oil and SAM-E on a daily basis to improve their mood, drinks kava sometimes when feeling anxious, and takes some l-theanine sometimes of they really need to burn the midnight oil for a big project also not welcome in your practice?

 

[birchswing]

If I discover a patient I have on meds is taking random junk like this, I have an educational session as well as a come to Jesus. They need to decide which they want to take and if they want to continue care with me. Seems harsh, but if something bad happens the cause will always be the useless psych meds greedy shrinks and evil pharma tricked them into taking, and never the different colored mix of pills in an unlabeled bottle found inside a box that appeared on their doorstep.


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I'm glad you are educated on foods and supplements and their interactions with drugs.

It can be difficult to find that combination of wisdom on medication and wisdom on the effects of food/supplements.

Some of the things I have found that aren't often known:
-Nutmeg and clove (found in many holiday foods) can contribute to serotonin syndrome
-Tylenol is serotonergic
-If grapefruit interacts with your medicine, then lime, bergamot (including Earl Grey tea), pomegranate, and anything with bitter orange does as well
-More DHA and EPA in your fish oil supplements is not necessarily a good thing (very complicated subject matter involving lengthy discussion)

There are other interactions/subject matters I am careful about, but those are the ones I have found people to be the most unaware of.

 

[nitemagi]

I'm glad you are educated on foods and supplements and their interactions with drugs.

It can be difficult to find that combination of wisdom on medication and wisdom on the effects of food/supplements.

Some of the things I have found that aren't often known:
-Nutmeg and clove (found in many holiday foods) can contribute to serotonin syndrome
-Tylenol is serotonergic
-If grapefruit interacts with your medicine, then lime, bergamot (including Earl Grey tea), pomegranate, and anything with bitter orange does as well
-More DHA and EPA in your fish oil supplements is not necessarily a good thing (very complicated subject matter involving lengthy discussion)

There are other interactions/subject matters I am careful about, but those are the ones I have found people to be the most unaware of.

I'd like to see some primary sources on these.

 

[birchswing]

I'd like to see some primary sources on these.

You are my primary source that these are little known facts. 🙂