This is the third of a multiple part series exploring Cosmetic Psychopharmacology. It includes the text of Joe's thesis and will culminate in a reanalysis and break down of the piece. Read Part One here.Part Two here Part Four here
Caffeine is commonly known as the substance that gives us the pick up after a cup of coffee or tea. It has been used for thousands of years. Many accounts of this drug are found in legends, normally associated with beneficial overtones attributed to the drink and its effects on health. The Chinese attribute its discovery to an ancient emperor 3000 years before the Common Era (Evans 1992). However, caffeine is not localized to Asia since Ethiopian legends also reference drinks containing caffeine, namely coffee. Caffeine has traditionally been used in a liquid form by steeping various plants (tea leaves and cocoa leaves) in boiling water and consuming the liquid. Its use has continued until today, being added into popular soft drinks. It is the most widely used drug in contemporary times (Lovett et al. 2005) and is considered to have few social downsides as evidenced by its near universal legality. Recent antioxidants discoveries, common compounds found in tea and coffee, have illuminated beneficial effects of these beverages aside from caffeine, which may be disassociated from the beneficial effects perceived from the action of caffeine itself.
Most of us are fairly familiar with the effects of Caffeine ingestion. Primarily it causes an increase in alertness and an abatement of sleepiness (Horne 1996). This is obviously one of the cosmetic effects of caffeine. Through ingestion caffeine can supplant the natural circadian rhythm and allow an individual to extend his/her period of wakefulness. The benefits of this are easy to see. For example an individual working as a long haul trucker benefits immensely by being able to use caffeine to stay awake while driving for extended periods of times. This allows him to avoid potentially dangerous scenarios such as falling asleep behind the wheel or driving while in a state of extreme tiredness. However, this is not the only effect of caffeine on cognitive functioning.
A study by Lieberman et al. in 2002 on Navy seals demonstrated that Caffeine also has beneficial effects on vigilance, learning, memory, and mood state. This suggests that while the primary benefit of caffeine is staving off sleepiness, it also can be used to more generally increase cognitive function. While the Navy seals are not by any means unhealthy (in fact they are most likely one of the most healthy groups one could study), they benefit from the administration of 200 mg of caffeine. What this suggests is that individuals at peak health still gain an advantage from caffeine ingestion, which enables them to better perform their duties. This is a prime example of cosmetic psychopharmacology in action and demonstrates that there is indeed a cognitive benefit to caffeine that is not present under purely abstinent conditions.
Cultural and Moral Views
Caffeine, being the most widely used psychoactive compound, has no real restrictions or strong moral opposition globally. The Mormon Church and other religions encourage abstinence from caffeine, but this abstinence extends to all psychoactive compounds in general. Many cultures have a long historical connection with various caffeinated beverages notably China and Japan. In general, most people do not view caffeine as a problem drug even though it is addictive.
Cocaine is found in the Coca plant of South America. It has had a long, rich history with both negative and positive aspects. Originally and still today, various native tribes chew(ed) Coca leaves along the range of the Andes Mountains. Spanish Conquistadors who took control of the region initially decried Coca leaves, but upon discovery that the locals were correct about the beneficial effects, taxed the plant (Freye and Levy 2009). Many workers in mines along the Andes range still chew the leaf while working, allowing them to work for longer periods at increased pace (Freye and Levy 2009). German chemist Friedrich Gaedcke isolated the cocaine alkaloid in 1855, which created the white powder commonly thought of today. This extraction technique allowed pure cocaine, which did not require chewing for ingestion. Cocaine then gained widespread use in medicine. Because of its anesthetic properties it could be used topically in various surgeries, gaining a long history of use in dental practices but also in other applications (Musto 1991).
Cocaine found another use in the wine Vin Mariani, which contained cocaine dissolved in ethanol. This was widely popular, with various other beverages also adding cocaine as an ingredient. Sigmund Freud published a work entitled Uber Coca which lauded the effects of cocaine. However, cocaine was not long declared universally beneficial. America prohibited the sale and distribution of Cocaine with the Harrison Narcotics Tax Act and later listed it as a controlled substance in the 1970 Controlled Substances Act. Currently cocaine is illegal in the United States and has a large black market revolving around its distribution. The use of crack cocaine, which can be smoked, increased its addictive potential and caused large-
scale addiction in impoverished communities.
Due to cocaine's illegal status in most developed countries, it is difficult to judge its potential cognitive benefits . However, anecdote does provide some insight. For instance, as mentioned before, the tribes along the Andes use coca leaves very frequently in their everyday work to give them added endurance and focus. This suggests that, much like caffeine, cocaine has the potential to increase wakefulness and focus. One important difference between these two stimulants however is the addictive potential of cocaine. While coca leaves are chewed by indigenous tribes, the leaves are not pure cocaine and this means that the dosage on average is lower than what an individual consuming cocaine usually ingests. Also, cocaine works directly on dopamine, a neurotransmitter that has reinforcing effects (it promotes the repetition of a behavior), meaning that it quite easily causes addiction in individuals exposed to it (Dackisa and Gold 1985). Due to the illicit nature of cocaine it can also be adulterated in ways that can cause harm to an individual.
Cultural and Moral Views
In the United States cocaine is often demonized as a very powerful negative influence on society. It is a powerfully addictive drug and has a strong association with delinquency. Crack cocaine, the smokeable form, is often abused in lower income neighborhoods and, because of this, has become largely associated with gang violence and its associated evils (Elliot et al 1998). However there are other segments of the population who use cocaine too. As far back as 1915, the New York Timeshad reported on cocaine use by traders on Wall Street and in a 1973 article referred to it as a "chic refreshment" (TIME). Outside the United States, there are both positive and negative connotations with cocaine use, but as of yet, no one has stopped the indigenous tribes of the Andes from using the coca leaf for their benefit.
Nicotine is another commonly used legal psychostimulant. It comes from the tobacco plant and also has been used by Native Americans in religious ceremonies for a long time. It was named after Jean Nicot de Villemain of France. It was first isolated from the tobacco plant by German chemists Posselt and Reiman (Henningfeild and Zeller 2006). It can be chewed, smoked, or administered topically. It is currently the leading cause of preventable death worldwide, with the Surgeon General in 1967 claiming that it is the main cause of lung cancer. Opinion has long been divided about nicotine.
Nicotine, like cocaine and caffeine, is a stimulant. It promotes wakefulness much like other stimulants. Nicotine also has been shown in multiple studies to increase attention and memory, both long and short term (Rezvani and Levin 2001). However there is much debate over these benefits. Several studies have shown that nicotine users have a lower attention and memory baseline when not under the influence of nicotine. Upon administration of nicotine however there is an increase in attention and memory. However on naive nicotine users (those previously unexposed), there is also an attendant increase in attention and memory suggesting that nicotine does have a cognitive enhancing effect. The difficulty with nicotine is establishing whether users use because they have a lower baseline capacity or if they use because nicotine has lowered their baseline capacity.
Cultural and Moral Views
Due to nicotine’s widespread use there are many different opinions on its use. Some contend that it allows them to focus and relax more easily while others contend that its use is detrimental. An important distinction needs to be made in regards to nicotine’s effects in and of themselves and the effects of the route of administration. Nicotine itself is not carcinogenic, however the additives applied to it are. Nicotine does have negative effects on cardiovascular health. Another important problem with nicotine use is secondhand smoke. Many studies have found that the negative effects of smoking extend not only to the individual but also to those who inhale the smoke due to proximity. This means that individuals who do not smoke have detrimental effects by being in close proximity to individuals who do (Zhu 2003). While this may not be a major problem for adults who can move away from smoke, it is import for those who live in the same household and cannot remove themselves from the situation, namely children. This issue has inspired many countries to ban smoking in public areas and indoors aside from in one's own home. There are large scale global efforts to decrease the use of products containing nicotine due to their highly addictive nature. Many smokers themselves hope to cease use but are incapable of doing so due to the addictive properties of the substance. And there have been large lawsuits tied to companies that distribute nicotine containing products because of their perceived use of misinformation and advertising to encourage use.
Alcohol is another widespread and commonly used psychoactive agent, different from cocaine, caffeine, and nicotine because it is a depressant. Alcoholic beverages have been consumed since prehistoric time (Roach 2005). Until 1796, alcohol was limited to alcohol water mixtures but Johann Tobias Lowitz was able to obtain ethanol through activated charcoal filtration. The use of alcohol is widely legal although there are many laws that establish a minimum age for the purchase and consumption of alcohol. Many religions use alcohol, notably the Christian use of wine in the sacrament. Alcohol also serves as a social lubricant, meaning many countries have a social setting around which alcohol consumption is typical and used for increased ability of social interaction.
Although ethanol is a depressant it has been shown to increase memory consolidation (Tyson and Schirmuly 2003). However the intellectual effects are of minor importance in a study of the reasons why it is used cosmetically. Primarily alcohol is used for its properties as a "social lubricant," essentially a means of lowering inhibition for an increased ability to socialize. This presents itself by decreasing self-consciousness and increasing the likelihood of approaching others. The effects of these alterations are evidenced by an increase in promiscuity associated with the use of alcohol. Obviously this increase in promiscuity demonstrates an evolutionary incentive to consume alcohol in an effort to pass on one's genes. Aside from this cosmetic increase in social openness alcohol greatly reduces mental capacity.
Cultural and Moral Views
Interestingly alcohol’s effects are also influenced by expectations, which vary by culture. For instance, not all cultures expect alcohol to behave as a social lubricant and, in accordance with this, those society's individuals do not exhibit disinhibition upon intoxication. This is also true of aggressiveness associated with alcohol along with sexual arousal. Many religions, including Islam and some Christian sects, mandate complete abstinence from alcohol. Others use alcohol in religious ceremonies or are permissive of their use. Generally, cultures that allow the use of alcohol look at extreme alcohol use as negative while finding no problem with moderate alcohol use. There have been periods of alcohol prohibition in the United States where an outright ban was placed on all alcoholic beverages. These varied opinions on alcohol have led to many moral disagreements over alcohol that continues to today, with no real consensus on its morality.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective Serotonin Reuptake Inhibitors are a class of drug which had their inception in 1967. Dissatisfied with MAOIs and Tricyclic antidepressants, which caused severe adverse side effects, SSRIs were developed to function on the sertonergic system instead of the noradrengergic system, the target of tricyclic antidepressants. These drugs quickly gained widespread use throughout the 80s and 90s as a result of massive marketing campaigns and clinicians preferring the less severe side effects. Currently antidepressants are the most common prescription in the United States, making up a multibillion dollar marketplace for drugs of this kind.
SSRIs have very subtle effects that occur over a significant time scale for effects to occur (Eison and Mullins 1996). Currently they are being contested as large-scale meta-analyses show little difference in mild to moderate cases of depression between SSRIs and placebo (Kirsch 1998) (Rief 2009). On a very small scale, SSRIs strengthen serotonergic signals by preventing the reuptake of serotonin at the synapse. This means that signals which are normally too weak because of the absence of adequate serotonin have a higher chance of coming through because the serotonin remains at the site of action for a longer time. The exact mechanism of the reduction in anxiety and depressive thoughts is unknown, however it is postulated that it may be because of an increase in cells of the hippocampus, which has been noted in animal models (Santarelli 2003).
Cultural and Moral Views
The SSRIs are a topic of great contention in current times. There widespread use raises questions of over prescription and pressure from drug companies. However, they do provide a large scale model of cosmetic use as the rates of clinical depression do not match up with the rates of prescription of SSRIs. They are often a subject of cultural interest, spawning several books, films, and art that touch on the use of Prozac or other SSRIs. Also important is their general lack of drug seeking behavior although there can be withdrawal symptoms associated with discontinuation.
Modafinil was synthesized in the late 1970s by the French Pharmaceutical company Lafon. It gained acceptance as a drug for use in Narcolepsy, shift work sleep disorder, and excessive daytime sleepiness due to sleep apnea. It is also used off label for
many other disorders but interestingly is
sanctioned in Maryland for use by law enforcement and paramedics. They are
allowed, in times of high risk or extended law enforcement operations to use
doses of 200mg of Modafinil once a day to increase alertness and allow workers
to maintain activity for a long period of time. There is much interest in its
cosmetic use, because several high profile athletes use it as a doping agent
which prompted a petition of the FDA for over the counter sale [OTC].
Modafinil's mechanisms of action are very unclear, but they do not work the exact same way as amphetamines even though they share similar pharmacodynamic features. The drug increases levels of monoamines and histamines. Modafinil has been found to significantly enhance performance on digit span, visual pattern recognition, spatial planning and stop signal reaction time (Turner 2003). Also latency was decreased in delayed matching to a sample, decision-making and spatial planning (Turner 2003). This means it took less time for test subjects to perform tasks involving decision making and spatial reasoning. When asked to self-report patients expressed that they felt alert attentive and energetic when using the drug (Turner 2003).
Cultural and Moral views
Modafinil is not a widely known drug and correspondingly has very little in the way of cultural significance. However, the military approves its use for fighter pilots and other armed personnel suggesting that its use is found to be acceptable in these professional ranks. Also, astronauts use Modafinil for mental augmentation and to give them a semblance of a sleep wake cycle in space, where the natural biorhythms of the earth do not apply due to the lack of clear sunrise and sunset. These various uses suggest that in terms of morality there are no common critiques of its use from the layman's perspective.
Methylphenidate (commonly known as Ritalin) was first synthesized in 1944. Beginning in the 1960s it was used to treat attention deficit hyperactivity disorder (ADHD). It rose to prominence in the 1990s as the diagnoses of ADHD was better understood and accepted as a condition in the medical community. It is approved for use in ADHD, postural orthostatic tachycardia syndrome and narcolepsy and is prescribed off label for lethargy, depression, neural insult, obesity, and other disorders to a lesser degree.
Methylphenidate is a psychostimulant and has the typical effect profile of such a drug. It works by increasing the release of dopamine and norepinephrine through preventing reuptake. The drug has been found to increase performance on spatial tests, planning, and working memory (Elliot 1997). It also increases alertness and wakefulness.
Cultural and Moral views
Due to methylphenidate's similarity to cocaine and amphetamines it has a high potential for abuse and addiction, this causes controversy over its use. There is a great deal of concern over its use by college students as a cosmetic agent for studying or remaining awake longer. This is a drug that has had a great deal of ethical discussion over its use, citing its efficacy as a mental augmentative agent and also its potential for adverse and addictive effects. Ritalin is unavailable without prescription and is considered a schedule II substance in the United States, the same status as cocaine.
Adderall is a mix of amphetamine salts that was introduced in 1996 by Shire Pharmaceuticals. It contains dectroamphetamine and a racemic mixture of amphetamine salts. It is approved for use in ADHD and nacrcolepsy patients and is used off label for some cases of depression and obesity.
Like amphetamines and methylphenidate, Adderall is a stimulant and has the associated effects of increased wakefulness. Adderall has been found to enhance performance on convergent thinking tasks only and having a two tiered effect, enhancement for low performing individuals and negative or no effect on high performing individuals (Farah 2009). Adderall is also thought to increase attentiveness.
Cultural and Moral views
Much like methylphenidate Adderall is used commonly on college campuses to increase energy, stay awake, and increase focus. Its use has been banned by different athletic organizations, most significantly the NFL. Because it is an amphetamine, its use carries with it a large potential for abuse and addiction. Generally the drug is thought to be acceptable for use in patients with the proper medical indications but is considered dangerous and immoral for use in healthy individuals.
Modern Use of Cosmetic Psychopharmaceuticals
While currently being of indeterminate moral standing the use of cosmetic psychopharmaceuticals is widespread in the developed world and on the rise. This is of importance to note because it demonstrates some real world truths about the current state of the legal status of psychopharmaceuticals. Because purchase and use of cosmetic psychopharmaceuticals is illegal, at least for those which require prescriptions for use or are illegal to possess, dosing is self-prescribed by individuals hoping to gain a benefit through pharmacological means. This means that there is no oversight to the use of psychopharmaceuticals for purposes of enhancement (outside of the law) or patients are feigning symptoms to gain access to these prescriptions and are using the drug in dosages suited for curative effects and not for augmentative effects (within the law). Even though the curative effects and the augmentative effects may have a similar dose range this isn't certain. Also, with self-dosing, there is a high chance of developing addiction to the compound being used. However, even though these risks are fairly obvious to people who use augmentative psychopharmaceuticals, this does not dissuade college students or professionals from off label use of these compounds. These same issues arise with self-administered use of the legal compounds alcohol, caffeine, and nicotine along with the illegal cocaine use because there is, again, no medical oversight.
Who Uses Cosmetic Psychopharmaceuticals?
In the Western world there seems to be an obvious pattern in those who use cosmetic psychopharmaceuticals for enhancement. In the US 6.9% -16.2% of college students have reported using psychostimulants for studying. For individuals between the ages of 12 to 18 years old, 2.4% of students have used psychostimulants for studying. These statistics illustrate the attraction of using cosmetic enhancement as a tool to improve performance of school work. By using these compounds, students are able to work longer, faster, and with greater attentiveness allowing for a minimization of time spent on work while allowing more time for other desirable activities or more work in general.
Professional scientists and intellectuals have prevalent rates of psychopharmaceutical use is too. A poll put online by the journal Nature asking scientists to respond about their use of psychopharmaceutical enhancement showed that 1 in 5 scientists used compounds for nonmedical purposes. Of those who did utilize pyschopharmaceutical compounds, 62 percent used Ritalin while 44 percent used Modafinil.
Some notable historical intellectuals and leaders have also utilized psychoactive compounds for their beneficial effects on the intellect and work rate. Freud was a vehement supporter of the use of cocaine and used it himself quite frequently. He also wrote a book proselytizing the benefits of the use of cocaine entitled Uber Coca. Jean-Paul Sartre used an over the counter medication called Corydrane that contained aspirin and amphetamine, which purportedly enabled him to write for 8 to 10 hours a day at the height of his activity. He also was a heavy smoker, around 2 packs per day. Adolf Hitler also utilized cosmetic psychopharmaceuticals being administered caffeine, amphetamines, methamphetamine, and cocaine by his personal doctor Theodor Morell.
From this point on we will be using the previous information to craft how we should ethically engage these pyschopharmaceutical agents. To reiterate, keep in mind the following points.
To be mentally ill is to be functionally (in the sense of being able to work and provide for oneself) and interpersonally impaired members of society. This leaves out those who can interpersonally and functionally operate in society, but are not up to the level that they want themselves to be. These are the individuals with health as opposed to Health.
When we are discussing augmentary methods we are dealing with situations in which someone cannot be classified as unhealthy but they hope to be better than they currently are. This is opposed to curative methods that take someone from a state of illness to a state of health or Health. While augmentary methods run afoul of creating a legitimate ontological distinction between the two states, the field of psychiatry is founded on a pragmatic basis and this allows us to draw a pragmatic distinction between health and Health.
It is important to remember that when we are discussing the moral permissibility of using certain pharmaceutical agents to enhance ourselves, we are not discussing the legal permissibility. While legality applies to a specific spatiotemporal location, morality aspires to transcend this barrier and give a prescriptive explanation of how we should act.
We must also remember the drugs that have been described and note their differences and similarities. This shows the wide breadth of both use and effects of cosmetic psychopharmaceuticals. This breadth shows how variant the situation between a given individual and a certain chemical can be. It also reminds us that while these compounds all fall under the category of drugs; they do not necessarily have common features.
Finally we must note the long history of psychopharmaceutical enhancement in human society. This is important to remember because it suggests that there is a common human urge to enhance one’s self through pharmaceutical means. This is found in our contemporary culture in both the professional and educational arenas.