Can ‘smart drugs’ benefit your patients?

By Naveed Saleh, MD, MS | Medically reviewed by Amanda Zeglis, DO, MBA
Published December 16, 2022

Key Takeaways

  • Common nootropics, or “smart drugs,” include stimulants like methylphenidate, modafinil, amphetamine, and dextroamphetamine.

  • Although the science underlying the cognitive-enhancing benefits of stimulants as nootropics in healthy patients requires further evaluation, these drugs can result in neuropsychiatric or cardiovascular complications.

  • Nootropic use in healthy individuals is fraught with ethical concerns, including the medical community’s support of interventions that make life “great” vs “normal.”

In popular culture, the prospect of taking a “smart drug” or other interventions for cognitive stimulation has inspired authors and filmmakers alike. In the 2011 film “Limitless,” Bradley Cooper’s character finds riches, fame, and power after taking a fast-acting nootropic called NZT-48.

Probably the most famous tale of cognitive enhancement, however, is the 1968 film “Charly,” in which a middle-aged janitor with mental disabilities undergoes surgery to become smarter but learns that his newfound intelligence comes with a price.

What’s the scoop on smart drugs (ie, nootropics, cognitive enhancers) in the real world? Do they work? And if so, is their use ethical?

Smart drugs in use

Real-life smart drugs used by the public include the stimulants methylphenidate, modafinil, amphetamine, and dextroamphetamine.

These compounds offer only limited enhancement of cognitive capabilities, by blocking the reuptake of norepinephrine and dopamine in the brain. According to research published in Frontiers in Psychiatry, these drugs may result in increased cognition and pleasure, and have become popular for use as “study drugs.”[]

Potential health risks

The effects of nootropics on patients with memory or learning conditions are well-known, but these drugs are increasingly being used by healthy people—including students and students and workers without cognitive deficits or diagnoses.

Although users of nootropic drugs claim in anecdotal accounts that these substances boost memory, attention, executive functioning, learning, and vigilance, their efficacy in healthy people has not yet been fully explored. Furthermore, their reported benefits are usually only temporary.

Because most nootropics are stimulants, they also moderate central noradrenaline, glutamate, and dopamine levels, potentially resulting in cardiovascular and neuropsychiatric complications, including dependence and tolerance.

Authors of a review article published in Drugs wrote that the use of cognitive enhancers can be associated with addictive behavior, as well as long- and short-term cognitive decline.[] The authors added that “the non-medical use of any potent psychotropic raises serious ethical and legal issues, with nootropics having the potential to become a major public health concern.”

Another concern over the use of psychoactive drugs for cognitive enhancement is that they may impair the perception of reality—including the consequences of the user's actions.

“Such cognitive enhancement methods are still being explored,” wrote the author of the article published in Frontiers in Psychiatry.

"It is unclear whether enhancers are actually effective or have the potential to alter and manipulate memories, moral autonomy, and personality."

Giovanna Ricci, Frontiers in Psychiatry

‘Epidemic’ substance misuse

Research points to increasing rates of smart drug use around the world.

A study published in The American Journal of Psychiatry found that between 2015 and 2016, approximately 16 million adults in the US used prescription stimulants, and 5 million adults misused prescription stimulants without experiencing use disorders.[]

Worldwide numbers vary widely. In the Swiss cantons (states), for instance, 54.5% of 1,139 vocational and upper secondary school students reported taking drugs for cognitive enhancement, according to the Frontiers in Psychiatry research.

The same study also found that in 2015, an “Adderall epidemic” gripped young adults in the US. These students weren't taking the drugs for any therapeutic indications, but rather as off-label agents to increase competitive advantage.

Students used these agents to study longer and more attentively while sleeping less. Amphetamines were similarly misused to improve test scores.

Ethics of a ‘great’ life

In 2015, the US Presidential Commission for the Study of Bioethical Issues published a document on cognitive enhancement and presented its findings/recommendations to the scientific community.

The commission considered all types of neural modification in their assessment and tried to lay out a path for informed, sensible, and productive engagements to foster public discussion regarding cognitive enhancement.

One area that continues to be of great concern among experts is the endorsement of interventions that allow for “optimal functioning.” Although the use of interventions to restore or sustain normal functioning is widely accepted, what standards should there be for those individuals who seek more?

“Medicine’s essential, commendable function in service of achieving a good, healthy life is not to be considered as automatically extendable to living a ‘great’ life, or to attaining above average, excellent performances in a socially-sanctioned [sic] function or service,” wrote the author of the review published in Frontiers in Psychiatry. “Hence, justifications for specialized enhancements meant to achieve extraordinary lifestyles or performances will not necessarily be obtained starting from and according to medical principles.”

Nootropic use in healthy patients

Experts suggest that due to the lack of evidence on the efficacy, safety, and social ramifications of nootropic use, their prescription in healthy patients should be eschewed.

As reported in a review published by Nutrients, one possible exception could be the use of herbal substances as nootropics.[]

Herbal alternatives have been shown to exhibit few adverse effects or contraindications. Whatever the case may be, both synthetic and herbal nootropics should categorically be avoided in pregnant patients.

An example of a natural nootropic that is marketed as a dietary supplement is deanol (DMAE). This compound is found naturally in the brain, and small amounts can be found in fish, such as salmon or shellfish.

This choline precursor permits the brain to optimize the synthesis of acetylcholine, which is the main neurotransmitter of memory and learning. According to the Nutrients research, EEG data from people taking DMAE supplements for 3 months reflected increased attention and alertness, as well as mood elevation. Intriguingly, the compound also reportedly induced lucid dreams and improved sleep quality.

"Future research regarding nootropics should focus on experiments with more diverse human groups, whether in terms of age, health, gender, or weight."

Malík, et al., Nutrients

It should also mainly focus on young, healthy people, mostly university students, who use these substances a lot and obtain them, especially on the black market,” the Nutrients authors continued. Furthermore, already advanced methods based on neuroimaging assessment should be used more in experiments and studies to confirm or refute the potential beneficial effects.”

What this means for you

Stimulants are often misused as nootropic agents in healthy people looking for “smart drugs.” The use of these agents in this capacity is controversial and not recommended due to their potential for medical and psychiatric adverse effects. However, the field of nootropics is dynamic, and things could change with the introduction of newer agents coupled with a better understanding of the ethics of cognitive enhancement.

Read Next: Psychedelic drugs: New wave of depression management?
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