In medical practice, cognitive enhancers (also called nootropics) are defined as therapeutic
drugs treating specific cognition impairments in patients with attention deficit hyperactivity
disorder, Alzheimer’s disease, stroke schizophrenia or aging.
However, the non-medical use of cognitive enhancers with the aim of increasing mental
alertness and concentration, improving memory, fighting wakefulness and boosting energy
has been spreading worldwide2. In this concern, scarce investigations have been carried out on
the possible risks of chronic non-medical use of nootropics, and these risks seem to be largely overlooked, especially among students3. Considering the ever more competitive nature of
modern societies, which also reverberates into workplaces, cognitive enhancers are reasonably
expected to become even more common over time4. Nonetheless, long-term consequences are
as yet unknown.
Cognitive enhancers, used by healthy individuals, are widely known as nootropics: they
consist of drugs, supplements and other substances that are allegedly known to improve
cognitive function, particularly executive functions, and to strengthen memory, creativity or
even motivation. Pharmaceutical substances and compounds known as ‘cognitive-enhancers’
allegedly boost mental performance and the ability to focus and keep concentration. In broader terms, such drugs are often claimed to heighten and foster the acquisition of motor capabilities and affective skills (i.e., one’s ability to deal with anxiety stemming from performing
certain work tasks or eliciting feelings of trust and affiliation).
It is worth noting, however, that no drugs are licensed by medical authorities to be recommended and prescribed as ‘cognitive enhancers’. Thus, the definition of ‘performance-enhancing drug’ is usually linked to the off-label use of drugs prescribed for specific medical conditions. These substances are usually stimulants that preferentially target the catecholamines of
the prefrontal cortex of the brain to induce their effects5.
Historically, amphetamines have been the first drugs used off-label for the purpose of
fostering memory consolidation and increasing concentration6. Since these substances are
legally controlled as drugs of abuse, they can only be obtained on illegal markets. This purchase channel is also used to obtain methylphenidate, which is undoubtedly the most misused
drug as cognitive enhancer5,7. Mostly prescribed for treating Attention Deficit Hyperactive
disorder (ADHD) and narcolepsy, methylphenidate has been scheduled as an illegal drug in
many countries for its abuse liability and side effects, resulting in a rapid expansion of methylphenidate legal analogs onto the drug market. Alternative prescription drugs for the treatment of narcolepsy and ADHD, such as modafinil and armodafinil, are also used as cognitive
enhancers8. Finally, two last drugs should be mentioned among nootropics: atomoxetine, a
selective nor-adrenaline reuptake inhibitor licensed for the treatment of children with methylphenidate-resistant ADHD or undergoing methylphenidate side effects9, and donepezil, a
second-generation acetylcholinesterase inhibitor licensed for the treatment of mild to moderately severe symptoms of Alzheimer-related dementia10. At the same time, there has been
renewed interest in older prescription drugs (e.g., beta blockers, to decrease performance anxiety) and illicit psychostimulants (e.g., cocaine, amphetamines), sometimes in different
forms or doses.
Whereas there is still little consensus on the actual effectiveness and nature of the cognitive benefits of the above-mentioned drugs in healthy subjects13, their use to enhance the level
of performance in specific workplaces has been reported for decades14.
In fact, cognitive enhancement has been a mainstay of military research in the US since the
Second World War with the use of amphetamines, modafinil and other cognitive enhancers in
the most recent military operations (e.g., Vietnam war, Korean war, operations Desert Shield
and Desert Storm in Iraq, later sustained military operations in the Middle East)15,16. Whereas
the military use of cognitive enhancers has been known for many years, not only in the US but
internationally. More recent studies reported that other occupations present a high prevalence
of use: medical doctors and health professionals (e.g., surgeons, surgical technicians’ anesthetists), transportation workers (e.g., truck drivers, car drivers, taxi drivers), financial traders,
clinical investigators, research managers and lawyers. Finally, the increase of precarious and
part-time home works has been recently associated to psychological discomfort and an increase in prescriptions of psychotropic drugs, and a rise in the misuse of cognitive enhancers
can be hypothesized17-19.
Another important factor to be taken into account is the role of the internet as a source of
information through web forums and as a way of obtaining those substances. Such dynamics
also constitute a cultural shift in the way drugs are obtained and consumed: they are anonymously received and safer than street drugs trafficking, although the actual composition and
nature of the substances cannot be precisely ascertained. This latter fact creates a gap of information on the diagnosis of misuse in cases of possible intoxications and fatalities, since neither
analytical screening nor confirmation methodologies are currently available for documenting
exposure to those profuse and chemically diverse substances. In addition, apart from intoxications and fatalities, it has to be reminded that several of these substances present a potential
for abuse liability and abstinence symptoms, which, instead of improving work pressure and
overload, can worsen the environmental situation.
In conclusion, we wish to draw the attention of the whole scientific community and policy
makers to the increasing importance of the misuse of cognitive enhancers, and to improve
public awareness of the phenomenon and contextual political strategies to stop this incoming
threat for the health of current and future worker