The billion dollar business of being smart
Author(s): Krishna Chinthapalli
Source: BMJ: British Medical Journal , 14 Sep 2015 - 20 Sep 2015, Vol. 351 (14 Sep 2015 - 20
Sep 2015)
Published by: BMJ
Stable URL: https://www.jstor.org/stable/10.2307/26521850
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BMJ 2015;351:h4829 doi: 10.1136/bmj.h4829 (Published 14 September 2015) Page 1 of 2
Observations
OBSERVATIONS
HEADS UP
The billion dollar business of being smart
Demand for cognitive enhancement is huge and growing
Krishna Chinthapalli neurology advanced trainee, Royal North Shore Hospital, Sydney, Australia
The prolific French novelist Honore de Balzac wrote for 15 drills is an hour not spent hiking, learning Italian, making a new
hours a day with the help of his “precious essence.” After a recipe, or playing with your grandchildren, it may not be worth
dose, he said, “Ideas march into motion like battalions . . . it.”8
Memories charge in . . . The cavalry of metaphor deploys with International sales of non-prescription supplements for cognition
a magnificent gallop; the artillery of logic rushes up.”1 He also exceed $1bn (£650 000; €880 000) a year and are rapidly
eventually took it up to 50 times a day. As far as de Balzac was growing. Ginkgo biloba, vitamins, and even caffeine are
concerned, caffeine was his “smart drug.” common ingredients. Some add piracetam (related to the
Caffeine is still the drug of choice for many college students in epilepsy drug levetiracetam), jellyfish proteins, or even “edible
search of the same effects. Most have used coffee, caffeine pure 23.5 carat gold flakes.”
drinks, or caffeine tablets to help them study.2 In the United Prescription drug manufacturers have been keen to take a slice
States, caffeine is now being supplanted by the prescription of this market. Cephalon, which released modafinil in 1998 for
stimulants Adderall (amphetamine plus dextroamphetamine), narcolepsy, was marketing the drug for off-label uses such as
methylphenidate, and modafinil. Some 5-15% of college and fatigue or depression with little clinical support.9 It worked:
university students report taking these stimulants to help 80% of modafinil prescriptions were for off-label use between
academic performance but most do so only occasionally (40% 2001 and 2006, but it eventually also led to a $425m fine
had used them only once or twice).3 Colleges with higher entry imposed in 2008.10 This was the first time a drug company was
criteria have a higher prevalence of stimulant use. In high prosecuted for promoting off-label uses that lacked scientific
schools, too, 7% of final year students took a prescription evidence. The company also extended the patent from 2001 by
stimulant without a prescription in 2014.4 obtaining a patent on a specific formulation that ran until 2014.
The number of students using stimulants legally has also been Generic companies could circumvent this new patent by creating
increasing because these drugs are indicated in the treatment of different formulations, and four of them applied to do just that.
attention deficit hyperactivity disorder (ADHD). One in nine In May 2015 the Federal Trade Commission fined Cephalon
US children has a diagnosis of ADHD, and the prevalence is $1.2bn for unlawfully extending its monopoly by paying the
increasing by 5% a year.5 Some of this increase may be due to generic companies $300m to delay their generic drugs until
malingering, with a quarter of college students thought to be 2012.11 Meanwhile, modafinil sales were $1bn a year.
feigning symptoms (for prescriptions or incentives such as Cephalon had a longer term plan, common in the drug industry,
extended time).6 known as “product hopping.” Cephalon wanted to switch users
The UK has fewer data, but a 2012 online survey of university from modafinil to its newer compound armodafinil, which has
students showed that lifetime prevalence of drug use to help a patent until 2016, before generic modafinil became available
academic performance was 24% for caffeine pills, 6% for in 2012. Armodafinil has a patent until 2016. To do this, it raised
modafinil, 4% for methylphenidate, and 2% for amphetamine.7 the price of modafinil tablets from $5.50 to $13.60 over five
Two thirds of remaining students said that lack of access was years until 2009 and introduced armodafinil at $9 a tablet.12
the only reason they had not tried such drugs. Methylphenidate and amphetamine work by increasing
Growing market extracellular dopamine levels, but the mechanism of action of
modafinil is not fully understood. It may increase cortical levels
Aside from stimulants, other tools purport to keep your brain of catecholamines, glutamate, and serotonin.13 Whatever its
sharp. Crosswords are being replaced by brain training games, mechanism, modafinil has fewer side effects, particularly
now a billion dollar industry. Overstated claims by software producing less dependence. A recent systematic review
companies led to a consensus statement last year by more than concluded that modafinil improves executive functions.14
60 neuroscientists warning that evidence was sparse and of poor
quality. They concluded, “If an hour spent doing solo software
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BMJ 2015;351:h4829 doi: 10.1136/bmj.h4829 (Published 14 September 2015) Page 2 of 2
OBSERVATIONS
However, 22 of the 24 studies considered only a single dose of 3 Smith ME, Farah MJ. Are prescription stimulants “smart pills”? The epidemiology and
cognitive neuroscience of prescription stimulant use by normal healthy individuals. Psychol
modafinil for effects on cognitive tasks and side effects. Bull 2011;137:717-41.
4 Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the
future national survey results on drug use, 1975-2014. Volume I, secondary school
Banned in chess students. 2015. www.monitoringthefuture.org//pubs/monographs/mtf-vol1_2014.pdf.
5 Centers for Disease Control and Prevention. Attention deficit / hyperactivity disorder.
“With Adderall, I’d characterize the effect as . . . correction of 2015. www.cdc.gov/ncbddd/adhd/data.html.
6 Musso MW, Gouvier WD. “Why is this so hard?” A review of detection of malingered
an underlying condition. Provigil [modafinil] feels like ADHD in college students. J Atten Disord 2014;18:186-201.
enhancement,” Paul Phillips, a professional poker player, told 7 Singh I, Bard I, Jackson J. Robust resilience and substantial interest: a survey of
pharmacological cognitive enhancement among university students in the UK and Ireland.
the New Yorker.15 Phillips won more prize money within six PLoS One 2014;9:e105969.
months of taking amphetamine than in the previous four years. 8 Allaire JC, Bäckman L, Balota DA, et al. A consensus on the brain training industry from
Stimulants are allowed in poker tournaments but banned in the scientific community. ScienceInsider 2014 Oct 20. http://longevity3.stanford.edu/blog/
2014/10/15/the-consensus-on-the-brain-training-industry-from-the-scientific-community-
chess. 2/.
9 Connecticut Attorney General’s Office. Attorney general announces $6.15 million settlement
In the competition for grades, Duke University in the US has for illegal drug marketing. Press release, 29 Sep 2008. www.ct.gov/ag/cwp/view.asp?
banned stimulants, stating that “the unauthorized use of a=2795&q=423868.
10 Phillips and Cohen. Cephalon pays $425 million. Press release, 29 Sep 2008. www.
prescription medication to enhance academic performance” phillipsandcohen.com/News-Reports-of-P-C-Cases/Cephalon-pays-425-million.shtml.
constitutes cheating.16 There has been little public debate about 11 Federal Trade Commission. FTC settlement of Cephalon pay for delay case ensures $1.2
the ethics of powerful “smart drugs,” which may arrive soon billion in ill-gotten gains relinquished. Press release, 28 May 2015. www.ftc.gov/news-
events/press-releases/2015/05/ftc-settlement-cephalon-pay-delay-case-ensures-12-billion-
due to increasing consumer demand and increasing research ill.
into dementia treatments. For now we can still have a cup of 12 Pringle E. The rise and fall of Provigil. 21 Sep 2010. www.opednews.com/articles/The-
Rise-and-Fall-of-Provi-by-Evelyn-Pringle-100921-377.html.
coffee. 13 Minzenberg MJ, Carter CS. Modafinil: a review of neurochemical actions and effects on
cognition. Neuropsychopharmacology 2008;33:1477-502.
14 Hawkes N. Modafinil does enhance cognition, review finds. BMJ 2015;351:h4573.
Competing interests: I have read and understood BMJ policy on 15 Talbot M. Brain gain. New Yorker 2009 Apr 27. www.newyorker.com/magazine/2009/04/
declaration of interests and have no relevant interests to declare. 27/brain-gain.
16 Duke University. Academic dishonesty. https://studentaffairs.duke.edu/conduct/z-policies/
Provenance and peer review: Commissioned; externally peer reviewed. academic-dishonesty.
1 De Balzac H. The pleasures and pains of coffee. Michigan Quarterly Review Cite this as: BMJ 2015;351:h4829
1996;35:273-7. http://downlode.org/Etext/pleasures_pains_coffee.html.
2 Franke AG, Christmann M, Bonertz C, Fellgiebel A, Huss M, Lieb K. Use of coffee, © BMJ Publishing Group Ltd 2015
caffeinated drinks and caffeine tablets for cognitive enhancement in pupils and students
in Germany. Pharmacopsychiatry 2011;44:331-8.
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