Mental enhancers widely used now are merely a precursor By Karen Kaplan and Denise Gellene, Tribune Newspapers

: Los Angeles Times 12:58 PM CST, December 20, 2007 Forget sports doping. The next frontier is brain doping. As Major League Baseball struggles to rid itself of performance enhancing drugs, people in a range of other fields are reaching for a variety of prescription pills to enhance what counts most in modern life. Despite potential side effects, academics, classical musicians, executives, students and even professional poker players have embraced the drugs to clarify their minds, improve concentration or control emotions. "They made me a much better player," said Paul Phillips, 35, who credited the attention deficit drug Adderall and the narcolepsy pill Provigil with helping him earn more than $2.3 million as a poker player. The medicine cabinet of so-called cognitive enhancers also includes Ritalin, commonly given to school children for attention deficit hyperactivity disorder, and beta blockers such as the heart drug Inderal. Researchers also have been investigating Aricept, which is normally used to slow the decline of Alzheimer's patients. Effects on brain well-known These drugs haven't been tested extensively in healthy people, but their physiological effects in the brain are well-understood. They are all just precursors to the blockbuster drug that labs are racing to develop. "Whatever company comes out with the first memory pill is going to put Viagra to shame," said University of Pennsylvania bioethicist Paul Root Wolpe. Unlike anabolic steroids, human growth hormone and blood-oxygen boosters that plague athletic competitions, the brain drugs haven't provoked similar outrage. People who take them say the drugs aren't giving them an unfair advantage, just enabling them to make the most of their skills. In the real world, there are no rules to prevent overachievers from using legally prescribed drugs to operate at peak mental performance. What patient wouldn't want their surgeon to be completely focused during a life-or-death procedure? "If there were drugs for investment bankers, journalists, teachers and scientists that

made them more successful, they would use them too," said Charles Yesalis, a doping researcher and professor emeritus at Penn State University. "Why does anyone think this would be limited to an athlete?" The growth of the brain drugs bears a resemblance to the evolution of plastic surgery after World War I -- developed to rehabilitate disfigured soldiers but later embraced by healthy people who wanted large breasts and fewer wrinkles. The use of cognitive-enhancing drugs has been well-documented among high school and college students. A 2005 survey of more than 10,000 college students found 4 percent to 7 percent of them tried ADHD drugs at least once to remain focused on exams or pull all-nighters. The ubiquitous stimulant is coffee. But as scientists were developing drugs to treat serious brain disorders, they found more potent substances. Sharon Morein-Zamir, a psychologist at the University of Cambridge in England who writes about the ethics of brain enhancement, said her interest in the medications was largely academic. But when someone she knew who had been taking Provigil for a neurological condition offered her some pills, her curiosity was piqued. "I knew the literature and wondered what it felt like." The drug helped her focus as she worked at her computer for hours straight. But she wondered if it was a placebo effect. Phillips, the poker player, started using Adderall after he was diagnosed with ADHD five years ago and later got a prescription for Provigil to improve his focus. ADHD drugs work by increasing the level of the brain chemical dopamine, which is thought to improve attention. Provigil's mechanism of action is not well understood, but boosting the impact of dopamine is thought to be part of it. The drugs improved his concentration during high-stakes tournaments, he said, enabling him to track all the action. "Poker is the sort of game that a lot of people can play well sporadically, but tournaments are mostly won by people who can play close to their best at all times," he said. "It requires significant mental effort to play in top form for 12 hours a day, five days in a row." In the world of classical music, beta blockers such as Inderal have become nearly as commonplace as metronomes. The drugs block adrenaline receptors in the heart and blood vessels, helping to control arrhythmia and high blood pressure. They also block adrenaline receptors in the brain.

"You still have adrenaline flowing in your body, but you don't feel that adrenaline rush so you're not distracted by your own nervousness," said Dr. Bernd Remler, a neurologist at the Medical College of Wisconsin in Milwaukee. That's why Sarah Tuck, 41, a flutist with the San Diego Symphony, takes them to stave off the jitters that musicians refer to as "rubber fingers." She estimates that three-quarters of musicians she knows use the drugs at least occasionally. Prescriptions for Inderal and other beta blockers can be readily obtained by physicians. Tuck said some doctors told her they use the drugs to calm their nerves before making presentations at medical meetings. Drugs have a downside But cosmetic neurology, as some call this practice, has risks. Ritalin, Adderall and other ADHD drugs can cause headaches, insomnia and loss of appetite. Provigil can make users nervous or anxious and bring on headaches, while beta blockers can cause drowsiness, fatigue and wheezing. One Stanford University study found low doses of Aricept improved the performance of healthy pilots as they tried to master new skills in a flight stimulator, but the side effects -- dizziness and vomiting -- were less than desirable for a pilot. No one has conducted thorough studies about how brain-boosting drugs would affect healthy people after weeks or months of use, said Dr. Anjan Chatterjee, a neurologist at the University of Pennsylvania. Negative consequences may not be limited to people who popped the pills. Martha Farah, a bioethicist at the University of Pennsylvania, said she is beginning to detect resentment toward students who use the drugs from classmates who don't. In an article Thursday in the journal Nature, Morein-Zamir and neuroscientist Barbara Sahakian say that clear guidelines are needed. It may be reasonable to ban the drugs in competitive situations, such as taking the SAT. But in other cases, they wrote, people such as airport screeners, air-traffic controllers or combat soldiers might be encouraged to take them.