Beyond Normal?

The Brave New World of Lifestyle Drugs and Cosmetic Psychopharmacology

Part One:

Mood and Well-being

What is a Lifestyle Drug?
Lifestyle Drug: A drug used to treat a condition that is not (necessarily) lifethreatening but that has a significant impact on the quality of life.
Oxford English Dictionary (Draft Additions June 2001)
Viagra tablet. (Pfizer)

Lifestyle Drugs: The Controversy

Treating problems that were once accepted as inevitable, normal parts of life Fighting limitations imposed by aging, genetics, or even normal human physiology Famously, Viagra (not psychiatric, but notable) Widely criticized; sometimes lack social approval, health insurance coverage We will explore:
– –

● ●

Some kinds of lifestyle drugs available today The ethical questions raised by lifestyle drug use

Lifestyle Drugs: Important Notes

Given that any given drug could be appropriate for more than one condition... Let's refer to the “non-lifestyle” use of a drug as the one which conforms to traditional norms of medical necessity – the treatment of a lifethreatening illness Any given drug might have both “lifestyle” and “non-lifestyle” applications A drug is an inanimate object. The ethical questions are all about how we use it.

Drug Use and Abuse
● ●

Is a lifestyle drug the same as a drug of abuse? Drug abuse is a loaded phrase. What does it mean? Divergent schools of thought:
– –

1. Public Health

Use of a drug in a way which is detrimental to society Use of a drug in violation of the law Tends to be circular or defined with reference to #3... Any non-medical use No dominant, consistent, non-self-referential definition?

2. Political
● ●

3. Medical and Psychiatric
● ●

Use and Abuse: Running in Circles
● ●

What do the experts say? American Psychiatric Association, 1972:
…as a general rule, we reserve the term drug abuse to apply to the illegal, non medical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien. [*]

American Medical Association

defined in terms of medical supervision or lack thereof

Other definitions: World Health Organization

Similar; Not very helpful

[*]Wikipedia - http://en.wikipedia.org/wiki/Drug_abuse#ref_apa1972

Use and Abuse: Legalistic Jungle

Definitions and sets of definitions that are logically circular are not very useful for answering ethical questions (or for very much else...) Definitions which fall back on current social norms – which can change - also of little use Perhaps we should be more interested in the effects of a drug than the intent of its user... Enough about politics. Onwards to the exciting world of cosmetic psychopharmacology...

● ●

What is cosmetic psychopharmacology?

The use of psychiatric medication on healthy people to induce desirable personality traits. Term coined by Peter D. Kramer, M.D. in his 1992 book. More about this book a bit later...

Relationship between Cosmetic Psychopharmacology and Lifestyle Drugs
Cosmetic Psychopharmacology is the use of a drug (which, in that case, can be thought of as a Lifestyle Drug) to modify one's personality in a desirable and not merely corrective fashion.

Meet.... Prozac (Fluoxetine hydrochloride)

Early Selective Serotonin Reuptake Inhibitor (SSRI) Well-known, controversial

Listening to Prozac

Dr. Kramer noticed that some of his patients showed dramatic personality changes upon treatment with Prozac. They become more outgoing, extroverted, flexible, socially adept – qualities which were not simply obscured by depression, because the patients were lacking in them to begin with In some cases, treatment was ended, and the patient's depression did not return – but the old, subdued personality did.

Listening to Prozac

Kramer's findings led him to re-evaluate the standard view of personality as a set of permanently fixed traits. Not all psychiatrists could justify similar enthusiasm for Prozac – but the idea of a “personality pill” entered the public mind.

http://www.ucl.ac.uk/~ucbtdag/bioethics/project.html

Who Responds to Antidepressants?

Research, of course, focuses on clinically depressed patients – but what about others? “Anything that responds to antidepressants is depression” ? This line of thought has interesting consequences. The discovery of iproniazid – early MAOI
– – – –

Was a candidate for a tuberculosis medication TB Patients in a veterans' hospital were observed to become inexplicably cheerful They had not been formally diagnosed with clinical depression prior to taking the drug. Several possible explanations...

Why did an SSRI become the first candidate for a “Lifestyle Antidepressant” ?

Speculation: MAOIs carried significant risks, and were subsequently used only for cases of bona fide clinical depression. Subsequently discovered tricyclics also had very unpleasant side-effects

Possible benefits of certain antidepressants for the non clinically-depressed – taboo subject? Does merely proposing research of such applications threaten the social approval of antidepressant use for those with unambiguous medical need?

Part Two:

Attention, Cognition and Wakefulness

Attention-deficit hyperactivity disorder (ADHD)
● ● ●

Inability to focus, hyperactivity, distractability Well-known, controversial status Most prevalent, effective treatment is Amphetamines – calming/focusing effect (paradoxical)

Amphetamine Use and Abuse

Some persons without ADHD diagnosis use as study aid.... Does this mean they have undiagnosed ADHD? Not necessarily...

http://tv.ku.edu/flash/images/3633.jpg

Amphetamine

In average person, promote wakefulness; increase energy Under some circumstances, people are given performance enhancers:
– –

With little regard for side-effects With social and state approval

When?...

Amphetamine goes to War

Armies not shy of using performance enhancers... Recognition of effects, mass production: just in time for World War II

http://service.spiegel.de/cache/international/0,1518,354606,00.html

Amphetamine Soldiers On
● ●

Used by both sides. Excessive use leads to nervousness, paranoia, hallucinations “Amphetamine psychosis”

German soldiers at Stalingrad.

http://www-cgsc.army.mil/milrev/portuguese/2ndQtr01/hahn.asp

Amphetamine – Time for Discharge?

American friendly fire incident in Afghanistan blamed on “go pills” (Dexedrine) How are use and abuse defined when you're at war? Pentagon demands better drugs...

F-16 Falcon. US Air Force

Meet... Provigil (modafinil)

Provigil (modafinil): A New Stimulant

Originally used to treat narcolepsy – uncontrolled sleepiness Produces wakefulness without the “high” of the amphetamines Few side effects With continued doses, persons can function for several days; no crash (rebound) afterwards Can still fall asleep if desired

● ●

Provigil (modafinil) goes to War

Study at Army Aeromedical Research Unit Pilots given modafinil sustained 40 hours of continuous wakefulness with little performance degradation

http://www.eustis.army.mil

Shift Work Syndrome
● ●

Provigil approved as treatment Defined as sleepiness resulting from irregular sleep/wake patterns Tends to result from occupational stress. We all have it? Could be an example of how we create a new “disease” to avoid legitimizing lifestyle drugs. Provigil may be approved for Over the Counter sale in the near future And if/when we all take it with every breakfast, will we still pretend we are treating a disease?

● ● ●

Provigil in Olympic Doping Scandal: Kelli White
● ●

American sprinter 100m victory at 2003 World Championships (Paris) Tested positive for modafinil – which was banned on Aug. 3, 2004 - retroactively Stripped of medals; banned for two years

BBC News

http://news.bbc.co.uk/sport2/hi/athletics/3727595.stm

Exploring Doping

Well-Known Facts – No Time to Review
– – –

Use of performance-enhancing substances Arms race between sport organizers and athletes Increasing number of world-class athletes disgraced in doping scandals What is the ultimate goal of controlling doping?
● ●

The Real Questions

Eliminate “unfair advantages” ? Not likely Athletes should not require drugs to be competitive

Does the technology of the near future doom such efforts to failure?

Diversion: Doping Thought Experiment

Devil's Advocate: (highly idealized situation)

Assume that some athletically valuable ability correlates with the blood concentration of a certain endogenous (natural to the body) substance. Imagine an athlete who has naturally high levels of this substance. Imagine a second athlete, having lower levels. Now, he injects a quantity of this substance He has now become indistinguishable from his genetically gifted colleague. Where is the crime?

– – – – –

Doping in Chess

FIDE (World Chess Federation) wants to mimic Olympic doping rules Hopes of making chess an Olympic sport Newly required tests for drugs which may enhance chess play

http://www.fide.com

Doping in Chess

First time such a rule has been introduced Massive protest among players – take one guess why... Penalties might include steep ($100,000) fines Caffeine included in the list of banned substances
http://www.bcmchess.co.uk

Should Everyday Life be Treated Like an Olympic Sport?

If doping is policed in the Olympics and in chess tournaments, why not, with equal rigor... ... in school? ... in business? ... everywhere?
– –

● ● ●

Imagine the Nobel Prize requiring a lifetime of regularly scheduled, clean doping tests Absurdity?

How About a Human Memory Upgrade?

CX516 (Ampalex™)
– – – – –

Developed by Cortex Pharmaceuticals, Inc. Enhances activity of AMPA receptors Intended as a treatment for the cognitive deficits produced by Alzheimer’s disease In Phase I clinical trials, appeared to improve learning and memory in healthy adults. Currently in Phase II trials for safety and efficacy in the intended application

Various Older “Smart Drugs”

Piracetam
– – – –

Derivative of GABA Some studies find improved cognition Inhibits some forms of brain damage? Widely used in Europe

http://en.wikipedia.org/wiki/Image:Piracetam.png

Some dietary supplements claim to improve brain function...

The Big Questions

When is a drug a lifestyle drug? What uses of a lifestyle drug are ethical? Is cosmetic psychopharmacology ethical? Who should be free to use which drugs? When? Where?

http://www.artchive.com/

Against Lifestyle Drugs and Cosmetic Psychopharmacology

Personality modification is serious business. Do we know where we're headed?
● ● ● ● ●

“Psychic steroids for mental gymnastics” ? All drugs have side-effects; sometimes long-term “no free lunch” ? Subtle changes in cognition are hard to detect Unknown dangers

Do we like the possible destinations...?

Brave New World

Famous dystopian novel: 1932 Features a drug known as soma – a perfect narcotic instant happiness in tablet form. This drug practically eliminates discontenthelping the dystopia perpetuate itself

Other Arguments (Against)

Society needs psychological diversity, which could be threatened by cosmetic psychopharmacology Yet another expensive medical technology – widening of gap between rich and poor Religious / Doctrinal Objections? Plenty to choose from

One More Danger...
Ending up like this famous rodent. If we could block all unpleasant emotions, what remaining stimulus would lead us to do anything? (classic problem)

http://www.wireheading.com/

In Favor of Lifestyle Drugs and Cosmetic Psychopharmacology

The obvious promises of the technologies Classic Argument: will be invented anyway and used despite possible bans; might as well find constructive uses Improving quality of life is the purpose of medicine?

How to Decide

What could you gain?

Previously discussed benefits

What could you lose?
If the use of a particular lifestyle drug (for cosmetic psychopharmacology or otherwise) becomes socially expected, life can become complicated for those who refuse. Something important. See “reasons against.”

Exercise: Determine the identity of the following three Lifestyle Drugs...

Who Am I?

I am a recreational drug which affects the nervous system. My effects include euphoria and relaxation. I have many side effects; some are fatal. Can I be used ethically? Should I be mixed into popular drinks?

www.chem.purdue.edu

1

● ●

How about me...?

I am a well-known synthetic drug which affects the nervous system. I do not cure or treat a disease; I only make life more pleasant. Can I be used ethically? Should I be sold without a prescription?

2

http://www.pharmpedia.com

And what about me...?

I am a recreational stimulant! I am addictive, and may cause heart trouble Should I be sold at restaurants?

http://oceanexplorer.noaa.gov

3

Ready for the Answers?

1

http://www.answers.com

Ethyl Alcohol

2

http://www.pharmpedia.com

Aspirin

3

Caffeine

Lifestyle Drugs: Nothing New?
● ●

Need we even discuss nicotine? A 20th century celebrity: Valium (diazepam)
– – –

Sedative: “Mother's Little Helper” Best-selling drug in USA: 1969 – 1982. [*] Wildly popular: 1978 - 2.3 billion pills sold [*]

Looks like society already accepts some lifestyle drugs. What determines which ones?

[*] Obituary of Leo Sternbach, inventor of Valium: http://www.guardian.co.uk/medicine/story/0,,1583671,00.html

The Future?
● ●

Continuation of bioethics debates: definitely Development of lifestyle drugs with:
– – –

Reduced side-effects Reduced cost Greater prospects for legality (non-addictive, noneuphoriant, socially useful – boost productivity?) Genetic engineering? “Cybernetic implants”? Other things currently confined to science fiction

Related Technology – no time to discuss these
– – –

The End