I don't know why, but you all keep asking for an episode on nootropics.  For those of you who aren't in the know, these are drugs which are supposed to enhance cognitive function.  Nootropics are the topic of this week's Healthcare Triage.

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Let's get one thing out of the way early on.  Some nootropics are serious stuff and have actual use in the practice of medicine.  (?~0:24) is used in the treatment of narcolepsy.  (?~0:28) is sometimes used to treat dementia.  These drugs sometimes don't have a ton of evidence behind them, but enough to warrant further research certainly.

That's not what a lot of you are asking, though.  You want to know about the use of nootropics as performance and image enhancing drugs or PIEDs.  Think of the drug that was the subject of the Bradley Cooper movie "Limitless".  Evidently, these things are all the rage in Silicon Valley right now.  

Some of the drugs that people are using are serious in that they have proven biological effects both good and bad.  Ritalin, Adderall, and modafinil are proven to affect people.  Methamphetamines, which have been abused for decades, are also the drugs we use to treat disorders like ADHD.  When you use them, focus increases.  But the beneficial effects have been proven in people who have deficits.  It's not clear whether their use in normal people gives them a boost, at least, not proven to Healthcare Triage standards.  Some studies do exist.

To the research!  A 2013 randomized controlled trial looked at how Modafinil affected relatively normal peoples' creativity.  The main outcome of interest was a measure of task motivation, along with neuro-psychological tests from cognitive assessments.  In this trial, those taking the nootropics saw improvements on some tests of planning and working memory, but not in paired associates learning.  They also saw enhanced task enjoyment, but no effects on creativity were significant.  So the results are sort of conflicting but it's some like these that give people hope.  

They think that taking these drugs will make them smarter or work harder when they're sleeping.  A 2014 study randomized healthy volunteers to either a single dose of Modafinil or a placebo.  The main outcome of interest was the response latency on the Hayling Sentence Completion Test.  That test is considered highly sensitive to prefrontal executive functioning.

Researchers found that those taking the drug had an increased latency of responses.  That's not what you're looking for.  It made normal people slower.  Of course, that's what you'd want in an ADHD drug.  You want people to be less impulsive and more focused.  That's not necessarily what you want in a normal person.  

Let's not cherry pick the research though.  A systematic review looked at many studies.  They found that methylphenidate did improve memory a bit, but it had no other consistent enhancing effects.  Modafinil improved attention for well-rested individuals.  In sleep deprived people, it helped to maintain wakefulness, memory and executive functions more than placebo did.  However, repeated doses of the drug couldn't prevent deterioration of cognitive performance over a longer period of sleep deprivation.  

There's also been a Cochrane review of Piracetam, one of the most popular nootropics.  Researchers found 24 studies with almost 12,000 participants.  The main outcome they examined was "global impression of change", which is pretty much what it sounds like.  Do you feel a difference?  And they didn't.  There were no significant differences in cognition, immediate memory, delayed memory, speech or mental status.  These studies were mostly on those who were cognitively impaired but there's even less reason to think you'd see a difference in otherwise normal people, and you're getting all the side effects that come along with these drugs.  They're by prescription for a reason.  

The even more common practice, though, is to use supplements or over-the-counter substances to get these same effects.  People will recommend (?~3:41) or ginseng or you name it.  These are supplements.  If you've watched any of our gazillion episodes on supplements, you know what I'm about to say.  They're unregulated and you have literally no idea what you're actually getting.  Even if you did, these substances are all different.  There's no reason to believe that if one worked, others would, and there's no good evidence that any of them work at all.

Look, let's take caffeine.   It's a stimulant and if you take it, you definitely feel effects.  You may be more awake or alert, but it's not making you smarter, and after a while, you develop a tolerance and if you take too much of it, you get jittery and don't feel so good.  Caffeine is a nootropic.  It's also a fantastic example of how you might think about most of these substances.  If you take them, you might feel something, but it likely isn't increased intelligence.  Over time, tolerance happens and the side effects will appear if you increase the dose.  That doesn't mean I don't like a cup of coffee in the morning.  It helps me wake up and a cup of tea might help me feel less sluggish late in the day, but I'm actively seeking those proven effects.  I'm not gonna try and tell you it makes me work better or that I learn more by drinking them.

There's no magic bullet here.  Anyone who tells you otherwise is probably trying to sell you something.  If the results are ever proven, believe me, the whole world would know.  We'd likely start putting all this stuff in the water.

Healthcare Triage is supported in part by viewers like you through Patreon.com, a service that allows you to support the show through a monthly donation.  Your support helps us make this bigger and better.  We'd especially like to thank our research associate, Cameron Alexander, and our first ever surgeon admiral, Sam.  Thanks Cameron.  Thanks Sam.  More information can be found at patreon.com/healthcaretriage.  

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