Amphetamine (Adderall; Barr Labs) and methylphenidate (Ritalin; Novartis) are two of the drugs frequently mentioned in neuroenhancement. The physiologic properties of these medications have an interesting history. In ophthalmology, amphetamine is classically used for localization of Horner’s syndrome. When present in the synaptic junction of two neurons, amphetamine induces release of neurotransmitters, effectively activating the circuit. Interestingly enough, cocaine (stimulant), also acts in the synaptic junction by preventing reuptake of the neurotransmitters; this effectively prolongs the effect of neurotransmission.

In theory, increased neurotransmission may translate into improved concentration, as those with ADHD require to function. Its effect on a high-functioning Ivy-league economics major who has an essay to finish is more debatable. While individuals have reported increased productivity through stimulant use, we suspect that there may be a graded response depending on the initial amount of neurotransmitter present. Simply put, if you were high-functioning to begin with, these medications may not work for you. Furthermore, these medications indirectly result in activation of your neurotransmitter receptors to increase conduction. Long-term use may result in tachyphylaxis, due to the desensitization of the receptors. You may need more drug to achieve the same affect for subsequent uses.

Anjan Chatterjee, a neurologist a UPenn, has written about both the clinical outcomes and ethical ramifications of “cosmetic neurology”. His recent paper in Psychopharmacology detailed a study on the impact of Adderall on creativity. The preliminary data is inconclusive, although he suspects that the baseline capabilities of the individual clearly influences the efficacy (or detriment) of the medication on cognitive function.

The side-effect profile of these drugs consists of a grab bag of systemic involvement that includes the cardiovascular,  neurological, and most other body systems. While the majority of its users experience little to no side effects, the fact that we cannot control which neurons are affected by the drug is quite disturbing. Given that neurotransmission is enhanced, stereotyped actions such as tics and blepharospasms are potentially accentuated. Assuming that the target audience of cosmetic neurology are high-strung overachievers who may already suffer from tics when under stress, this combination does not bode well.

With all medical issues aside, the ethical use of neurostimulants is questionable. Some have argued that these medicines are akin to private tutoring–they enable us to achieve our potential. Are anabolic steroids equivalent to weight training? I hope not. This is doping. At best, they “might” enable us to retrieve information we already have in our brains through alternate (not necessarily faster) means. Neuroenhancement cannot be banned either; it would be technically impossible. As Margaret Talbot quotes in her article, “[it's hard to imagine a university administration that would require students to pee in a cup before they get their blue books]“. More data is needed to evaluate the classes and efficacy of neurostimulants before we can make a ruling.

Until then, you may do just as well trying absinthe to spur your creativity.

Pharma goodies...okay, maybe not the French chocolate cookies

I’m going to miss the days when big pharma showered gifts embroidered with their logos to doctors. Ever since the voluntary ban on branded gifts, pharma has ceased to supply our department with pens. The resident area still has several left, but our stash is rapidly depleting. Given my hospital’s  hybrid documentation system, my pens actually run out of ink every 2 weeks, assuming I don’t lose it or contaminate it in a C. diff patient room.

Sure, I understand the ethical problems of product placement, especially if pharma is giving us mugs, napkins, mp3 music players, bags, flash drives, and whatever-else-you-least-think-is-excessive…but pens? Who cares if I have my pen advertises a monoclonal antibody? In fact, some branded pens are decent writing implements–they don’t clump out dried ink like those crappy bank pens. I remember that when I was in medical school, Bob Goodman would organize  No Free Lunch rallies to collect pharmaceutical pens in exchange for unlabeled plastic pens that were only half full of ink. I assume that it was for a good cause, but why would I give up my stainless steel Pfizer pen with German-made tungsten carbide tip refills for a clearly inferior product? I don’t doubt that product placement influences product opinion, but it doesn’t influence drug choice. In the hospital setting, whatever on medicare/medicaid formulary dictates what I prescribe anyway. In fact, my pens have saved me from embarassment when patients ask me about drugs that they’ve seen on TV. I’d glance at my pen and see what the generic name equivalent is. The CFO or committee that got a pharma kickback for approving the drug in the first place should be punished, not a lowly worker like me. It is such a tragedy…

The only consolation at this point are the goodies I already have. My ipod shuffle knock-off is pretty cool, but my favorite goodie is probably the green ceramic mug with an attached nose from Flonase. The nose is horridly unsightly and only adds bulk to a perfectly good mug. It is the perfect example of excess. I’ll post up a picture when I find it in my boxes. What is your favorite pharma gift? Send in pictures, and I will post it up!

Floor demonstration at AAO Atlanta 2008

I was fortunate enough to find time to attend the Academy meeting in Atlanta.  It was equally as overwhelming as other residents had told me, given the immense publicity that the companies bring to the conference.  Several days of the conference were dedicated toward subspecialties, while the last few included general ophthalmology talks.  Each lecture required additional registration fees on top of the floor passes. Given that I had little to benefit from learning about the latest surgical techniques, I attended the free conferences, which were surprisingly informative (One lecture for those new to practice discussed coding and billing issues, a topic that I doubt I would learn much in residency).  I also attended two evening events, one at the Georgia Aquarium, the other at the CNN Tower. Very impressive to the greenhorn.

The trade floor itself was decked out in style. Hundreds of vendors hawked their wares in an expansive grid of tables. Surgical instruments, books, imaging machines, and anything one could imagine lined the floor. Some venders provided cookies, drinks, even ice cream to lure attendees to their booths. 

Overall, it was a good experience. Although I probably won’t be returning in another 3 years, I’ll know what to expect next time I return. Of course, no trip to Atlanta was complete without touring the Coca-Cola factory museum. It was conveniently located within a 5 min walk through centennial park. I sampled all 40+ flavors of Coke products over the course of 3hrs…definitely worth the $20 admission fee!

outside of the Coca-cola museum

lobby of the Coca-cola museum

Yum!