Cosmetic Neurology: A Brazilian Brain Lift

by Parker Anderson, Isabella Cannava, Abigail Ganz, Daevon Gurley, Samuel Hutchinson, Julia Galiza Soares art by Yixin Jia

art by Yixin Jia

Introduction

My alarm goes off at nine a.m. I hit snooze, then snooze again. I have to finish two readings before University Writing, but I’m too tired to care. I wish I didn’t need so much sleep, I wish my eyes could skim over the readings a bit faster, I wish I could’ve gotten breakfast, but I also wish I wasn’t so hungry. I check my planner during lunch and realize I have a Korean quiz—I wish my memory was better, both for the fact that I have a quiz and for the still-unknown vocabulary. As I climb the stairs to Cognitive Science, I wish my legs didn't tire so easily. As I write this article, I wish my mind would stop wandering and that my hands would stop drifting off the keyboard and onto my phone.

Columbia University is no stranger to stress culture, and my anecdote likely struck a chord or two with many college students that are inundated with readings, papers, and problem sets. We like to both procrastinate and stress over our procrastination, and this closed circuit creates a system begging for intervention. Regardless, it often feels like there are just not enough hours in a day to get everything done. Given these circumstances, it is no surprise that the majority of college students experience some sort of sleep disturbance—difficulty falling asleep or staying asleep [1]. Insufficient sleep is known to result in impaired learning and overall reduced cognitive functioning [2]. In this infinite loop of having too much to do and too little time, the idea of popping a pill in exchange for higher-quality sleep and boosted brainpower may sound tempting. Perhaps the most well-known sleep aid is melatonin, a natural hormone known to regulate sleep-wake cycles whose levels vary according to the time of the day [3]. It is estimated that more than six million people in the United States take melatonin supplements before going to sleep [4]. While supporting healthy sleep with a naturally occurring hormone seems innocuous, melatonin use is only the tip of the iceberg when it comes to the ever-growing use of natural and artificial substances with the purpose of cognitive enhancement, most commonly referred to as “smart drugs” or “nootropics” [5].

What are Nootropics?

Derived from a rough translation of the Greek “nous” (the mind) and “trope” (change), nootropics are a diverse and ever-growing family of compounds that are known to interfere with high-level brain functions [5]. Such substances can be derived from either synthetic or natural products, and generally fall into three main categories: dietary supplements, synthetic compounds, and prescription drugs [5]. While some nootropics show effect immediately after the first dose, most require long-term application [6]. While most prescription nootropics are often recommended by health experts to treat cognitive abnormalities their unprescribed use is increasing at alarming rates [5].

Caffeine, a naturally occurring stimulant, is the most popular nootropic in the world, being consumed by more than 80 percent of adults in North America [7]. Caffeine binds to adenosine receptors in the brain, blocking the binding of adenosine. The blockage of adenosine receptors indirectly affects the release of neurotransmitters such as norepinephrine, dopamine, acetylcholine, serotonin, glutamate, and gamma-aminobutyric acid (GABA), which are all involved in maintaining regular sleep-wake cycles [8]. By disrupting the transmission of these neurotransmitters, caffeine has all of its effects that we know and love. Extensive literature associates the use of caffeine with improved attention, alertness, and athletic performance [9–11]. Caffeine has simply become part of many college students’ daily routine, as made evident by the long lines inside the local Pret A Manger—where they offer a subscription for an unlimited supply of espressos for a mere $34.99 a month—at any time of the day. However, while caffeine may suffice for some of us, an increasing number of college students are resorting to the use of more powerful substances in an attempt to improve their academic performance [12].

Prescription stimulants are the first-line treatment for attention-deficit/hyperactivity disorder (ADHD), a condition characterized by symptoms of impulsivity, inattention, and hyperactivity that appear in childhood [13]. Amphetamine (Adderall) and methylphenidate (Ritalin) are two commonly prescribed drugs for the treatment of ADHD [14]. Given the cognitive-enhancing effects of these substances, individuals of all ages and backgrounds may be enticed to think of these prescription drugs as a genie in a medicine bottle [12]. In fact, the highest rates of incorrect usage of these substances are seen among college students [15]. The clinical and neuroscientific debate in the field of neurology regarding cognitive enhancement gave rise to the controversial but growing subfield of "cosmetic neurology," where pharmacological interventions are used to augment, rather than simply treat, brain function [16]. By consulting recent neuroscientific literature on the neural impacts of nootropics and considering the bioethics associated with cognitive enhancement, we can arrive at a more robust understanding of how cosmetic neurology can change the academic ecosystem as well as the pharmaceutical market.

Your Brain on Nootropics

Both Adderall and Ritalin stimulate the central nervous system by affecting the reward and pleasure centers, as well as heightening attention and focus [17]. Lenz (2012) discussed that these substances act via the brainstem reticular formation, an important center for many behavioral processes like motion, mood, and sensation. They do so by raising the levels of dopamine and norepinephrine—two chemical messengers in the brain that inform physical responses [17, 18]. Short-term effects following increases in these chemicals can alter attention and cause biological responses like hypertension, increased heart rate, sleepiness, and euphoric states, among other symptoms [18]. Adderall and Ritalin therefore modulate behavior by priming the brain to focus attention on a specific task—a paper with a rapidly approaching deadline, for example— therefore encouraging the behavior—writing—that accomplishes said task [19].

Recent neuroimaging studies on the effects of repetitive, long-term use of these medications in ADHD patients have shown minor changes in neuronal structures, particularly in regions responsible for coordinating complex behaviors, like the basal ganglia [20]. These studies uncover the drugs’ potential to affect the brain’s plasticity—the ability to change and adapt the brain’s structure to new stimuli over time [21]. However, the lack of longitudinal studies in the literature explains why we are currently uncertain of the effects of ADHD medication on long-term neuroplasticity. The usage of these medications by healthy individuals can lead to behavioral and biological changes, such as increased aggression and altered grey and white matter volume, respectively [22]. Harro (2015) emphasizes that these medications are often used recreationally by young adults and college students, as their cognitive effects can also be used to enhance healthy brain functionality in addition to treating neurodivergent brain functionality. Chronic exposure to Ritalin in rats affects the number and size of dendritic spines, which play a vital role in learning and memory [23]. As a result, the medial prefrontal cortex, a critical area for planning, sensory binding, and attention, has more synapses and higher firing rates [23]. Continual use of nootropics, even in neurotypical brains, can therefore lead to lasting changes in important areas of the brain.

Too Good To Be True?

The prospect of enhancement may be misleading when it comes to pharmaceuticals. As with most drugs, the side effects of nootropics warrant consideration, especially when one is using them for purposes outside of treatment for a neurological disorder [24].

Presently, there is considerable uncertainty about whether nootropics used to enhance academic performance result in substantial changes to the structure of the brain or increased risk of neurological dysfunctions. A study led by Urban & Gao (2014) provides insight into both the mechanics of nootropics and their modulation of the brain. The study investigated the use of ampakines, which are drugs that bind to the glutamatergic AMPA receptor and modulate neuroplasticity by increasing synaptic responses through long-term potentiation (LTP). LTP is the persistent strengthening of synapses as a result of patterns of activity. The FDA does not currently allow ampakines on the market, and the study cautions that the potential recreational and black-market use of the nootropic could be dangerous if it exceeds the tightly controlled experimental dosage. The rationale behind this is that due to ampakine’s influence throughout the brain, this brain-wide modulation of plasticity by LTP could cause a decrease in long-term depression (LTD), which is the weakening of unnecessary synaptic connections over time. LTD is just as important as LTP, because the maintenance of synaptic connections that are no longer useful for the successful functioning of the body can lead to negative effects. LTD thus plays a vital role in refining our circuitry. LTD is also involved with the creation of spatial maps and motor functions [25]. This risk to LTD suggests a high opportunity cost associated with nootropic use.

The Pressure to Succeed

As we are all too aware, the media often portrays cosmetic neurology as a common aspect of American collegiate culture and an effective study aid [26]. This general assumption is dangerous on the horizon of advancements in cosmetic neurology because of the potential introduction of drugs like ampakines to the black market. The increased potency of new drugs increases the chances of unprescribed use, taking advantage of the plasticity of the brain and impairing cognitive function [25].

A survey of students and parents gathered general opinions about cognitive enhancement and found large support for personal accountability and integrity in deciding whether to partake in cognitive enhancement [27]. However, regardless of personal opinion, the pressure to succeed can be so astronomical that students have decided to utilize nootropics anyway, despite the lack of scientific information about these performance-enhancing drugs. It is important not to confuse a lack of immediate physiological side effects with a lack of side effects altogether. For example, only after half a century of recreational use did doctors discover that cigarettes were the cause of unprecedented cases of lung cancer [28]. While we are now more aware of the potentially dangerous side effects of nicotine use, there is not enough scientific evidence to make robust judgments about the pros and cons of nootropic use—we simply do not know the effects these drugs may have on our brains and bodies further down the road.

Accessibility of Enhancement

Furthermore, evaluating how to ethically use nootropics becomes even more complex when we consider that they are enhancement drugs. This factor complicates the assessment of their utility as well as the question of whether we can judge the efficacy of drugs meant for enhancing mental performance in the same way that we evaluate drugs meant for treatment of illnesses or conditions. The keystone of this ethical debate is pinning down the role of

medicine: is it a mechanism for treating disease, or a means for improving a patient's quality of life? [16]. While these two ideals often overlap, developments in cosmetic neurology are creating a rift between understanding what medicine can do and what it should do. Because cosmetic neurology is used to enhance an already healthy baseline, studying the effects of these drugs becomes complicated. The administration of nootropics to subjects who do not have a diagnosed medical need for them can call many ethics of medical practice into question.

Inequalities as a result of the privatization of healthcare are already prevalent, and cosmetic neurology seems certain to perpetuate and widen pre-existing socioeconomic gaps. One can look to the environment of university stress culture as a way to visualize the potential consequences of increased cosmetic neurology. The competition that university atmospheres breed relating to “beating the curve” and bolstering one’s resume in comparison to others can encourage stratification of students via cosmetic neurology. At the

lowest tier of cognitive enhancement, we have the caffeine consumer, whose cup of coffee allows them to stay awake longer, but doesn’t alter their mental capability. Then, a tier up, we have the recreational Ritalin user, who churns through assignments with augmented focus and drive. What’s important to note here is that Ritalin affects mental processes (i.e. focus), whereas caffeine affects physical processes (i.e. wakefulness) [17, 29]. Finally, at the highest tier, we have the ampakine-amped student with an illicit stash—and likely a cohort of private tutors—whose burning of the midnight oil actively optimizes the structure of their brain.

From here, we can see the potential ethical barriers to the introduction of nootropics into the pharmaceutical market. Acquiring these cognitive enhancers requires significant financial resources and contributes to an uneven playing field [30]. Academia is already an uneven playing field, with factors such as socioeconomic status and access to opportunities creating stark divides between students, and cosmetic neurology introduces a way to artificially enhance these gaps. In other words, nootropics give the wealthy marginally more control over their neuroplasticity, enabling them to modify and enhance cognitive ability through private medicine inaccessible to populations with lower incomes.

When it comes to creating policy surrounding nootropics, some take a more laissez-faire approach to cosmetic neurology, contending that prohibiting nootropic use will not cease their production or consumption [24]. If this approach to policy is taken, it is reasonable to expect that the aforementioned discrepancies in accessibility will be exacerbated due to nootropics being sold to and used by only the people who can afford to pay top dollar.

Between these two opposing viewpoints, it becomes difficult to contextualize the cosmetic neurology debate under solely ethics or economics. Instead, we should look to physicians and scientists, and more specifically neurologists, as experts in the field, as they focus on the tangible effects of these drugs on our physical state and well-being. Anjan Chatterjee, Professor of Neurology at the Perelman School of Medicine at the University of Pennsylvania, sees cosmetic neurology and cognitive enhancement as inevitable, with neurologists serving as a type of “quality-of-life” consultant [31]. This consulting role would mean that neurologists would be responsible for informing patients about the risks associated with cognitive enhancement and help them navigate its potential dangers. This role also extends to observing the patient’s current and desired states and determining whether nootropic use is warranted on a case-by-case basis [31]. Some neurologists advocate for alternative means of cognitive modulation in order to capitalize on the brain’s natural plasticity and ability to adapt to its environment. Examples of these alternative methods for treatment include computer games for cognitive training as a way to improve memory, as well as physical exercise and sleep for cognitive enhancement [32, 33].

However, we should not want to consider physicians in an ethical vacuum. More specifically, we should question whether neurologists, who would be prescribing and perhaps profiting off of nootropics, should be acting in a consultant-type role. Furthermore, access to a consultation with a neurologist can be an immense financial burden, let alone providing for a regularly scheduled appointment routine. Strong comparisons can be made between cosmetic surgeons and cosmetic neurologists, as cosmetic surgeons have acquired a profit-seeking, malpractice-prone stereotype due to plastic surgery’s increased popularity and accessibility. The American Board of Cosmetic Surgery states that any physician is allowed to perform a cosmetic procedure, leading to complicated and dangerous procedures being performed by inexperienced surgeons on uninformed patients [34]. If these are the policies in place regarding cosmetic surgeries that can sometimes be life-threatening, what evidence is there that cosmetic neurology will be treated much differently? As policies are designed in response to the emerging field of cosmetic neurology, the consequences of cosmetic procedures for physical appearance should undeniably be considered in thinking about the potential effects of introducing cosmetics into the neurology field.

Conclusion

As I leave my final class of the day—Korean quiz painstakingly completed—I head home exhausted. Would I have more energy and more drive if I had opted, like some of my peers, to seek out a cosmetic-neurological fix? Perhaps. Adderall or Ritalin may have heightened my focus during the day, but their long-term, unprescribed use also carries a heavy dose of risk, including addiction and physical alterations to the architecture of the brain. The degree to which these substances should be regulated or prohibited is an active topic of ethical debate among physicians, but we all face the pressures associated with their use and misuse. How we decide to react to these pressures, however, is up to us.