What if a drug could help our bodies cope better with shift work, help us stay alert at our desks when we need to meet deadlines, or allow a sleep-deprived surgeon to keep a steady hand? Safety and health practitioners have always focused on drugs known to impair cognitive function, and the associated risks this can bring into the workplace. But a new generation of chemical compounds -- known as pharmacological cognitive enhancers or "smart drugs" -- developed to improve cognitive function and counter fatigue, is providing a different kind of challenge.
Pharmacological cognitive enhancement has been a feature of military research since the 1940s. The British Medical Association report notes that the US Army Air Force (the predecessor of the US Air Force) experimented extensively with drugs to help pilots out on operations, and pilots used amphetamines -- known as "go pills" -- in the Second World War.
The non-researched use of amphetamines was also applied to special operations. Use continued in the Korean and Vietnam wars, and during the strikes on Libya in 1986 and operations Desert Shield and Desert Storm in Iraq. The use of such drugs has also been blamed for so-called friendly-fire incidents in Afghanistan in which US troops fired on their own or allied forces.
More recently, US defence organisations and those of other countries, including the Netherlands and China, are studying the use of modafinil to maintain alertness for pilots for extended periods.
Much of the media frenzy about these drugs has centred on the student population, but there is growing evidence that they are also used in workplaces, in particular in high-pressure environments, with low job security, and where people operate at the limit of their capabilities.
For businesses and their safety and occupational health (OH) advisers, the question of whether employees are using these drugs and how they might affect performance, safety and health is something they can no longer afford to ignore. The importance of the issue was underlined last year when the British Medical Association (BMA) published a report, Cognitive Enhancing Drugs and the Workplace (bit.ly/2doxELv), which included advice for OH physicians on how to approach employee use.
This report describes use of cognitive enhancers among students, doctors and the military, adding that "their dubious benefits might also seem attractive to others working shifts and/or in safety-critical roles, such as in transport, healthcare, emergency services and utilities, to improve focus, wakefulness and performance when fatigued". It argues that a history of use through student years may translate into later use in the world of work.
People use cognitive enhancers for many reasons. They are licensed, for example, for those suffering from medical disorders including dementia, attention-deficit hyperactivity disorder (ADHD) and narcolepsy.
Alongside prescribed use, healthy people are also using these drugs without prescription and for non-medical purposes, to study and work more effectively, deal with stress and keep performing during shifts. Evidence suggests that healthy people who use cognitive enhancers are buying them over the internet or using friends' and family members' prescriptions. The BMA stresses that "buying prescription-only medications without a prescription is illegal and possession with intent to supply is taken seriously in the UK".
Drugs sometimes used by healthy people include stimulants, such as methylphenidate to improve vigilance, attention, focus, and speed of processing; modafinil, a "wakefulness agent" used primarily to treat sleepiness associated with narcolepsy; and memory-improving drugs that treat dementia. Modafinil, one of the most high-profile of the new smart drugs, is licensed in Europe solely to treat narcolepsy but elsewhere some countries license it to combat insomnia or shift work sleep disorder.
A combination of technological, social and economic factors is helping to drive use of smart drugs. Barbara Sahakian, professor of clinical neuropsychology at the University of Cambridge, says cognitive abilities are becoming increasingly important to performance in a global environment as structural and technological developments change our work settings. At the same time, stress, long hours, lack of sleep and shift work can adversely affect these abilities. Evidence on prevalence of use in healthy people is limited. Most of the data relates to students in North America, with estimates of between 2% and 16% using these drugs. The BMA says more recent studies of students have reported figures of 11% to 25%, while other surveys indicate a prevalence of 1% to 20% in many European countries, including the UK.
Outside student groups, the data is patchy. Sahakian highlights one 2015 study by German health insurance company DAK, which involved more than 5,000 respondents aged between 20 and 50. Of these, 6.7% reported the lifetime use of pharmacological neuroenhancement -- up from 4.7% on the previous report in 2009. Users' most common aims were to boost work performance, to improve mood and reduce anxiety.
The survey showed that users' motives included: enhanced performance in specific situations such as examinations, presentations and negotiations (41%); easier attainment of goals (32%); more energy and better mood for other interests (27%); inability to do the work otherwise (25%); and gaining a competitive edge at work (12%).
"Something that would be interesting would be a survey of shift workers," says Sahakian. "We don't know what the usage is among them, and in the US modafinil is actually approved for sleep disturbance due to shift work."
Danny Clarke, group operations director at consultancy ELAS Business Support (www.elas.uk.com), who previously sat on the board of the European Workplace Drug Testing Society, highlights company drivers as another key group. "It would be interesting to see how these drugs are used by heavy-goods vehicle and van drivers, who are known to be big users of stimulants such as caffeine, to maintain output and performance," he says.
Body of evidence
In people suffering from known neuropsychiatric disorders, the body of evidence in favour of drug prescription to improve cognition is growing. "Cognitive enhancers can improve concentration, memory and other aspects of cognitive performance in those who have impaired functioning," the BMA states.
The BMA report goes on to consider the effects of common smart drugs used by healthy adults. Some of the effects it picks out may have direct relevance to safety and health practitioners looking for potential workplace risks. For example:
methylphenidate -- primary studies have reported that this improves spatial working memory but may influence performance in conflicting ways. Though it can enhance executive aspects of spatial function on novel tasks, it can impair performance on previously learned spatial tasks and increase the speed of response before information is processed
modafinil -- this maintains wakefulness in sleep-deprived individuals. There is no effect on memory in available studies of healthy subjects, however, though it appears to maintain memory in sleep-deprived subjects compared with a placebo. But if sleep deprivation is prolonged, "repeated doses of modafinil do not prevent deterioration of cognitive performance and instead maintain wakefulness and impair self-control -- inducing over-confidence".
The report concludes that "most cognitive enhancing drugs yield only moderate effects in the healthy", and that "in healthy individuals, functioning at an optimum level, it is difficult to improve their cognition". It goes on to warn that healthy users may be unaware of the limited efficacy of the drugs, and users' expectations about their potential often exceed their actual effects. "Users are also likely to be unaware of the potential for adverse side effects or drug interactions, or the legal consequences of using or supplying them without a prescription."
Sahakian welcomes the BMA's conclusions, but questions its use of the word "only" in relation to "moderate effects".
"Moderate effects are quite substantial on a day-to-day basis," she argues. "They may not be large, but moderate is better than we get from most drugs we use. A moderate drug effect is actually quite significant." She points out that an Academy of Medical Sciences report in 2008 said that even a 10% improvement in memory score could produce a higher A-level grade or degree class.
"I think there are potential benefits -- if drugs like modafinil are shown to reduce accidents in shift workers, that is something to think about in the workplace in terms of health and safety," she suggests. Her own research has also shown potential cognitive benefits in the workplace. A study she conducted with Professor Lord Ara Darzi at Imperial College London found that doctors deprived of sleep for one night who took modafinil worked more efficiently when solving working memory and planning problems. They were also less impulsive decision-makers and were more able to redirect their attention flexibly. It concluded that fatigued doctors might benefit from pharmacological enhancement in situations that require efficient information processing, flexible thinking, and decision-making under time pressure.
"Lots of people take caffeine," Sahakian points out, "but this has side-effects, such as tremors and palpitations. We looked at modafinil and sleep-deprived doctors because some doctors take caffeine when they do operations at night, which can lead to hand tremors. Not everyone can tolerate caffeine. Maybe there are better wake-promoting, alerting agents that would help people in situations where there are safety issues for themselves or others."
Sahakian's research has also shown that modafinil can increase "task-related motivation". This is important in the workplace, she says. "If a person doesn't want to do a given task and can't get down to it, they take these drugs and find the job is more interesting and pleasurable. It improves their motivation for doing the task. So that is another aspect -- how it affects coping with work you don't find desirable but have to do."
If these drugs are effective in improving wakefulness and performance for those working shifts or long hours, or who are already under stress, a key ethical issue is whether they risk simply perpetuating poor working environments and ultimately increase short- and longer-term worker health problems, both physical and mental.
If shift workers are having problems with sleep, or City traders feel under constant pressure to perform, or surgeons have to operate when overtired, shouldn't their employers and the wider society address the root causes?
"As a society, we should think about what is driving this usage," says Sahakian. "There are, of course, important ethical and societal issues around this." She points out there are other non-pharmacological ways to improve cognition, such as a through exercise, which promotes neurogenesis (new cell growth) in the brain and improves overall physical health. "But there are also people who need a fast fix," she says. "If people are stressed -- and this goes back to the question of shouldn't we be working on why they are stressed -- or can't sleep or are told to work at night, it's not that easy just to say 'exercise more or get more sleep'."
Clarke at ELAS is also concerned about the extent to which these drugs can contribute to perpetuating poor working conditions, and even suggests they could exacerbate them.
"It may increase expectations; if people perform better for longer and increase output, that becomes the new norm," he says. "People may take these drugs if they're tired or fatigued -- but the real issues are why are they fatigued and how can we tackle the cause of this?"
Outside the box
There are several ways safety and OH professionals can manage potential risks from these drugs. Principally, they should understand that a proportion of the workforce, and particular groups, might be using them. "If you look at drugs and workplace safety generally," says Clarke, "the perception is that it's about the impairment drugs and alcohol might cause. But these are drugs used potentially for performance enhancement. This makes it an interesting area but managing it is not straightforward."
One challenge is that people who take smart drugs, for whatever reason, believe they are beneficial. Clarke continues: "But they also need to know there can be negatives in terms of side-effects, longer-term effects or if drugs bought over the internet are not what they claim to be."
In terms of employer management, Clarke puts smart drugs in a wider category of prescription medications that can affect an individual's ability to carry out safety-critical functions.
Too few GPs have OH training, he says, so, when they prescribe drugs, they often don't think about the ability of a patient to work safely. "More broadly, for some people these drugs will improve cognitive function, so they might perform better or more safely. But there can be a flipside. It can lead to over-confidence or people thinking they can do certain tasks they're not naturally able to undertake, or go on longer when they are actually physically fatigued even if their mind doesn't know it. You might feel you can undertake certain tasks but the body itself is fatigued."
Clarke urges employers to take a broad view. "We find a lot of firms focus too much [in their general drug policies] on testing when what they need is to look more at training, awareness and education."
He recommends they look first at their workforce profile. "During training, they need to talk about medication. Not just what staff might be taking but how and why, and what effects it could have."
The BMA report concludes by stressing the importance of awareness, education and training. It says OH physicians and others caring for patients who work need to:
be aware that a proportion of the workforce may be prescribed pharmacological cognitive enhancers for medical conditions (such as ADHD and narcolepsy) and may require informed OH guidance and assessment of fitness to work
be aware of the licensed indications for pharmacological cognitive enhancers, their benefits, potential side-effects and drug interactions, and their impact on the person's ability to work safely
consider routinely asking about the use of pharmacological cognitive enhancers in patients who are students or in social groups likely to use them
be able to advise employees and managers of the risks of misuse, and ensure employees have easy access to information about the advantages and dangers of using cognitive enhancers
be able to advise employees and managers on non-pharmacological methods of enhancing performance, including education, exercise, diet, stress management techniques and avoiding excessive alcohol consumption
be able to advise on designing shift work schedules to minimise circadian disruption, sleepiness and fatigue.
The BMA also recommends discussing the legal position on healthy people using drugs, the uncertain long-term risk profile in healthy individuals, and the fact that the known "modest benefits" are not necessarily long-lasting and the risks associated with reduced self-control and over-confidence.
The report calls for more research, a position Sahakian agrees with: "We ought to look at some of the leading [drugs] people are using that do seem to be effective in the short term, have relatively limited side-effects and no obvious addictive potential, and get the government and pharmaceutical companies to work together on a long-term study to make sure they are safe for people to use and effective."
In the meantime, and in the absence of this more in-depth research, the BMA recommends "potential users might be better directed toward more conventional ways of enhancing cognitive functions and countering fatigue, including improving work-life balance, exercise, diet and optimising shift schedules". These are all strategies "that have been shown to have a greater effect on cognitive performance with less risk".