This study investigated knowledge of, attitudes towards, familiarity with, frequency of being asked for prescriptions for, and comfort levels with prescribing CE drugs among 832 primary care physicians in Germany. The study showed an especially high knowledge level regarding CE among the participating subjects with MPH being the most widely known substance for CE. In contrast to this high knowledge level, only 5.3% of the physicians stated that they were very familiar with CE, and 43.5% described themselves as being not familiar with the subject. 40.8% of the surveyed primary care physicians had been asked for a prescription for CE during the last year followed by 19.0% which had been asked during the last month and 7.0% during the last week. Comfort levels to prescribe CE drugs are low among the surveyed physicians and significantly lower than to prescribe sildenafil (Viagra®). Another main finding is that comfort levels to prescribe a CE drug are mainly affected by the age of the asking subject followed by the availability of non-pharmacological alternatives, fear of misuse of the prescribed drug and the missing necessity of needing the drug.
We demonstrated that nearly all surveyed primary care physicians (96.0%) reported that they knew about the possibility of pharmacological CE. This is significantly higher proportion than among students in previous studies. Two studies among nearly 10,000 students reveal that about 80% of surveyed students knew about this possibility of CE [12
]. Furthermore, 81.4% of German students stated to know about using substances of any kind for CE which was significantly higher in university than in high school students [13
]. We can only speculate about the reasons; one reason may be the higher age of the surveyed primary care physicians going along with an increase of professional expertise being probably associated with age. In distinction from our previous study among students, in this study we were not able to detect differences regarding sex [13
]. Regarding stimulants, 39.8% of the students knew about prescription stimulants for CE and 57.9% about illicit stimulants for CE [12
]. Primary care physicians were less informed about the use of illicit stimulants but more informed regarding prescription stimulants. Even if this and previous studies examine the knowledge of CE, there are no comparable data regarding the single substances for CE.
Although nearly all physicians had heard about the possibility of CE, only about half of the physicians felt they were not familiar with the topic of CE, and only a minority of physicians felt very familiar with CE. As compared to Banjo and colleagues, we obtained comparable results for feeling very familiar with CE (Banjo and colleagues: 4.0%, present study: 5.7%) [9
]. However, Banjo and colleagues reported a higher percentage of physicians (57.0% vs. 43.5% in our study) feeling not familiar with CE and a respective lower percentage (39.0% vs. 49.9% in our study) feeling somewhat familiar with CE. We can only speculate about possible causes for these differences. One might be the different time point of assessment (2009 in the study by Banjo et al. and 2011 in our study) or differences in information systems between Canada and Germany. Another explanation for the low level of familiarity may be the fact that prescription drugs for somatic disorders are much more prevalently prescribed than prescription drugs for CE belonging to the group of drugs prescribed for mental disorders by primary care physicians [1
Compared to Hotze and colleagues, the percentage of primary care physicians who reported being asked for a prescription of a drug for CE during the last week was considerably lower in our study: 62% in the survey by Hotze and colleagues receive requests “to prescribe interventions for what they view as enhancement purposes” monthly and 12.0% daily as compared to 7.0% during the last week, 19.0% during the last month, and 41.0% during the last year in our study presented here. We can only speculate about the reasons for his difference. Age and sex of the participants of the two studies is comparable (Mean age in our study: 54.3 years, Hotze et al.: 52.6 years; sex in our study: male: 68.1%, female: 31.1%, Hotze et al.: male: 72.0%, female: n.a.). Unfortunately, neither Hotze and colleagues nor our study describes the requesting individuals (age, sex, students, workers, etc.). One possibility is that the requesting individuals in the study of Hotze and colleagues had different characteristics than the requesting individuals remembered by the surveyed primary care physicians in our study. Furthermore, in the introduction section of our questionnaire we defined CE drugs to be “substances which are used with the purpose to enhance one’s own cognition and that CE drugs have been developed for the treatment of cognitive decline (e.g. dementia in elderly people) or cognitive disturbance in younger subjects (e.g. attention deficit hyperactivity disorder, ADHD)”. Hotze and colleagues asked about “how often patients requested medicine or services that the physicians considered to be for enhancement rather than therapy” [2
]. Thus, the definition in our study is much more precise and tight than in the study of Hotze and colleagues and may be the main reason for the significantly higher requesting rates in Hotze and colleagues.
Using vignettes of patients requesting a physicians’ prescription of a CE drug, we probed participants about their behaviour in case of a healthy 25-, 45- and 65-year old individual having cognitive problems and therefore participants having a reason for prescribing a CE drug. We found age of the requesting patient/client to be the main factor determining comfort level of the surveyed primary care physicians. However, even if the aim of all three scenarios is cognition enhancement, the reasons for the requests are different (to cope with stress at graduate school, improve productivity at work, leading an active life to counteract subjective cognitive decline). This has to be considered when interpreting that age of the requesting person is the decisive associated factor. Further participants’ characteristics were found to play no role (sex, etc.). This is in line with previous results of Banjo and colleagues who found that the age of the requesting patient/client as being a key determining factor [9
]. Furthermore, they found the same in case of a healthy 25-, 45- and 65-year old individual without any cognitive problems and with reasons for requesting a CE drug [9
We found that fear of misuse, availability of non-pharmacological methods of achieving the same goals and the fact that the requesting individual does not need the drug to be the most relevant reasons affecting physicians comfort levels of prescribing CE drugs in case of the 25-year old college student and the 45-year old employee. These results confirm the results of Banjo and colleagues [9
]. Beyond that, in our study as well as in Banjo and colleagues the factors to improve patient’s overall health and wellness, to improve daily living and the assumption/fact that the drug is age-appropriate were the most crucial factors regarding the prescription of a CE drug to the 65-year old individual feeling concerns about his ability to perform everyday activities. Fear of legal liability as well as the aspect that the use of CE drugs constitute a form of cheating played a very minor role in both studies. This is in line with previous results of our group: In an interview study about reasons of students justifying their use of stimulants for CE compared to caffeine we found that legal aspects play a very minor role for them [22
]. Interestingly, for student users as well as potential prescribers (primary care physicians) legal aspects play a minor role.
The last set of questions was about a comparison of sildenafil, MPH, modafinil and a hypothetical CE drug prescribing to patients having the label indication. We found that the highest comfort level for prescribing these agents was for sildenafil (comfort level 7
13.1%) compared to MPH (comfort level 7
1.8%), modafinil (comfort level 7
2.5%) and the hypothetical CE drug (comfort level 7
1.9%). These results are similar to those of Banjo and colleagues [9
] and show that there is some degree of similarity in transnational attitudes. Furthermore, when asked to freely respond on their answers, Banjo and colleagues show that the surveyed physicians stated to be more familiar with sildenafil and that the latter should have a better safety profile. Further comments show the primary care physicians being afraid about the abuse potential of stimulant drugs.
Beyond that, we found that male primary care physicians had a higher comfort level to prescribe sildenafil, modafinil, MPH or a hypothetical CE drug to patients having an indication for a prescription. This is in line with previous results by Ponnet and colleagues searching for determinants of physicians to prescribe MPH for CE using the theory of planned behaviour (TPB). They found that gender influenced attitudes towards prescribing MPH for CE, too: Compared to male physicians, female physicians had more negative attitudes towards prescribing MPH for CE [23
]. However, they used a vignette presenting a healthy university student and did not probe for older patients/clients with or without reasons/symptoms for a prescription.
Finally, primary care physicians have a crucial role of the supply of prescription drugs for CE, they are meant to be gatekeepers to the medical system and they are the first who are contacted by the general public searching for a physicians’ prescription. However, at the present time the prescription of CE drugs by primary care physicians is much less prevalent than the prescription of somatic medication to patients [1
At present primary care physicians have to decide what to do on their own regarding CE. Although nearly all of them reported that they knew about the phenomenon of pharmacological CE there is a lack of guidelines aimed at primary care physicians. One possibility is that the existing guidelines to neurologists for adult and paediatric populations could be adopted. The “Guidance of the Ethics, Law and Humanities Committee” for neurologists provides neurologists with an overview of ethical, legal, and social issues surrounding CE as well as practical guidance for responding to an adult patient’s request for CE drugs developed by Larriviere and colleagues [24
]. These guidelines propose that neurologists have no obligation to prescribe CE drugs and may ethically refuse a prescription. They should exercise “their clinical and ethical judgment to decide whether to prescribe medications for neuroenhancement”. It would be “ethically permissible for neurologists to prescribe such therapies, provided that they adhere to well-known bioethical principles of respect for autonomy, beneficence, and nonmaleficence” [24
Beyond that, “Ethical, legal, social, and neurodevelopmental implications” have been developed for pediatric CE [25
]. Graf and colleagues stated that prescribing CE drugs to children and adolescents without a neurological diagnosis is not justifiable. In “nearly autonomous adolescents” this dogma should be weaker, but prescribing CE drugs should be not advisable “because of numerous social, developmental, and professional integrity issues” [25
These position papers are primarily directed at neurologists, but the conclusions are indeed relevant to primary care physicians as well. What is missing from the discussion is the development of a more general set of guidelines that can apply to all physicians – neurologists, primary care physicians, and others – that will assist them in their decision-making with respect to prescribing CE. Much more data about the phenomenon of CE is needed. At least, medical education and post-graduate education of physicians should contain information about the pro-cognitive limitations, the fact of pro-cognitive placebo-effects and the relevant side effects as well as the safety profile of potential CE drugs as well as ethical and social implications. Clients claiming for a CE prescription should be elucidated by their physicians.
A few questions for further studies arise based upon the presented data and should be addressed in further studies to inform the debate about CE: We do not know if the clients asking for a prescription are younger students needing help to perform better in school and university or older ones complaining cognitive decline. This would be an important additional piece of information that could be used to characterize claims for CE and the prescription of CE drugs. Therefore, further studies among primary care physicians should address the question of characteristics of patients asking for a CE prescription. Furthermore, the present study does not assess if the clients ask for a special drug (e.g. MPH) which they want to get prescribed or if they ask for general pharmaceutical cognitive help. In this respect we do not know what requested primary care physicians do after having been requested for a prescription. The behaviour after being asked for a prescription should be addressed in further studies as well. Beyond that, we did not ask for interventions primary care physicians do after being asked for a prescription e.g. counselling regarding alternative possibilities to enhance cognition or mood and if they explain the small pro-cognitive effect as well as the (dangerous) side effect profile of the present drugs. To address these questions and questions to the close context in case of being asked for prescribing a CE drug may be contents for qualitative research (interview studies) among primary care physicians. Unfortunately, these questions cannot be addressed by the use of anonymous questionnaires (neither paper-and-pencil, nor web-based). Therefore, in depth interviews of primary care physicians should be done.
Some limitations of the study are worth identifying. A general problem of anonymous surveys is the possibility of misunderstanding questions and the interpretation of the questions by the participants. Together with the use of case vignettes this may lead to a certain kind of fuzziness of data obtained. Furthermore, the relevance perceived by the participants may influence the answers obtained. The more important aspect regarding understanding and interpretation of this survey may be the socially undesirable behaviour of misusing substances to enhance cognition which can be regarded to be comparable to the use of drugs for physical enhancement. Answering questions regarding such a stigmatizing subject – even if the survey is anonymous – may lead to socially desired answers depicting a bias of the present data.
The sample of primary care physicians of Rhineland-Palatine is large, but is neither representative of Germany nor other countries. Furthermore, the response rate was 30.2%. This response rate of only 1/3 means a selection bias. We can only speculate about the reasons of non responding to the questionnaire (e.g. lack of time, feeling that the topic is not important, socially non-desired opinions, etc.). These aspects make it difficult to generalize from the results.
Beyond that, the logistic regression analysis was the most appropriate method to analyse the data of this survey study. However, several times ORs are quite close to 1.0 and the analysis of pseudo-R Squared are smaller than 0.1 which limits the explanatory power of the analysis.