If the baseball steroid hearings have taught us anything, it's that people will risk a lot to succeed in our overly competitive culture. From performance-enhancing drugs for athletes to cosmetic surgery for celebrities, it's become commonplace for Americans to use medical advances to gain a competitive edge.

It's no different for academics, it seems. Students have long looked for a way to gain an academic edge, and some are willing to use chemical means to do it. There's always been caffeine, of course, and in the 1980s, ephedrine-based drugs such as Dexatrim helped students pull all-nighters. Then, in the late 1990s, as prescriptions soared for stimulants such as Ritalin and Adderall to treat attention-deficit hyperactivity disorder (ADHD), students began using these drugs for a pre-exam study boost.

There's little evidence that stimulants actually improve students' performance. Nonetheless, their use foreshadows what many see as the inevitable rise in the use of drugs that hold the promise of enhancing academic performance by improving concentration, alleviating fatigue and, potentially, enhancing memory and cognition.

Indeed, many more new drugs being developed to treat ADHD, narcolepsy and Alzheimer's disease will soon come to market, bringing with them medical and ethical concerns about their potential for off-label use by people looking for a cognitive boost.

"Healthy people will be using cognitive-enhancing drugs more and more," says Cambridge University neuropsychologist Barbara Sahakian, PhD. "Already the use on college campuses and elsewhere is widespread."

A new world

Accounts of students taking their friends' ADHD medications have been around since the late 1990s. In 2001, the University of Michigan's Monitoring the Future Project, which tracks teen drug use, started asking about non-prescription use of Ritalin. Data from 2006 finds that 2.6 percent of eighth-graders, 3.6 percent of 10th-graders and 4.4 percent of 12th-graders admit to taking Ritalin without a prescription.

Those numbers increase for college students, particularly those who attend highly competitive schools, according to a national study conducted by University of Michigan researcher Sean Esteban McCabe, PhD, and colleagues. His 2005 study, published in Addiction (Vol. 100, No. 1), found that 6.9 percent of a representative sample of college students from 119 colleges and universities had used Ritalin, Dexedrine or Adderall without a prescription. Only 4.1 percent had used the drugs in the past year, but that number varied significantly by school with rates as high as 25 percent at some schools and as low as zero at others.

These numbers are much lower than for marijuana and alcohol, which continue to be the most common substances used by college students: In the past year, 30 percent of college students have used marijuana and 80 percent have used alcohol. But the rates are equal to or higher than other drugs, such as cocaine, amphetamines and hallucinogens. What makes them particularly different is the reason students take them.

"It's this brave new world," says Ralph Castro, manager of Stanford University's substance abuse prevention services, who's been monitoring use of Ritalin and Adderall on his campus. "Before, students would use alcohol and drugs to get high and escape academic stress. With this, nearly 70 percent say they're using [these drugs] to improve attention and 54 percent to improve study habits."

And although most students report taking these drugs to study, many also take them to party.

"I think [many students] start during final exam week and find out that they can take it and stay awake and alert for long stretches," says Ohio State University psychologist Bill Frankenberg, PhD, who found similar rates of stimulant abuse as McCabe in a survey he conducted. "Then they're in contact with people who show them how to grind it up and snort it and use it recreationally to get high."

Such abuse has clear risks. Even when taken as prescribed, Adderall and Ritalin can disturb sleep patterns and stunt growth. In high doses, they can cause seizures. And yet, says McCabe, there is no evidence that the nonmedical use of prescription stimulants helps students perform academically. In fact, research shows that nonmedical users of prescription stimulants are more likely to be students with lower grade-point averages.

Another drug beginning to capture the attention of those looking for a cognitive boost is Modafinil (marketed as Provigil). This stimulant, developed to treat narcolepsy and also being tested for ADHD and several other disorders, has few known side effects and a much lower risk of dependence than Ritalin and Adderall. Several studies have shown it can boost attention, memory and concentration in healthy people, though at least one study found it didn't work any better than a large dose of caffeine. There are no data on how many healthy people use it, but its sales far exceed what you'd expect based on the number of people with narcolepsy-and testimonials to the drug's effectiveness abound on the Internet. Some people say they obtain it easily from their physicians and others buy it online, where it costs about $5 a pill.

Ethical questions

Although there are still few cognitive-enhancing drugs easily available, researchers predict that within 20 years there will be many.

Most, if not all, will make their way into use by the general public. "Healthy people will be using cognitive enhancing drugs more and more," says Sahakian, adding that the Internet will provide increasingly easy access.

In an attempt to address the issue long before it becomes commonplace, psychologists and others connected with the field of behavioral neuroscience are discussing the ethical implications of these drugs. In an article in Nature Reviews (Vol. 5, No. 5), University of Pennsylvania psychologist Martha Farah, PhD, along with Howard Gardner, PhD, Eric Kandel, PhD, and others, detailed the potential for a boom in neurocognitive enhancement drugs and emphasized the need for serious ethical debate.

That debate is heating up. Last year, Sahakian and Morein-Zamir discussed a number of critical ethical questions in a commentary published in Nature (Vol. 450, No. 7173), including whether people are cheating when they take these drugs to get ahead and whether people will feel pressure to take drugs or give them to their children to keep a competitive edge.

In the end, says Sahakian, because there is clearly a demand for these drugs, regulations are needed.

Farah adds that unless there's an attempt to regulate the use of these drugs for the explicit purpose of cognitive enhancement students' unsupervised use of ADHD medication will continue and spread to other drugs. Currently, she says, using these drugs without a prescription is against the law.

Meanwhile, "physicians prescribing these drugs tend to see themselves in the role of healers, not academic performance enhancers. So both the law and doctors' professional roles conflict with current practices, and at some point society will want to reconcile these conflicts."

Beth Azar is a writer in Portland, Ore.