Department of Health System Management, Ariel University, Ariel, Israel.
J Clin Psychopharmacol. 2021;41(2):100-102. doi: 10.1097/JCP.0000000000001336.
Methylphenidate (MP), a drug of choice for attention-deficit/hyperactivity disorder (ADHD), is a federally restricted substance CII in the United States because of abuse and dependence, and similar restrictions are practiced in Canada and around the world. This designation is given to drugs with medical value that present a high potential for abuse. In view of these severe restrictions, it is concerning to find out that a large group of healthy young adults, at least as large as the ADHD group of patients, take MP for cognitive enhancement, in an attempt to improve their academic achievements during studies and examinations. These young adults buy MP illegally and consume it without any medical supervision. The objective of the present debate piece is to present the ethical and clinical issues that need to be addressed in an attempt to solve this dilemma.
The issues presented here are systematically reviewed and discussed along the following lines: MP effectiveness in enhancing cognitive achievements in healthy people; "As these are normal healthy people, what is the duty of physicians to 'treat' them?"; potential benefits of cognitive enhancement to healthy people; the risks of MP; "How do these young people get their MP?"; and "What can be done?"
Methylphenidate is widely used for cognitive enhancement without medical supervision. The effectiveness of MP for cognitive enhancement is well documented along a dose-response curve. Congruent with the results of the randomized trials, repeated studies based on interviews suggest that numerous young people report that cognitive enhancement helps them in improving their academic achievements, and hence also improve their feeling of well-being. Presently, most regulatory and medical organizations limit the use of MP to ADHD and narcolepsy. Yet, the American Academy of Neurology ruled that there is a moral, ethical, and legal basis to prescribe the drug for cognitive enhancement. The drug has known dose-dependent adverse effects that can have serious ramifications and may often lead to poor adherence. The relative risk of MP causing sudden death/arrhythmia is 1.46 (95% confidence interval, 1.03-2.07), and there are estimated 20 million college and university students in the United States in 2020. The rate of sudden death/arrhythmias in this age group ranges between 1 and 10 per 100,000. This translates to an excess of 146 deaths caused by MP every year in the United States considering postsecondary students only.
We propose that an ethical-clinical debate should be followed by an action plan to ensure that the present reality of millions of young people taking unsupervised MP is not accepted as a force majeure that cannot be changed.
哌醋甲酯（MP）是治疗注意力缺陷多动障碍（ADHD）的首选药物，由于滥用和依赖，在美国被列为管制物质 CII，加拿大和世界各地也实行类似的限制。这种药物具有医学价值，但滥用的可能性很高。鉴于这些严重的限制，令人担忧的是，发现一大群健康的年轻成年人，至少与 ADHD 患者群体一样大，出于认知增强的目的而服用 MP，试图在学习和考试期间提高他们的学习成绩。这些年轻人非法购买 MP 并在没有任何医疗监督的情况下服用。本辩论文章的目的是提出需要解决的伦理和临床问题，以试图解决这一困境。
本文系统地回顾和讨论了以下问题：MP 在增强健康人群认知能力方面的有效性；“既然这些都是正常健康的人，医生的职责是什么？”；认知增强对健康人的潜在益处；MP 的风险；“这些年轻人是怎么得到他们的 MP 的？”；“能做些什么？”
哌醋甲酯在没有医疗监督的情况下被广泛用于认知增强。MP 对认知增强的有效性沿着剂量反应曲线得到了广泛的证实。与随机试验的结果一致，基于访谈的反复研究表明，许多年轻人报告说，认知增强有助于他们提高学习成绩，从而也提高他们的幸福感。目前，大多数监管和医疗组织将 MP 的使用限制在 ADHD 和发作性睡病上。然而，美国神经病学学会裁定，为认知增强开处方在道德、伦理和法律上是有依据的。该药物有已知的剂量依赖性不良反应，可能会产生严重后果，并且经常导致药物不依从。MP 导致猝死/心律失常的相对风险为 1.46（95%置信区间，1.03-2.07），2020 年美国估计有 2000 万大学生和大学生。该年龄组的猝死/心律失常发生率为每 10 万人 1 至 10 人之间。这意味着仅考虑中学后学生，每年就有 146 多人因服用 MP 而死亡。
我们建议，应该进行伦理-临床辩论，然后制定行动计划，以确保目前数以百万计的年轻人未经监督服用 MP 的现实情况不会被视为无法改变的不可抗力。
