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    OpenAccess Life context of pharmacological academic performance enhancement among university students – a qualitative approach 1* 2 2 ElisabethHildt ,

    ]Klaus Lieb and AndreasGünter Franke Abstract Background: Academic performance enhancement or cognitive enhancement (CE) via stimulant drug use has received increasing attention. The question remains, however,whether CE solely represents the use of drugs for achieving better academic orworkplace results orwhether CE also serves various other purposes. The aim of this studywas to put the phenomenon of pharmacological academic performance enhancement via prescription and illicit (psycho-) stimulant use (Amphetamines,Methylphenidate) among university students into a broader context. Specifically,wewanted to further understand students’ experiences, the effects of use on students and other factors, such as pressure to perform in their academic and private lives. Methods:

    sample of 18 healthy university students reporting the non-medical use of prescription and illicit stimulants for academic performance enhancementwas interviewed in a face-to-face setting. The leading questions were related to the situations and context inwhich the students considered the non-medical use of stimulants. Results: Based on the resultant transcript, two independent raters identified six categories relating to the life context of stimulant use for academic performance enhancement: Context of stimulant use beyond academic performance enhancement, Subjective experience of enhancement, Timing of consumption,Objective academic results, Side effects, Pressure to perform. Conclusions: The answers reveal that academic performance enhancement through the use of stimulants is not an isolated phenomenon that solely aims at enhancing cognition to achieve better academic results but that the multifaceted life context inwhich it is embedded is of crucial relevance. The participants not only considered the stimulants advantageous for enhancing academic performance, but also for leading an active lifewith a suitable balance between studying and time off. Themost common reasons given for stimulant usewere tomaximize time, to increasemotivation and to copewithmemorizing. According to the interviews, there is a considerable discrepancy between subjective experiences and objective academic results achieved. Keywords: Cognitive enhancement, Academic performance enhancement, Stimulants, Ethics, Attitudes, Life impact, University students Background other prescription drugs (modafinil, antidementives), The non-medical use of so-called “smart drugs” among aswell as illicit drugs (e.g. illicitAMPH, cocaine) have students with the aim of increasingmental performance been used in this context [2-4]. has attracted considerable media attention over the Regarding the effects of these “smart drugs”, there is very past few years [1]. In particular, prescription stimulants limited scientific evidence to support the pro-cognitive (methylphenidate,prescription amphetamines e.g.Adderall®), properties in healthy individuals. Current research data from randomized double-blind placebo-controlled trials (RCTs) among healthy subjects show inconsistent (pro-) *Correspondence: hildt@uni-mainz.de 1 Department of Philosophy, Johannes GutenbergUniversity ofMainz, Jakob cognitive effects on solely simple and higher cognitive do- Welder-Weg 18,D – 55099Mainz,Germany mainswith stronger pro-cognitive effects on sleep-deprived Full list of author information is available at the end of the article © 2014Hildt et al.; licensee BioMed Central Ltd. This is anOpen Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),which permits unrestricted use, distribution, and reproduction in anymedium,

    the originalwork is properly credited.

    find outmore about the reasons for stimulant use, experi- Analysis enced effects of stimulants and their impact on academic Recordswere transcribed verbatim by a personwhowas results and theuser’s life in- andoutsideuniversity,we con- not involved in the interview procedure.The anonymous ducted semi-structured interviews on a group of university transcriptions were then analyzed systematically using a studentswhowere experiencedwith the use of stimulants qualitative approach based on inductive category develop- for enhancementpurposes. ment [29-31]:Two independent raters (Hildt and Franke) analyzed the transcriptions blindly.

    The answers given Methods by the participants relating to the impact of the use of Participants prescription and illicit stimulantson individual life context We posted placards on public bulletin boards throughout in- and outside university were analyzed and categories the University ofMainz campus asking students who subsequently formed. To ensure objective analysis, only had used prescription or illicit (psycho-) stimulants those categories uponwhich both raters agreedwere used (amphetamines=AMPH,methylphenidate=MPH, ecstasy, for the final analysis for thispaper. cocaine) for CE purposes to contact us anonymously Based on thismethod, some preliminary results concern- via email. Placards promised an expense allowance of ing users’ views on the (moral) differences between caffeine 30,-Euros forparticipation.Onlyhealthy studentswithout and illicit/prescription stimulants forCE [9] and concerning psychiatric disorders (e.g. attention-deficit hyperactivity information transfer [32]have alreadybeenpublished. disorder (ADHD), schizophrenia) and current physicians’ prescriptions of psychoactivemedication (e.g.Ritalin®)were Results included in the study. 22 interviewswere carriedout. Participant characteristics have already been described in Franke and colleagues (2012) concerningusers’ views about Interview guideline (moral) differences between caffeine and prescription/illicit An extensive semi-structured face-to-face interview guide- drugs [9].To summarize, only some (n=30) students con- line was developed. After gathering socio-demographic tacted us via telephone or e-mail. Having corresponded information (age, sex, study subject, grades, etc.)we asked with these candidates to identify potential exclusion criteria questions concerning the intake of prescription and illicit and following a further planning procedure, 22 interviews stimulants with the particular intention of academic per- were carried out.

    4 interviewswere not analyzed because formance enhancement and factors associated

    with this of diagnosedADHD, Pseudologia fantastica or technical use. Of particular interest here are questions relating reasons. 18 interviews entered further analysis. to the background of (psycho-) stimulant use, such as Among all participants (n=18=100%), 77.8% (n=14) “Why did you take the stimulant?”, “Did you experience a had used illicit stimulants (AMPH) and 38.9% (n=8) considerable increase in mental performance?”, “Did prescription stimulants (MPH). 22.2% (n=4) had used your academic results actually improve as a direct result prescription as well as illicit stimulants for academic of taking the stimulant drug?”, “Did you experience performance enhancement. negative side effects?”. Participants were 25.8±2.88 years old (mean). 66.7% (n=12) of all participantsweremale, 33.3% (n=6) female. Procedure Participants had already completed 7.35±3.79 semesters A psychologist and three interviewers were trained for (mean) and were attached to three different departments the interview procedure. The psychologist examined all (Humanities:

    44.4%, n=8;Natural Sciences: 33.3%, n=6; participants to ensure that all candidateswith psychiatric Economics: 22.2%,n=4). diseases and current physicians’ prescriptions of psycho- The average age of first stimulant use for CE was active medication were excluded. Subsequently, each 20.4±2.88 years. Frequency of stimulant use for academic participantwas interviewed by two people at a time.The performance enhancement varied widely from nonrecur- interviewswere tape-recorded.To avoid lossof information ring use up to daily use during specific periods of time, e.g. (e.g. acousticproblemsof sound recording),one interviewer during exampreparation. asked the questions whilst the other noted down answers Based on the selected answers concerning the impact to closed questions and catchwords to open questions to of stimulant use on the students’ personal life, categories complement the tape-recording. were formed independently by two raters. Rater 1 created Participants gave written informed consent for being 9 categories and rater 2 created 8 categories.

    The raters interviewed and for the tape-recording of the entire inter- agreed on

    6 categories. Categories with congruent con- view. They received an expense allowance of 30,- Euros tents thatwere formed by both raterswere used for fur- when the interviewwas over.The studywas approved by ther analysis (Figure 1).Herewe partly reproduce direct the local Ethics Committee of the Landesärztekammer speech as stated by the interviewees to give a lively insight Rheinland-Pfalz (MedicalAssociationRheinland-Pfalz). into the embedded context ofCE

    library and I studied all the way through with hardly got better, though.”). any breaks.”). A student participant emphasized that he experienced For others, themain benefitwas to gain time or com- an improvement inmemory functions (“Usually I have pensate for lost time. These students might take the to get things intomy short-termmemory and then into drug if they left too little time to prepare for an exam my long-termmemory, basically just reading through a (“I thought: ‘Oh no, only 3 days to go till the exam, I couple of times.Under Ritalin itwas enough to read over don’t know a thing and I need to know it all by heart. it quickly and I was able to remember it days afterwards What should I do?’And then I took Ritalin for three withoutRitalin.Well, as I said, the things that I studywith days and hardly slept.”). Ritalin stay there longer.”). Some students took stimulants just on the night before Another participant reported a

    positive effectwith regard the exam in order to prepare for the test. According to to learning simple content (e.g. vocabulary); however, them,AMPH isparticularly suitable in this respect insofar the beneficial effects were less pronounced when it came as it reduces the sleep requirement (“Sometimes when I tomore complexmaterial and negative effectsweremen- knew: ‘Alright tomorrow there’s a test and I haven’t done tionedwhen attempting to learn and understand complex anything again’. Then I took it in the evening and Iwent material (“If you have to understand the link between to school in themorning without any sleep having spent everything, it (AMPH)wasn’t a big help at all. SoAMPH the night studying.”; “The problem is, if you study the is good for everything that you just have to learn by heart. night before, then you have to take amphetamines again AMPHwas good in thatmoment. Butwhen it getsmore the nextmorning.”). complicated thenAMPH is justobstructive.”). A considerable number of students used stimulants, Others described the effects of (illicit) AMPH as even particularly prescription stimulants,

    during exams. more ambivalent. A student said: “Reading a text with However, some students viewed the side effects of (illicit) AMPH is quite nice, you’re just concentrated and awake, AMPH as problematic during exams or in situations with but your attention isn’t thatmuch better and because of some kind of “external control” (“I tend to sweatmore and that yourmemory is not working that well either.What talk faster and I have a faster flow of words. And inmy was that on the other page? It’s there but not well con- opinion, this is conspicuous.”).Nevertheless, some students nected. It’s like a virtual picture in your head, you can wereonAMPHduring exams. access it but it’s not connected at all.” One participant Whereas most participants used CE predominantly reported of lack of concentration and inability to focus during exam periods, i.e. for 2-3 weeks or sometimes on a defined task under illicit amphetamines. longer, a few of the students took the drugs for longer Beyond that, users of (illicit) AMPH also considered periods of time: one student because he felt permanently other effects to be of relevance in their stimulant use. under time pressure, and another reported to have taken For some students, an important aspect ofAMPH intake (illicit) AMPH regularly for an extended time period in is that less sleep is requiredwhich leads to an acquisition of the past as a consequence of its addictive effects. time. For instance, AMPH enabled them to learn during the night before their exam (“The advantage is the oppor- Category

    3: subjective experience of enhancement tunity to be awake and concentrated which doesn’t really We received multifaceted responses to the question make studying better though. It’s just gaining time.”).Other inquiring to what extent the students experienced an participants value an increase in creativity (“You have loads actual increase in performance as a result of drug use. of ideas that you never had before.”) Some participants A considerable number of students reported an increase also suggested that AMPH improved communication: in concentration and receptiveness and in their ability “[In the German written exam] I took it because I felt to focus on the learning material. The used stimulant that the flow of words and what you say increases, so was considered particularly to be helpful in situations in writing downwhat you’re trying to put intowords gets which the brain is required to record large amounts of easier and evenmore creative”. information. A typical answer is: “I could focus better and Iwasn’t as distracted.” Category

    4: objective academic results Some participants described an increase in theirmo- A crucial questionwith regard to the relevance of CE in tivation to revise (“…normally, when I have to study academic performance is whether participants’ results for long I get bored. (…)That’s the difference I noticed actually improved.The answers obtainedwere inconsistent: when I started taking Adderall. I didn’t really want to althoughmost students considered the use of stimulants to stop…”).Others stressed the ability to achievemore in have had some positive influence, only few participants

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