Introduction
Cognitive enhancing drugs (CEDs) are believed to improve cognitive functions such as attention and motivation [1,2]. They are prescribed for conditions such as dementia, attention deficit hyperactivity disorder (ADHD) and narcolepsy [3, 1]. Further to their prescribed use, off-prescription use of CEDs has been reported, particularly by students during university assessments [4, 5]. Survey data have identified a number of subjective benefits experienced as a result of taking CEDs, such as improved concentration, the ability to study for longer [6], increased alertness [7], increased focus, productivity and drive [8], increased mental stamina or endurance [9] and a greater interest in work [10]. The reasons for taking CEDs have been found to include the fear of academic failure, the need to meet high work demands, overcoming procrastination and boosting motivation [11, 12]. Beyond these reasons, some individuals may also be self-medicating to treat undiagnosed attention deficit problems that they are experiencing [6, 12]. Although the perceived effects of CEDs in everyday settings have been investigated [13-15], the CEDs included in such surveys were either looked at more generally as prescription stimulants or the use of a range of different CEDs was surveyed. Given that modafinil is recognised as the most commonly used CED off-prescription [16-18], the research reported in the current paper focused specifically on understanding the user profile and perceived effects of modafinil when taken for non-medicinal purposes.
Modafinil is a mild psychostimulant drug prescribed for narcolepsy [19], sleep apnoea, shift worker sleep disorder [20, 21] and ADHD [22]. The recommended dose for modafinil is 200mg taken once daily [23]. Modafinil has been found to be well-tolerated, with a low incidence of adverse effects and low potential for abuse [24]. It is well absorbed, reaching peak plasma concentration between two and four hours following oral administration, and has a half-life of approximately 12-15 hours [25, 26]. Modafinil’s mechanism of action, while not yet fully understood, is complex. It is thought to act primarily through noradrenaline (NE) and dopamine (DA) transporter inhibition [27, 28]. It also acts on serotonin, histamine, gamma-aminobutyric acid and glutamate [29]. It is believed that modafinil’s action on orexin also results in increases in the hypothalamic release of histamine [30] and one of the actions of histamine is arousal and wakefulness. Therefore modafinil, when taken at the end of the day or in the evening, may result in an extended period of wakefulness which some individuals may find advantageous, particularly when working towards a pressing deadline. The most common adverse effects of modafinil are headaches, nausea, nervousness, rhinitis, diarrhoea, anxiety and insomnia [27]. In rare cases high doses of modafinil may also induce psychosis [31]. Modafinil has been found to enhance some aspects of cognitive performance in the laboratory. Gilleen et al. [32] administered a 200mg daily dose of modafinil to healthy volunteers over a 10 day period alongside cognitive training. They found that performance on a language learning task, which drew upon attentional, comprehension and working memory processes, was significantly greater in the modafinil group compared with controls. Whilst other studies (e.g., [33]), have reported similar effects of modafinil in non-sleep deprived, healthy individuals, these effects may be stronger when baseline performance is lower [34]. Differences in baseline performance may also explain the results of Repantis et al.’s [18] systematic review of the effects of modafinil in healthy subjects. They found a moderate positive effect for a single dose administration of modafinil on reaction time, divided, sustained and selective attention. However, Battleday and Brem [35] suggested that some of the cognitive tests employed may not have been sensitive enough to detect improvements in healthy, non-sleep deprived adults. Repantis et al. [18] acknowledged that the cognitively enhancing effects of modafinil are greater in sleep-deprived individuals and that the effects of CEDs depend, to a certain extent, on an individual’s baseline performance. Randall, Shneerson and File’s [36] analysis of the effects of modafinil in healthy students revealed that modafinil only benefitted performance in those with lower IQ, where significant improvements were found in sustained attention, speed of response and visuospatial and constructional ability. It may be that people choose to take modafinil when perceived cognitive demands are high or when their performance may be lowered through some form of impairment such as low baseline levels (i.e. [18]), lower IQ (i.e. [36]) or through the use of other drugs. In unimpaired individuals, modafinil may have little or no enhancing effects, although the basic testing paradigms used in some laboratory-based studies may not be robust enough to detect modafinil’s effects [35].
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However, the studies reviewed so far have demonstrated the effects of modafinil when measured under laboratory conditions rather than when it is used illicitly, off-prescription, in daily life. Laboratory-based research takes place in controlled environments, providing very useful behavioural, pharmacodynamic and pharmacokinetic information about modafinil use. Nevertheless, off-prescription use of modafinil occurs in uncontrolled environments, often concurrently with other drug use. Drug interactions, dosage levels, perceived effectiveness, motivation and frequency of use and the quality of drugs are all factors which are likely to reflect the real-life experience of modafinil use. Online surveys, therefore, provide important information regarding everyday experience with modafinil that cannot be obtained via laboratory-based research.
Gaining such information is important since, in recent years, health concerns have been raised regarding the off-prescription use of modafinil for cognitive enhancement [37, 2]. Further to these concerns, it appears that modafinil is commonly used for academic study, at least in elite universities in the UK Higher Education sector. For example, one in five students at Oxford University reported the use of modafinil [5] and one in ten students at Cambridge University reported the use of either modafinil, Adderall or Ritalin for the purposes of cognitive enhancement [38].
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Despite these health concerns and reported prevalence rates, there is no published study focused on both the positive and the negative perceived effects of modafinil and how these may be related to patterns of use, use of other drugs and psychiatric diagnosis. Therefore, the survey reported in the current paper sought to address this gap in the literature. The main aim of the study was to investigate the modafinil users’ perceived experiences of the drug and how this related to frequency of use. A further aim was to gain a greater understanding of the modafinil user’s profile via the collection of demographic information, motivations for using modafinil, how they accessed the drug and to what extent they were aware of the dangers of unsupervised use, such as those relating, for example, to dosage levels and dependency.
Strong associations have been found between CED use and the use of illicit drugs such as cannabis, cocaine, amphetamines and MDMA/ecstasy [39-42]. These associations beg the question as to whether illicit drug users are more likely to take CEDs because they are more open to using drugs in general. Therefore, the current study also aimed to investigate concurrent illicit drug use by modafinil users. Modafinil has been found to have mood enhancing effects [43, 44] and has been identified as having therapeutic potential for depression and cocaine dependency [27]. The perceived effects of modafinil amongst drug users and people with a psychiatric diagnosis have not, however, been explicitly investigated outside of the laboratory. Thus, a further aim was to investigate the psychiatric status of modafinil users.
Given that modafinil appears to be used most commonly by students [5, 38], when underperformance is likely [18] or work demands are high [11], it appears that modafinil provides benefits at cognitively demanding times. It seems to offer many potential benefits such as improved attention, speed of response and visuospatial ability [18, 36], yet it also has low incidence of adverse effects [28]. Bearing these points in mind, it was hypothesized that 1) more frequent use of modafinil would yield greater perceived benefits and 2) the perceived benefits would outweigh the perceived negative effects (or risks). Additionally, as it appears that modafinil has the effect of ameliorating poor performance, it seemed very plausible to assume that the benefits provided by modafinil cease to be present once the drug has worn off. Therefore, it was also hypothesized that 3) these reported benefits would not persist beyond the immediate use of modafinil. Finally, bearing in mind the mood-enhancing effects of modafinil [43, 44], it was also hypothesised that 4) individuals with a self-declared psychiatric diagnosis would perceive greater benefits of modafinil use compared with those not reporting a psychiatric diagnosis.
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