Conceptual and Contextual Aspects of Nonmedical Use of Prescription Drugs for CE in Canada
When referring to “medical uses” of prescription drugs, I designate uses for which the drugs are approved according to their labels and for which they are typically prescribed and medically supervised. The term “off-label” designates uses that depart from the original indication but that are nevertheless under medical supervision with the intent of treating a disorder or an identified psychiatric or neurological condition. I reserve the term “cognitive enhancement” for uses that do not intend to treat an identified disorder but rather to augment performance and that are not typically under medical supervision (nonmedical uses). (To my knowledge, no drug has been approved for CE per se in Canada). I readily acknowledge that these terms are broad nets that capture fluctuating and evolving realities related to prescription drugs. For example, the American Academy of Neurology (AAN) has called for greater medical oversight and supervision of enhancement uses,4 therefore blurring the medical/nonmedi- cal dichotomy captured in the presented definition of CE. Also, some uses captured under “enhancement uses” may in fact be disguised self-treatment (i.e., individuals using drugs for purposes described by some as CE could in fact be self-medicating, for example, for attention deficit hyperactivity disorder [ADHD]). Accordingly, the phenomenon of CE can be captured by different, even diverging, frameworks.5-6
Defining CE as a form of nonmedical use of pharmaceuticals is not benign from a regulatory standpoint but could be consistent with Canadian discussions and governance. It signals that pharmaceuticals such as stimulants used for CE, many of which actually require prescriptions in Canada, fall under a regime of health products that are regulated by complex federal law and clinical practices. In Canada, stimulants are typically schedule III substances, meaning that their possession is controlled and their illegitimate possession punishable.1 (I recognize that some authors have suggested that CE technology [e.g., pharmaceuticals, neurostimulation] be considered as a separate category).7-8 However, irrespective of the virtues of the proposal of considering cognitive enhancers as a distinct category, this would require rather substantial changes to legislation and clinical practices at this time. Otherwise said, it is more likely—unless important changes occur—that, in Canada, CE with pharmaceuticals will be dealt with under the current regime even if it represents a patchwork of legislations and regulation of clinical practices.