‘Cognitive enhancers’: A qualitative exploration of university students’ experiences with prescription medicines for academic purposes

Abstract

Qualitative work with students who use prescription medicines for academic purposes is limited. Thus, a more nuanced understanding of tertiary students’ experiences is urgently needed. Our study – which draws on five semi-structured interviews with New Zealand university students, complemented with information from local newspapers, blog entries and discussion forums – reveals students’ motivations and perceived effects, their risk perceptions and provides insights into the circumstances enabling the engagement with prescription medicines for academic purposes. Students were influenced by peers and social norms; and ideas about identity, morality and fairness also played a role for engaging with cognitive enhancers. Students used high levels of stress and workload to justify their use but took individual responsibility for their practices. By taking responsibility in this way, rather than considering it as a product of their environment, they buy into the neoliberal university discourse. Unexpectedly, some participants were already receiving medically justified psychopharmacological treatment but extended and supplemented this with nonmedical use. Others considered their use as being for academic emergencies, and that their low level of use helped manage risks. Overall, students viewed pharmacological cognitive enhancement for improving academic performance as cautious, safe, and morally acceptable. We argue in this paper that a local understanding of students’ motivations, justifications and perceptions of pharmacological cognitive enhancement is required, to tailor policies and support systems better to their needs and behaviours.

Keywords

Prescription medicines cognitive enhancement prescription stimulants university students risk perceptions users’ experiences

Introduction

Healthy individuals are increasingly using different substances for pharmacological cognitive enhancement (Coveney et al., 2011; Franke et al., 2014; Maier et al., 2018). Pharmacological cognitive enhancement is typically defined as the use of prescription medicines to improve cognitive performance at work or while studying (Maier et al., 2018; Maier & Schaub, 2015; Maslen et al., 2014). Recent research has shown a wider range of substances are used, including alcohol and illicit substances, and that these are used for a wider range of practices than enhancing cognitive enhancement (Maier et al., 2018). For example, a range of substances can be used to manage stress with an anticipated improvement in academic performance, which is not ‘cognitive enhancement’ per se. For convenience, we will continue to use the label cognitive enhancement as this is the most commonly used term. However, we will show that the use of substances goes beyond and is more complex than the merely cognitive enhancement, with prescription medicines used for a range of academic purposes.

Recently, the availability of prescription medicines has increased, which may be connected with increased nonmedical use of prescription medicines (Mccabe et al., 2006). Nonmedical use of prescription medicines refers to either the consumption of medicines which were not prescribed, or using it differently from doctors’ instructions (e.g. used in greater quantities or longer time frames) (Lakhan & Kirchgessner, 2012; Majori et al., 2017).

There are several classes of prescription medicines used to enhance performance; however, the most common are stimulants, such as methylphenidate or amphetamines, usually used to treat attention-deficit/hyperactivity disorder (ADHD) and commonly referred to as ‘smart drugs’ (Franke et al., 2014). Prescription stimulants have been compared to illicit drugs such as cocaine or amphetamines in terms of their effects on cognition. This comparison has highlighted prescription medicines’ potential for abuse (McHugh et al., 2015; Svetlov et al., 2007) and calls for action from relevant actors, such as regulating nonmedical use of prescription medicines (Greely et al., 2013; Maier et al., 2018; Smith & Farah, 2011).

Nonmedical use of prescription medicines is increasingly prevalent among university students pursuing improvements in their academic performance (Munro et al., 2017; Urban & Gao, 2017). Stimulants are the most commonly used prescription medicines among students for academic purposes (Brandt et al., 2014; Deline et al., 2014). Their use has often been justified by the need to cope with stress, exam anxiety and issues of time management (Maier & Schaub, 2015). In most cases, students are unaware of addiction risks and adverse health effects (Majori et al., 2017). The belief that prescription stimulants can increase academic performance could be influenced by (social) media attention given to pharmacological cognitive enhancement (Hildt et al., 2014; Petersen et al., 2021), despite there being little concrete evidence for efficacy (Franke et al., 2014).

Less is known about how students experience the use of cognitive enhancers in light of their life circumstances, and risks that they associate with these medicines. Their voices are still widely missing in this context despite some notable exceptions such as the studies by Petersen et al. (2015a, 2015b). Although the use of cognitive enhancers among university students has been extensively researched in the US, most of the work outside the US is either quantitative or has not involved students who have engaged in pharmacological cognitive enhancement (Batisse et al., 2021; Petersen et al., 2019; Ram et al., 2021; Sharif et al., 2021). Qualitative studies with Australian and UK students found that students considered it a way to get ahead and balance competing demands (McDermott et al., 2021; Partridge et al., 2012; Steward & Pickersgill, 2019). Other studies found that in academic contexts students may consider the use of cognitive enhancers safe and morally acceptable (Desantis & Hane, 2010; Petersen et al., 2015a, 2015b). Interviews with US students who engaged in pharmacological cognitive enhancement found that the most prevalent motives were personal enhancement in terms of academic performance and mental health (Bennett & Holloway, 2017; Desantis et al., 2010; DeSantis et al., 2008). Another US study with users found that rather than believing there were objective benefits, students found that it changed their perception of studying, and ‘made work fun’ (Petersen et al., 2015b). Thus, in addition to a cognitive dimension, there is an emotional dimension to pharmacological cognitive enhancement, reflecting the need to listen more carefully to students’ voices than done to date.

In New Zealand, universities have observed prevalence rates of nonmedical use of prescription medicines similar to those observed in Europe: 4% at the University of Otago (Narayanan et al., 2021) to 6.6% at the University of Auckland (Ram et al., 2016). Given the increased rates of prescriptions observed in the country to treat cognitive disorders, the likelihood of nonmedical use may also increase. An indication of this shift is outlined by Ram et al.'s (2017) study on attitudes of cognitive enhancers among university students as they found that the acceptance of enhancers is increasing. There has also been some quantitative work exploring the link between users and non-users of cognitive enhancers and students’ motivation and learning strategies (Ram et al., 2019). However, there is no qualitative research exploring cognitive enhancement practices in New Zealand and thus there is a need to more deeply explore students’ experiences of pharmacological cognitive enhancement, their motivations and circumstances enabling it to be able to provide more nuanced policy advice through revealing potential areas of concern.

Neoliberal ideas and individual responsibility for success have been ingrained into New Zealand’s tertiary students since New Zealand adopted and implemented many free-market ideals and practices in the 1980s (Crothers, 2018; O’Neill, 2015; Thrupp et al., 2021). Given the scope and far-reaching implementation in all sectors of the ‘New Zealand Experiment’, the country and its uptake is often considered a blueprint for countries in the Global North (Crothers, 2018). The New Zealand neoliberal education system creates students who have been shaped up to become part of, and to produce and perform, a neoliberal society (Nairn et al., 2012; Wood et al., 2020). In this way, students are framed and often operate as consumers of education. Tertiary education is a private investment into future job opportunities rather than a right or public good (Thrupp et al., 2021). Success thus is the responsibility of each individual student leading to heightened competition, individualism and individual responsibilisation in and outside the class room with tremendous impacts on their wellbeing (Davies & Bansel, 2007; Gair & Baglow, 2018; O’Neill, 2015; Shore, 2010; Wulf-Andersen & Larsen, 2020). This exploratory research seeks to add to our knowledge on the practice of pharmacological cognitive enhancement in real-life settings by exploring perceptions and study experiences among students in a neoliberalised New Zealand university.

Methods

Five in-depth semi-structured interviews were conducted in a New Zealand University with students using prescription medicines. We conducted semi-structured interviews, as these allowed us to engage in participants’ interpretations, probe for responses and clarify ambiguities. We additionally sought student voices from New Zealand newspapers, blogposts and discussion forums referring to the use of prescription medicines. We included this additional method as fewer students participated in the study than we anticipated, indicating the sensitive nature of sharing cognitive enhancement practices. Moreover, per our recruitment procedure (detailed below), we were not able to directly recruit further students into the study.

Participants

To identify students that used cognitive enhancing drugs, several of the present authors designed a larger quantitative project investigating prevalence of pharmacological cognitive enhancement. That study was in part designed to serve as a screening tool for this project (approved by the University of Otago Human Ethics Committee, Ref: 15/091). Thus, we were permitted to retain details of students interested in participating in further research, and in particular, identify those who used cognitive enhancers. Of the 550 students who participated in that project 19 used cognitive enhancers, with 14 of those agreeing to participate in further research and these students were all invited to participate in this study. Five agreed to the semi-structured interviews that form the basis of this project. This current study was approved separately by the University of Otago Human Ethics Committee (Ref: 15/120). The low uptake of participation may reflect the difficulties in recruitment and the sensitivity of the research topic with only a handful of students willing to share their experiences despite diverse measures put in place to protect participants’ information and privacy. These measures included but were not limited to: a separate project email address to communicate with potential participants; only the research assistant having access to this email account; and the research assistant anonymising the raw data before the authors saw the data (including the survey data) to ensure privacy of participants.

Data collection

Interviews were conducted in 2015 and 2016 amongst undergraduate and postgraduate students and were held on campus or in a place convenient for both the interviewer and the student. The semi-structured interview schedule was guided by a desire to gain a more holistic understanding of the life circumstances of interviewees that might influence why they are drawn to cognitive enhancement drugs for study purposes. Interviews commenced with demographic questions (ethnicity, year and subject of study). Participants were then invited to share their narrative, from choosing their studies to their career goals and their experience of university. The interviewer used prompts and probes to elicit further information about stress, the influence of outside factors, or the use of substances for cognitive enhancement substances. Overall, the discussion covered topics such as student life, coping strategies during examination times and knowledge of risks and benefits of pharmacological cognitive enhancement. Informed consent was recorded through a signed consent sheet. Interviews lasted between 39 min and an hour and 15 minutes. Interviews were digitally audio recorded and transcribed verbatim. Data was anonymised before analysis and no personal identifying characteristics were disclosed. Table 1 provides an overview of the students who participated in the study.

Table 1.

Background information on participants.

Participant	Year of study	Area of study	Gender	Mental health condition	Prescriptions
1	Undergraduate	Law	Female	None	None
2	Undergraduate	Engineering	Male	None	None
3	Postgraduate	Arts	Female	Depression and anxiety	Diazepam, buspirone and mirtazapine
4	Undergraduate	Sciences	Female	Dyspraxia and mild ADHD	Methylphenidate
5	Undergraduate	Arts	Female	Anxiety	Melatonin

The comments of these five participants were complemented by an online search to identify further materials where students discussed their use of prescription medicines. Dowling et al. (2016) suggest that digital data supplementing and complementing interviews can enrich our understanding and analysis of social life. Therefore, online information published between 2007 and 12 December 2017 was included in our analysis. By using the advanced search setting (tag ‘site:nz’), it was ensured that all items were published in New Zealand and were written in English. Four searches using Google were conducted using different names given to smart drugs (ritalin OR rubifen OR concerta OR methylphenidate; (dex)amphetamine OR adderall OR Dexas; modafinil OR modavigil; and racetams OR aniracetams) in combination with (study OR exam OR assignment OR test OR essay). The search identified a total of 1420 results within the. nz domain; however, after the first six to seven results pages, articles were found to be repeating or not relevant, leaving 162 articles. These articles were further screened for relevance to shortlist the articles which mentioned the use of prescription medicines by students. Most of the articles were general information, related to ADHD, testing of the drug, or briefly mentioned the drug; leaving 17 articles to be included: 12 newspaper articles, three forum discussions, one research study and one legal case documentation.

The ethical considerations of conducting research based on online forum materials written by private users who did not have the intention of taking part in research has been considered from different perspectives (Bassett & O’Riordan, 2002; Flicker et al., 2004; Hudson & Bruckman, 2005). The data in this study were taken from publicly accessible online forums posted by individuals, who used pseudonyms, and were available to anyone with access to the Internet.

Data analysis

Interview notes, transcripts and online materials were thematically analysed using ATLAS.ti. The data was extensively read to identify themes. A coding scheme was developed and tested on a sample of text (Braun & Clarke, 2006) with three of the authors. The final coding structure for the interviews, newspaper articles, discussion forums and blog entries included the following codes: types of substances used, perceived effects, risk perceptions, identity as a student, peer influence and social norm.

Quotes were used to illustrate the importance of the codes. Citations may have been edited in the following ways. Marks of speech hesitation (e.g. ‘uh’) were removed. Words that are usually used in informal speech but make sentences hard to read in print (e.g. ‘okay’, ‘like’ and ‘you know) were removed. Some quotes were kept unedited to communicate participants’ difficulty to express themselves.

The research assistant sent participants their transcripts for checking to ensure they felt their experiences and thoughts were adequately represented before the analysis stage, but also to ensure they feel comfortable with what they shared during the interview before their anonymised transcripts were shared with the wider team. Some of the prescription medicines used for cognitive enhancement are classified as ‘controlled drugs’ in New Zealand, which means the penalties for their non-prescription use are more severe than normal medicines. This could be one of the reasons why students hesitated to participate.

Results

We analysed contents of the interviews, articles, blogs and forums associated with students’ experiences of nonmedical use of prescription medicines for cognitive enhancement.

Types of substances used

Prescription stimulants such as methylphenidate (Ritalin) or mixed amphetamine salts (Adderall) were the most common medicines mentioned by students to improve their cognitive performance and score better marks, typically referred to by their brand names (i.e. Ritalin/Adderall). We have chosen to use the names our participants used for authenticity of the students’ voice, rather than the convention of using International Nonproprietary Names for medicines.

Students on discussion forums particularly praised the benefits of prescription stimulants, describing them as “the study drug of choice for wunderkinds” and claiming that “ADHD pills for normal people make you concentrate hardout”. Forum participants promoted their use, describing stimulants as a miracle pill. However, descriptions of how they worked were vague: “Mates and flatmate rave about the restorative and focusing powers of methylphenidate”, “Pills can do everything”, or “modafinil is something that looks good”. The comments indicate a discrepancy between the scientific evidence for the effects of these stimulants and what people read into them or want to see in them. This can indicate a lack of knowledge on the medicines they were promoting, and that myths relating to cognitive enhancers are potentially the source of their perceived effectiveness.

Users recommended Adderall over Ritalin based on their experience of the different effects between the two medicines. However, they recognized that Adderall was difficult to access in New Zealand and admitted that Ritalin would be sufficient. Despite the promotion of these specific stimulants, students still used a variety of other substances to cope with university stress and workload in order to improve their academic performance. Amongst the students interviewed, melatonin, diazepam (Valium), buspirone, mirtazapine and alcohol were also mentioned. This highlights that substance use for academic purposes is not limited to stimulant use. One participant explained:

“I’ve been prescribed buspirone by my psychiatrist, which is supposedly beneficial for cognitive abilities, like concentration and memory. […] I take mirtazapine in the evenings. And then I get prescribed Valium for the anxiety, which is brilliant. […] I always take them when I’m writing an essay. […] I like to drink while I write, as well – just to relax me, that’s really beneficial […]and even though I struggled with it, I didn’t feel that I struggled as much as I did last semester, or last year, so maybe it’s helping a wee bit”. (Participant 3)

It should be noted that this student is seeing a psychiatrist and, thus, belongs to a minority of students. However, she acknowledges changing the dynamics and the patterns of use of drugs that she has been medically prescribed. This shows how some students may try to combine different substances solely for academic purposes, which may indicate higher risk behaviours. Furthermore, it highlights the fact that some students can have more access to substances than the average student. In fact, two other participants also had medical diagnoses (dyspraxia, ADHD and anxiety) (see Table 1).

Perceived effects

The students interviewed found mostly benefits in using stimulants for cognitive enhancement. In all cases, effects such as increased alertness and focus were described. One participant explains the effects she felt with Ritalin:

“I find you don’t tire as much. Normally, at 10:30 I’m like time for bed. I’m bloody tired, can’t concentrate on anything. But [with Ritalin] I was awake longer, and I was a lot more focused. Didn’t go on Facebook, or anything like I normally would. So, I guess, longer stints focusing on the assignment, as opposed to taking breaks every so often so you could be more efficient with your time.” (Participant 1)

While this student outlines the benefits she noticed, all participants who had used Ritalin were more wary about the overall effect it has on enhancing concentration. Rather, they attribute part of the benefits to a placebo effect. Furthermore, a few described some unwelcome side effects: “I guess you’re a little bit out of it afterwards, after you stop studying.” (Participant 2). Student voices reported in New Zealand newspaper articles also mentioned having taken stimulants too close to bedtime and being unable to sleep, as well as experiencing appetite loss and excessive sweating. Moreover, some described how Ritalin may increase concentration, but not necessarily on studying. These accounts of unexpected effects illustrate how students assess the importance of the side effects of using prescription medicines and how users seem to highlight fewer unwanted side effects and higher levels of academic benefits.

Risk perceptions

Addiction risks and perceived self-control

Whilst students described benefits of prescription medicines as study aids, they also acknowledged addiction risk. Many students online warned others of such risks: “I know an American exchange student who was always on it though so I guess you could get a bit addicted if you don't save it strictly for pulling yourself out of jams like the one I was in”. Despite the recognition of the addictive component of these medicines, most students thought they could manage their use. As long as they could control their practices, they considered it as safe. One participant explained the rituals and safety measures she took when using Ritalin to study:

“I don’t feel like there’s risks when I’m studying, because I’m always taking such controlled amounts, and I’m always thinking timewise, and I’m taking only one. I always have water with me, and things like that. […] I don’t think it’s something I’ll continue for the rest of my life. I’m sure as soon as I leave university, that’s it for me, to be honest. And I’m not fussed about it.” (Participant 1)

While the participant indicates that the repurposing of prescription medicines is safe as long as precautions are considered, she also outlines that she sees the use is only justified in the current environment. This shows that since cognitive enhancement occurred in a controlled setting and with a clear purpose, addiction risks were considered as minimal. Thus, it seems unlikely to this participant that her cognitive enhancement practices will be prolonged after graduation. This shows the importance that students give to individual responsibility to control and manage their use of pharmacological cognitive enhancement in a safe manner, but this statement also gives a clear indication that students in all interviews insisted on their autonomy in the matter and feel they are in control.

Health risks

Most students showed awareness that nonmedical use of prescription medicines involved certain health risks. However, they were unaware of the exact consequences or disregarded them in favour of the benefits. When asked if she believed there were any risks associated with the use of Ritalin, one participant answered: “Well, I'm sure there are. I don't know” (Participant 1). Confirming this indifference, one participant explained: “I know that there’s risks involved in terms of my health. I just don’t care about those risks” (Participant 3). These quotes illustrate that students did not perceive the risk of using prescription medicines as discouraging. Nevertheless, students were aware of the dangers. On several online forums, students shared options for safer cognitive enhancers or recommended alternative coping strategies. Among others, they recommended a good night’s sleep, a balanced diet, exercise, caffeine, herbal teas and other supplements, or even consulting a doctor.

Legal risks

Participants conceded that consuming medications without prescription or not following their doctor’s orders made them uneasy. One participant highlighted the irony of law students breaking the law to get better grades: “It is also illegal. We’re all a bunch of lawyers. It’d be a bit awkward.” (Participant 1). However, students seemed to assume the university would not be able to act if substances were consumed in a private setting. One participant explained:

“As for risks with university or people finding out at the university. I don’t know if there are any risks involved, because I’m not drinking in the library, and I’m not taking illegal drugs, and I’m doing it in the privacy of my own home.” (Participant 3)

Thus, they did not fear repercussions from the university itself for substance use, although it still might be considered as an offence within the wider code of conduct students need to subscribe to when they enrol in the University; so their practices operate within a grey zone.

Students’ considerations on the illegality of the practice reflected that they did not fear legal repercussions in the matter either. This could be due to past events, illustrating how small these consequences can be. Indeed, for example a student from a New Zealand university was caught supplying methylphenidate to three other students in 2012. Despite being initially charged, he was eventually discharged without conviction. It illustrates that nonmedical use of prescription medicines can lead to arrests and legal consequences, but it also demonstrates that small-scale offences, such as supplying prescription medicines to a couple of friends may not lead to conviction. Since peers seem to be the most common way to access such medications, the illegal nature of their use may be less salient. This contrasts with the purchase of recreational drugs, which would involve a dealer.

Most students obtained their supply of prescription medicines illegally. Out of all the participants who had used Ritalin, only one had an ADHD diagnosis and was prescribed the medicine. Other students generally got access through friends who were willing to sell or gift their medication. Some participants commented how easily they had access to Ritalin: “I’m pretty sure one of his friends actually just had a Ritalin prescription, and so would just sell them.” (Participant 3) or “I have a friend who’s got a prescription, and he needs them, but he doesn't take them as prescribed […] he just has stack upon stack, stacking up because he doesn't take them like he should.” (Participant 1). This shows that in contrast to illicit drugs that are usually obtained through the black market, prescription medicines are mostly obtained through peers and, thus, are more likely to be considered as a simple medication rather than a drug. This may also decrease perceptions of illegality, as the friend from whom they get them does possess them legally. Therefore, students’ perceptions of illegality seem to be quite low.

Students’ justifications

Students who were diagnosed with mental conditions reported that they felt justified in their medication use and argued that the medicines brought them to the same level as normal students: “I don’t really think it brings me an advantage over other students. I think it just sort of equalises.” (Participant 4). In contrast, students who used prescription medicines illicitly felt they needed to defend their decision to use them. Typically, they admitted having problems with finding a good balance in their studies and felt like their workload was unmanageable. One participant explained: “With my Ritalin use, it is more like, when I'm at the point where I don't see it is achievable any more, and I'm real desperate.” (Participant 1). However, it also shows that students felt that they could only justify using cognitive enhancers when they had tried every other option, using it as a last resort.

Despite the pressure they felt, all participants reported that they enjoyed studying. They felt that university courses were well organized, even though it was a lot of work. Moreover, all were aware of support systems put into place by the university (e.g. peer support groups, time-management sessions, counselling services). Those who had previous experience with these systems were satisfied. Yet, none of the students interviewed felt that their cognitive enhancer use, or the stress that caused their use, justified resorting to these support systems. One participant explained: “Although I do know it is there if I needed to, but I just... If you can, your aim is to go through university without seeing Student Health [counselling services].” (Participant 4). Although they all justified their cognitive enhancer use by the stress caused by university, none seemed to blame the university environment. For instance, one participant highlighted: “[…] it is stupid that I got myself in that situation, because everyone can manage it — why couldn't I?“(Participant 1). Thus, students seemed to buy into the neoliberal discourse of individual responsibility, endorsing their own responsibility for their lack of time management and use of cognitive enhancers.

Reasons behind the use of pharmacological cognitive enhancement

Identity as a student

The extent to which grades mattered to students pointed to how each participant identified as a student. Most described themselves as average in their class. However, they all thought they could achieve better. They wished to do better, possibly influencing their cognitive enhancement practices. Some students interviewed indicated feeling competitive and wanted to be in the upper end of the achievement spectrum. One participant reflected on the pressure she felt:

“It’s overwhelming […] I’m a perfectionist, so anything normally below an A minus is just not good enough for me. So… and I know that you can’t… Honours is judged against everyone else, and it’s competitive, it’s different structure to your undergraduate study.” (Participant 3)

The interviews further revealed a potential underlying driver to why students place such importance on grades. Future opportunities appeared to be a source of stress and worry. One participant mentioned her stress about needing to have better grades to find a job in a good company. Several students expressed concern about their futures, which they thought were dependent on their grades. Worries about academic grades and future life opportunities varied as a function of how each participant identified as a student.

Peer influence and social norms

Peers appeared to play an important role in students’ cognitive enhancement. Participant one described her friends as competitive and achieving well in class, which she said caused her stress and encouraged her use. Additionally, peers taking cognitive enhancers influenced students to engage in the behaviour themselves. Students also seemed to overestimate their friend’s use. Participant two affirmed that his friends used Ritalin more than he did and another participant explained how she thought people in her surroundings used cognitive enhancers:

“[It’s] not just some of my friends. A lot of people in my papers have done it. […] I didn’t really know it existed. I mean, I knew it existed but, I didn’t think it was as common. I don’t know anyone who takes it religiously for every assignment, but I’m sure there probably is someone out there.” (Participant 1)

This quote highlights two points on peer influence in cognitive enhancement practices. Firstly, the participant explained that she felt the need to use cognitive enhancers to stay on the same academic level as her friends. Thus, the importance of feeling part of the group was reflected in her individual decision to use cognitive enhancers. Secondly, the quote illustrates the fact that students assumed the habit of taking cognitive enhancers was widespread in the university community. Therefore, their pharmacological cognitive enhancement practices fit their perception of social norms, which in turn shows the power peer groups and anticipations have in the formation of social identity and the desire to fit in with a peer group.

Morality and fairness

Despite the perception that prescription medicine use was common, most students were quite scared to be open about their use. Although some were quite unsure of the moral acceptability of pharmacological cognitive enhancement, none of the students interviewed considered it as cheating. Two students reflected on the unfairness of having more time to write assignments but argued that the drug did not do the work for them. While one participant noted not wanting to rely on cognitive enhancers for studying, she also did not perceive it as cheating:

“Everything I wrote on the page was, like, I wrote it personally […], a drug doesn’t put words into your head, and then tell you what to write. It just, sort of enhances what’s already there.” (Participant 3)

Similarly, other students explained: “I genuinely don't think that Ritalin gets you over the line. It just gives you... makes you more awake, just like coffee does.” (Participant 1) and “I don’t take enough to gift super-genius, not that it would, it’s just a stimulant, it’s not a miracle pill.” (Participant 4). This highlights the fact that students want to keep a sense of autonomy and responsibility in their studies. Prescription stimulants were compared to over-the-counter substances such as caffeine, which emphasises the way students appear to minimise the effects of cognitive enhancers. This perception of minimal effects and this sense of autonomy may be the reason why using cognitive enhancers is not considered as cheating among students who use them.

Furthermore, one participant also contemplated the inequalities of access to cognitive enhancers. While some had not really thought of any ethical issues, others were quite conscious that society thought of cognitive enhancers as a form of cheating. One participant notes:

“I don’t like that people see it as unfair, so I tend to just, like, like, I could get it, a lot, for study, but I just don’t... unless I’m desperate. […] I personally don’t have ideas about the ethics, I just know that other people do, and that bugs me a little bit.” (Participant 1)

Pharmacological cognitive enhancement being seen as cheating seemed particularly upsetting to this participant. This could be because this definition conflicts with how she identifies as a student. While she would consider herself as an average but honest student; others would assume that she had cheated. These opposing ideas meant that students often felt the need to justify their cognitive enhancement practices.

Discussion

The present study focused on students’ experiences of university and how it relates to the use of prescription medicines for cognitive enhancement in New Zealand. It highlighted the ways in which students considered that their pharmacological cognitive enhancement practices were cautious, safe and did not constitute immoral behaviour. Novel aspects of their narratives included the way that some considered their use as being for academic emergencies, and that their low level of use helped manage risks.

The prescription medicines used by our participants to improve academic performance were like those reported in other studies (Franke et al., 2014; Maier et al., 2018). Melatonin, Diazepam, Buspirone and Mirtazapine were used by the participants as study aids. Hence, prescription medicine use for cognitive enhancement included not only stimulants but other medicines as well. Students did not reflect on long-term risks of combining different types of prescription medicines; this lack of awareness increases the potential for (inadvertent) higher risk combinations. Previous research has rarely focused on this type of misuse when investigating students’ experiences of cognitive enhancement. More importantly, the repurposing of stimulants by students who already receive medically justified psychopharmacological treatment has not been captured by less nuanced large-scale quantitative studies. Mental health conditions and more generally perceptions of students with and without underlying medical conditions have not been considered or compared in previous studies and requires further in-depth attention, particularly when developing support systems for students.

Students’ accounts of side effects were quite low in comparison with perceived benefits. When reflecting on addiction risks involved with prescription medicines, students strongly minimised the dangers and felt they had control over their practices. This is consistent with previous studies demonstrating that users felt addiction was a manageable risk and that it was an individual responsibility to stay in control of use (Hildt et al., 2015; Vrecko, 2015). Furthermore, participants in this study did not fear adverse health effects or legal consequences. This is in line with previous research demonstrating that many students perceive the use of prescription medicines as a soft, harmless and legal alternative to illicit drugs (Ford & Arrastia, 2008; Sanders et al., 2014). Perceptions of safety are often reinforced by the fact that the most common source of prescription medicines was friends, rather than the black market (Vrecko, 2015). Nonetheless, diving deeper in students’ perspectives, we found that the controlled setting and the clear purpose for cognitive enhancer use played a major role in students’ perceptions of safe and licit use.

Participants explained their use of prescription medicines for academic purposes by citing high levels of stress and unmanageable workload, which is consonant with previous research showing that individuals facing high academic demands were more likely to use cognitive enhancers (Sattler, 2018; Vargo & Petróczi, 2016). However, none of the participants attributed the blame to the university, but rather took individual responsibility for their cognitive enhancement practices. Their practices were shaped by an environment of heightened competition, individualism and individual responsibilisation to be the creators of their own fate and thus their future success in life. In turn, this responsibility caused stress with which they thought that they could only cope with cognitive enhancers to be able to stay in the game and remain competitive in comparison to other students. Previous research among users diverge. Some describe it as an autonomous personal choice and others frame it as an external pressure from a competitive academic environment (Forlini and Racine, 2009) but less attention has been paid to how neoliberal values and discourses shape students perceptions, experiences and practices. Moreover, peers play an important role in the onset of cognitive enhancement. Belonging to a peer group seemed to influence individual decisions to engage in cognitive enhancement. Students may want to stay at the same academic level as their peers, to be seen as an achieving student or to avoid being perceived as a failing student, linking with research exploring the role of social identity formation in learning (Bliuc et al., 2011; Sattler et al., 2014). Similarly, students estimated that pharmacological cognitive enhancement was common and widespread among their peers. This is consistent with research showing that students considerably overestimate prevalence of use among their peers and that misperceptions of peer behaviour can influence individual decision to use cognitive enhancers (Bavarian et al., 2013; Kilmer et al., 2015; McCabe, 2008; Vagwala et al., 2017). In turn, this desire to stay at the same academic level as their peers shows neoliberalisation processes permeate the New Zealand education sector. Peers compete, but also share with and take up (non)legal practices because of peer practices and to stay in the competition for future employment.

All participants identified themselves as average students; however, they all expressed the wish to achieve better grades and highlighted their individual responsibility for and the importance of grades for their future careers. Previous research has shown that students often assume that users of cognitive enhancers are either struggling students/procrastinators or highly motivated/over-achievers (London-Nadeau et al., 2019; Partridge et al., 2013). Aspects of our findings parallel risk factors identified in prior related studies (McCabe et al., 2005; Ponnet et al., 2015; Stoeber & Hotham, 2016). However, although previous research has examined students’ conceptions of a typical cognitive enhancement user, it has not taken fully into consideration how users themselves identify as a student and in which belief systems they operate, which may influence their choices to engage in cognitive enhancement practices. Moreover, our study showed that students with underlying mental health conditions in particular had easy access to repurpose prescriptions medicines for their academic needs such as being able to spend longer hours on an assignment and pull all-nighters. Participants indicated that the main driver for this practice was to remain competitive and feel successful in a highly competitive and individualised university system. The urge to use prescription medicines for academic purposes in this context is a novel finding and should be taken into account when policy and support systems are developed by universities.

Morse (1999, 2002) emphasizes that multiple qualitative methods within a single study may enhance the exploration of complex phenomena. Our study combined data from semi-structured interviews with online sources such as information from local newspapers, blog entries and discussion forums. The combination of these two qualitative approaches can be beneficial as complementary views of the phenomenon may be generated. Furthermore, it may also contribute to a more comprehensive understanding of students’ use of enhancement medicines and expand the breadth of our findings. We would recommend that future studies look more explicitly at the role identities play for the uptake of cognitive enhancers and students’ explanations as well as the role other study aids play. In addition, as our boutique sample points to, there is a need to further explore the perceptions of students with and without underlying medical conditions. As far as we know, our study was the first one to share the voices of students with underlying mental health conditions and indicate how they justify and come to terms with their repurposing of prescription medicines for their academic needs. Their discussions revealed complex entanglements of prescription medicines as cognitive enhancers. However, the use of cognitive enhancers is a sensitive topic, with some substances – stimulants – having greater potential penalties for use. Further research is needed to shed light on the underlying burden of the use of cognitive enhancers. With perceived pressure on students in neoliberalised universities increasing, the use of cognitive enhancers is on the rise. Future studies should be aware that participants can be difficult to recruit for sharing their experiences in some contexts (and especially outside the US), even when protective measures for students’ data and their anonymity are put in place.

We also recommend that universities develop specific policies that address the repurposing of medicines as cheating as our participants were less sure whether their practices are legal. By having clear guidelines for students and highlighting the health risks for students of using cognitive enhancers even as ‘emergency’ practice might deter some from using these cognitive enhancers. Methylphenidate, for example, in common with most prescription medicines has known contraindications and interactions with other medicines, some serious. A doctor would consider these risks when prescribing for a specific patient; which is not the case when a student takes medication prescribed for a friend.

Overall, this study revealed that students mention high levels of stress and workload to justify their use of cognitive enhancers, but still take individual responsibility for their decision to engage in pharmacological cognitive enhancement practices as a result of embodying neoliberal values that have permeated New Zealand society. In this paper, we attempted to add to the current academic discussion on pharmacological cognitive enhancement by investigating the perceptions and experiences of university students in New Zealand. Despite the fact that the generalizability of our findings to the student population in New Zealand is limited, our study provides a more nuanced view of the use of cognitive enhancers and particularly into the life worlds of users who legally access and repurpose stimulants for academic purposes. Internationally, the results of this study add to the body of knowledge on students’ experiences of cognitive enhancement and provide an understanding of potential underlying reasons for pharmacological cognitive enhancement for academic purposes, especially in relation to pre-existing conditions that complicate and allow students to repurpose prescription medicines for academic enhancements. Our work clearly points to the need for more in-depth work that moves beyond ‘census style studies’ that provide estimates of prevalence, but miss the complexities and nuances of use such as by people with underlying conditions.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Fanny Monnet

Christina Ergler

James Green

Auhtor Biographies

Fanny Monnet is a currently a doctoral student at the Vrije Universiteit Brussel. She graduated from the Department of Health, Ethics and Society, Care and Public Health Research Institute (CAPHRI) at Maastricht University. She is particularly interested in public health and health promotion.

Christina Ergler is a senior lecturer in Social Geography at the University of Otago, New Zealand. Her research interests are at the intersection of geography, sociology and public health and centre on how physical, social and symbolic environments shape and are shaped by the way people play, live, age fall ill and recover in particular places. She has published widely on the socio-spatial, structural and experiential dimensions of people’s health and wellbeing in transforming urban environments.

Eva Pilot is a researcher at the Department of International Health at the University of Maastricht. Her research interests cover: health geography, health monitoring, syndromic surveillance, environment and health and health system research.

Preeti Sushama is a researcher at the Department of International Health at the University of Maastricht. She is interested in environmental health.

James Green is a Chartered Health Psychologist and Senior Lecturer with the School of Allied Health, University of Limerick, and a researcher with the Health Research Institute, University of Limerick. He uses insights from psychology to explore health related behaviours and communication. His research interest centre on social pharmacy research, interprofessional education, communication between health professionals, adherence to medicines and understanding how people respond to symptoms in everyday life.

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