While doctors probably won’t applaud Stossel’s use of vodka as a pre-performance aid, his use of a Xanax and a beta-blocker will stir little controversy. He’s someone with an unambiguous, decades-long diagnosis of a debilitating anxiety disorder, and he’s using prescribed medication under medical supervision.
Still, nearly everyone feels anxious about public speaking. The racing heartbeat, dry mouth, and sweating that commonly afflicts public speakers is so widespread as to be normal. Medicine is a tool to treat sickness, but if nearly everyone experiences some of these symptoms when approaching a lectern, can anyone who’s nervous on a stage benefit from these medications?
For two of my friends, both writers, the answer is an unequivocal yes. Each of them uses beta-blockers, and they’re open about it with friends, though they asked me to not use their names in this book.
By most measures, these friends are wildly successful. They’ve managed staffs and appeared on television. I’ve watched both speak easily and adeptly in public. In person, each is gregarious, funny, and charming. Neither seems anxious.
They’re not the type you’d expect to need a chemical assist, but both credit the drug with transforming their careers.
The first friend, a woman in her fifties, won a public speaking competition in college. Early in her career she felt no nerves when speaking to groups of colleagues. But as she grew older, three things happened.
The first was an incident more than a decade ago. Her boss asked her on short notice to speak to a group. She was unprepared, and it went badly: She began sweating, and her voice rose to a high pitch. “It was a train wreck,” she says quietly. Afterward, she began worrying it could happen again.
As her career advanced, speaking became a bigger part of her responsibilities. “There was this shift where my performance as a speaker began to have a direct effect on how people viewed me as a leader,” she said. “I was representing my company, and if I did badly, it might hurt me during my annual review.”
The third complication was that she wrote a best-selling book, and she began giving paid speeches. She remembers her first big one, to a group of doctors who’d flown her first class to their event. At dinner the night before her appearance, the organizers made clear that she was the event’s big draw. “They hadn’t just invited me to fill the hour. What I had to say was really important to them,” she says, describing the enormous pressure she felt.
That’s why, before the trip, she’d gone to her doctor and asked for beta-blockers. The doctor was agreeable: He’d previously prescribed them for violinists and for a professional pool player. She took the maximum dosage before the speech. “All of my bad things that usually happened—the sweating, the breathing—didn’t happen,” she says. “I don’t know if it’s psychosomatic or not, but the pills just tamp down all of the physical sensations.”
Scientifically speaking, that’s exactly what beta-blockers are supposed to do. Discovered by Scottish pharmacologist James Black in 1962 as a treatment for heart disease, the chemicals inhibit the body’s response to adrenaline, lowering blood pressure and reducing the risk of heart attack. By the 1970s, doctors had begun using them to reduce performance anxiety, particularly in musicians. However, that remains a secondary use; beta-blockers remain primarily used to improve people’s circulatory system. For his work, Black won the Nobel Prize, and upon his death in 2010, the New York Times credited him with “extending the lives of millions of people.”
While propranolol won’t help my friend live longer, she says it has changed her life. “Now when I speak, I don’t feel nervous at all, and speaking has become a really fun and lucrative part of my career,” she says.
The other writer, in his forties, tells a similar story. He’d done some public speaking and TV appearances in his twenties and thirties, and he never had a problem. He didn’t dread public speaking. In fact, he enjoyed it. But at one point, he had a panic attack while at a podium. So before he went on a book tour, he asked his doctor for a prescription for a beta-blocker. He takes a tiny dose, half a tablet. “It just subtracts the possibility that your body is going to rebel against you,” he says.
These two friends use the medication in slightly different ways. The female writer describes getting nervous before most speeches, and she uses the medication to lessen this predictable jitteriness. In contrast, the male writer sees the pill as a safety net. He says he could probably perform without nerves nine out of ten times without the pill; he’s taking the medication as a precaution against the one-in-ten chance that something might trigger a panic attack.
“The medicine helps immeasurably, and I’ve become an evangelist for it,” he says. “It’s improved my career by making me a more confident public speaker.”
2.
When we think about “performance-enhancing drugs,” our minds immediately go to famous athletes using banned substances to build muscles and heal faster. Lance Armstrong, Mark McGwire, Marion Jones—the list of athletes whose legacies are tainted by alleged (or, in some cases, admitted) drug use seems to grow longer every year.
But athletes aren’t the only ones ingesting substances, banned or otherwise, to do their work better.
Much of this chemical enhancement is a legal and prosaic part of the daily routine. Consider caffeine, that ubiquitous energizer. Mark McLaughlin, the surgeon introduced on the first page of this book, uses it prodigiously to maintain energy during surgeries; the Yelp sales team, featured in Chapter Three, chugs Red Bull midafternoon to fuel their late-afternoon cold calls. Studies have consistently shown that caffeine increases cognitive function, alertness, and energy levels; caffeine is a potent enough performance enhancer that an athlete who has too much of it in his blood can be penalized under NCAA rules. My employer, like many, provides workers with all the coffee we care to drink, and many people have a hard time getting anything done if they don’t start their day with several cups.
Similarly, many professionals signal the end of the workday with a cocktail or two. It’s counterintuitive to identify alcohol as a performance enhancer, and indeed, for the vast majority of activities, even moderate doses will diminish performance. But despite this significant potential for harm, in some situations, in carefully moderated doses, alcohol’s disinhibiting qualities can be useful as a social lubricant. This is why so much business networking takes place over cocktails. My local newspaper, the Boston Globe, runs a weekly “Dinner with Cupid” column that chronicles a couple’s blind date, and it’s striking how many of these daters enjoy a solo cocktail while getting ready. There’s a reason it’s called “liquid courage.”
Throughout history, that chemical courage has extended to the battlefield, as well. In Shooting Up: A Short History of Drugs and War, the Polish historian Lukasz Kamienski chronicles how a wide variety of drugs—including alcohol, opium, cocaine, and LSD—have been not only embraced by soldiers, but systematically supplied to them by officers in armies dating back to the time of Homer. Many of the drugs are stimulants, which are used, Kamienski writes, to “build stamina, provide energy, eliminate the need to sleep, combat fatigue, and reinforce the fighting spirit. They also enhance courage, improve determination, and fuel aggression.” Between battles, soldiers use downers such as alcohol to deal with the stress and trauma of combat. Kamienski argues that the use of mind-altering substances makes sense given the existential dilemma at the heart of combat: Though humans have an inborn instinct for self-preservation, soldiers are routinely forced to march toward situations that increase their risk of death. Given that dynamic, Kamienski writes, “Wouldn’t it actually be astonishing if the military had not reached for pharmacological support?”
For white-collar workers, for decades the king of high-powered enhancers has been amphetamines. The first synthetic amphetamine was patented by a chemist named Gordon Alles, and it went on the market in 1932 as an over-the-counter inhaler called Benzedrine; a few years later, the drug became ava
ilable in pill form. (Alles was an unusually prolific chemist: A few years after developing amphetamines, he created the related chemical compound MDMA, better known as ecstasy.) Amphetamines work by increasing levels of the neurotransmitters dopamine and norepinephrine; this serves to inhibit drowsiness, improve concentration, reduce hyperactivity, and reduce symptoms of depression. In reading the history of amphetamines, originally marketed to ease sinus congestion, it’s striking just how quickly people began identifying other beneficial uses. By 1946, amphetamines were used to treat thirty-nine distinct clinical problems, including epilepsy, Parkinson’s disease, schizophrenia, alcoholism, narcosis, opiate addition, bed-wetting, migraines, depression, irritable colon, and radiation sickness.
As soon as the little pills hit pharmacy shelves, amphetamines emerged as the first widely used “cognitive enhancer,” taken by otherwise healthy people to help them think more sharply for longer periods of time. Jazz musicians took it to enable them to play longer sets. Beat Generation writers downed the heart-shaped green and orange pills; Jack Kerouac wrote On the Road during a three-week-long amphetamine binge. Doctors recognized the downsides of amphetamine use, which include psychosis, addiction, and death. Many people kept taking them anyway. “Despite a rising increase in adverse publicity and growing reports of potential addiction, Americans continued their love affair with amphetamines,” writes Elaine Moore in her history of the drug. “Students, professors, artists, musicians, medical personnel, truck drivers, athletes, writers, and actors became some of amphetamines’ biggest fans.” Moore, a medical technologist and health writer, recalls that the drug was so commonplace that when she was in college in the late 1960s, she used it herself to study for exams. In response to the dangers, amphetamines became more tightly regulated during the 1970s, which may have inadvertently led to the increasing popularity of cocaine.
By then, a new set of drugs used to treat a new kind of condition was taking their place. Since the 1930s, researchers had observed that stimulants have a beneficial effect on “behavioral-disordered” schoolchildren, and by the early 1960s pharmacologists had created the amphetamine variant methylphenidate, better known by its trade name: Ritalin. The underlying condition the drug was used to treat is not new: The first written description by a doctor of a child suffering from poor attention, focus, and impulse control dates to the sixteenth century. But during the 1960s, psychologists began paying more attention to the problem of “hyperactive” children, and using medication to treat them. By the 1990s, the conventional wisdom that children simply “outgrew” the condition in adolescence waned, and the number of people (including adults) taking stimulants to treat it increased. By 2014, according to the Centers for Disease Control, just over 10 percent of American children ages five to seventeen had been diagnosed with ADHD. The good news for these children is that drugs like Ritalin and Adderall are generally effective in treating the condition.
As with earlier generations of amphetamines, however, usage expanded beyond people prescribed to use them to treat a malady. The prevalence of unprescribed Ritalin and Adderall use remains the subject of much debate. Some studies of college students have suggested that up to one third are cadging the drugs from roommates or friends, and a 2016 study found that even though prescriptions of Adderall had remained flat in recent years, the number of people ages eighteen to twenty-five who reported taking it without a prescription (meaning they obtained it improperly from someone else) had increased 67 percent. Others suggest the problem of Adderall and Ritalin abuse is overhyped by the media. One 2015 study published in the Journal of Attention Disorders found that less than 5 percent of Americans aged eighteen to forty-nine had utilized drugs like Ritalin or Adderall for nonmedical use. Studies examining rates of usage in Europe similarly show low-single-digit numbers.
No matter how high or low the numbers, the alleged epidemic of unprescribed stimulant use has prompted concerns not only about risks and side effects, but about basic fairness. Writing in the New Yorker, Margaret Talbot describes becoming interested in cognitive enhancers after learning that a young colleague competing against her at work was using a prescription stimulant to pull all-nighters to work on stories. In her article, Talbot hits the points that are common in the debate over cognitive-enhancing drugs. These stories cite an “arms-race aspect” to the pharma-fueled competitive landscape. She raises the specter of parents drugging young children to perform better in school. Talbot writes: “This may be leading to a kind of society I’m not sure I want to live in: a society where we’re even more overworked and driven by technology than we already are, and where we have to take drugs to keep up; a society where we give children academic steroids along with their vitamins.”
That unpleasant vision notwithstanding, the more one reads about performance-enhancing drugs, the more one can’t help but wonder: How much difference would they make in how I work and perform? Writing on the Web site Slate, the journalist Joshua Foer describes how, intrigued by tales of Adderall’s properties as a performance enhancer, he consulted with a half dozen psychiatrists to assess the risks of taking the drug himself. The consensus: Used occasionally at low dose with no contraindicating conditions, it’s “probably harmless.”
So he tried it for a week. “The results were miraculous,” Foer writes. He achieved his best ever score on an online anagrams game. He read 175 pages of a dense text. “It was like I’d been bitten by a radioactive spider,” he writes, describing his unflagging productivity. “When I tried writing on the drug, it was like I had a choir of angels sitting on my shoulders. I became almost mechanical in my ability to pump out sentences. The part of my brain that makes me curious about whether I have new e-mails in my inbox apparently shut down. Normally, I can only stare at my computer screen for about 20 minutes at a time. On Adderall, I was able to work in hourlong chunks. I didn’t feel like I was becoming smarter or even like I was thinking more clearly. I just felt more directed, less distracted by rogue thoughts, less day-dreamy. I felt like I was clearing away underbrush that had been obscuring my true capabilities.”
However, Foer also describes feeling less creative while on Adderall—as if he’s thinking with blinders on. He recounts all the potential downsides of taking the drug, a list that includes insomnia, the risk of arrest for possessing it without a prescription, and becoming physically or psychologically dependent on it. He admits to taking a pill before writing the Slate article. While he stops short of guaranteeing he won’t take it again, he suggests he’s disinclined to take it in the future.
3.
In the early 2000s, Dave Asprey was juggling a full-time job at a start-up with a nearly full-time course load as an MBA student at the Wharton School. He was struggling. “My brain wasn’t working right,” he says. He ended up seeing a psychiatrist and a psychologist; the former did a scan of his brain. The doctors wanted to prescribe Adderall, but after doing some research, Asprey suggested the doctor also write him a second script for modafinil, an antinarcolepsy drug that was approved by the FDA in 1998.
Modafinil is sold by the pharmaceutical company Cephalon under the brand name Provigil; originally intended as a treatment for narcolepsy, it was subsequently approved for treating sleep apnea and sleep disorders caused by shift work. It’s the drug that Mark McLaughlin, the neurosurgeon in the introduction, said some of his colleagues take to stay alert during late-night surgery. Until my conversation with McLaughlin, I’d never even heard of the drug. I’m not alone: the psychologist Dave Asprey consulted had to Google it. But the psychiatrist wrote him a prescription and told him to try both drugs and report back.
Asprey hated Adderall. “It’s a really harsh drug. It’s not good for you,” he says. Modafinil, on the other hand, worked wonderfully. “Modafinil makes it a lot easier to do whatever you need to do,” Asprey says. The drug helped him stay focused and energetic. Asprey completed his MBA program; his start-up became successful and was acquired, with Asprey’s personal stake worth
$6 million. “Modafinil saved my career and got me through school,” he says now. “I took it just about every day for eight years.”
Modafinil is not an amphetamine. The drug was invented in France in the 1970s, and it’s not precisely clear how it works, but it’s proven to affect chemicals in the brain to increase alertness and ward off sleepiness. Like amphetamines, modafinil increases dopamine levels, but this effect is smaller, leading researchers to conclude that modafinil creates a lower risk for abuse. (It also doesn’t cause the same level of jitteriness.) The drug has been tested repeatedly in military settings—both in pilots and ground troops—in studies in which the soldiers are deprived of sleep for periods extending to sixty-four hours, given different types of drugs, and subjected to cognitive tests. The drug’s inventor, a French sleep researcher named Michel Jouvet, once boasted that modafinil “could keep an army on its feet and fighting for three days and nights with no major side-effects.” By 2008, the tech writer Michael Arrington had identified it as a popular drug among Silicon Valley entrepreneurs. In 2013, New York magazine labeled it “Wall Street’s new drug of choice.” ABC News called it “Viagra for the Brain.” On the Internet, testimonials piled up at biohacking Web sites.
Psyched Up Page 15