Use of cognitive and performance
  enhancing medications in an
     international sample of
  self-identified poker player...
Acknowledgments

      Co-authors
Joshua Caballero, PharmD, BCPP
Jose A. Rey, PharmD, BCPP

Barron I. Gati, MS
Background
Emerging area of
neurocognitive enhancement in
cosmetic psychopharmacology




         Neurology 2004;63(6):968-74.
     ...
Camb Q Healthc Ethics 2007;16(2):129-37.
Increasing interest in drugs for enhancing
   brain function parallels evolution ...
Poll in Nature revealed one in five
(self-identified) scientists reported
  having used neuroenhancers
            Nature ...
Neuroenhancer use
by students has been
  studied for exam
 preparation and in
classroom situations




Nat Rev Neurosci 20...
The use of performance enhancing agents
has also been studied in professions
ranging from pilots to classical
musicians…an...
One population neglected in these
    studies is poker players
Objective

To characterize use of and perceptions
about cognitive (e.g., methylphenidate,
modafinil) and performance enhan...
This study did NOT examine
the use of steroids, HGH, etc.
Methods
Survey development
A survey tool consisting of 38 questions
was created in order to:
1) assess the use of cognitive and
  ...
Pilot administered during WSOP
Pilot yielded suggestions by poker players to
 add products they use as CPEMs but are
 not widely seen in other studies in...
After pilot
  and revision,
   adult study
participants were
  recruited via
   invitations
   posted on
 Internet poker
 ...
Invitations linked with
informed consent process
    and survey online
Survey flow was accelerated by skip logic
and piping which reduced the total survey
  question burden for each participant
Reminder posts
        were used during
      survey administration
        and to announce
       closure on forums




D...
Statistical analysis

 Descriptive statistics (e.g., frequency
counts, standard deviation) were used
        to characteri...
Results
Survey response

Of the submissions received,
   198 poker players fully
completed the online survey
Data are reported on ...
Most poker players were from
  USA (59%), EU (24%),
     and Canada (11%)

96% of responders were male
 with an average ag...
Which best describes your poker playing STATUS?

o Professional (i.e., poker is your main source of income)
o Semi-profess...
Respondents self-identified
 poker playing status included
     amateur (37%), semi-
professional (35%), professional
  (2...
Respondents played poker online (67%),
live (18%), or an even mix of both (15%)
28% of those surveyed took at
   least one prescription
 medication to improve poker
        performance
Use of CPEMs to improve
    performance in poker


    Primary purpose was to
 focus/concentrate (73%), calm
nerves (11%),...
Which medications have you taken to improve your
performance in poker? [Please select all that apply; hold
down the Ctrl b...
Prescription Medication   Use (%)
        (N=55)
    Amphetamine/            62
  Dextroamphetamine
   Benzodiazepines    ...
Methods used by poker players to
 obtain prescription medications

              Via a physician 38%

            Given to...
80% of poker players took
some type of „other substance‟
   to improve performance
What other substance(s) have you taken to improve your
performance in poker? [Please select all that apply; hold
down the ...
Other substance   Use (%)
    (N=158)
    Caffeine        71
 Energy drinks      51
   Marijuana        34
    Alcohol    ...
46% took a dietary supplement to
improve their poker performance
Which dietary supplements have you taken to improve your
performance in poker? [Please select all that apply; hold
down th...
Dietary supplement   Use (%)
      (N=92)
    Vitamin B12        30
     Guarana           23
   Ginkgo biloba       8
   ...
Respondents
(n=105) reported they
knew/heard others used
marijuana to improve
poker performance
Survey comments: marijuana

Many poker players (n=96)
chose to write comments in
the optional text box at the
end of the s...
Marijuana comment examples
“Marijuana is by far the most safe and effective
 substance used to aid in poker performance,
 ...
Most common influence for WHY players
started taking medications to improve
poker performance was…




…previous use to im...
Predictors for use of CPEMs*

Negative                    Positive
Live poker                 Residence in
(p=0.045)      ...
Alcohol consumption
for any purpose in this
population was 86%

Players reported
drinking an average
of 9 days/month with
...
Discussion
Unmonitored use of
CPEMs and methods of
 acquisition highlight
safety concerns in this
cohort of poker players
Consequences of use can include
addiction, psychosis, and sudden death
(with structural cardiac abnormalities)*




      ...
Reproduction
      of an original
      (counterfeit)
      drug is more
      likely to be
      bought online




Europe...
Recent American Academy of
Neurology (AAN) Ethics, Law,
 and Humanities Committee
    guidance now states
   off-label pre...
Impact of AAN guidance

  Could help the majority of
 poker players who are not
currently getting their CPEMs
     from a ...
British Medical Association

   “…universal access to
  enhancing interventions
would bring up the base-line
  level of co...
CPEM users in this study
   typically had tried them for
reasons other than poker prior to
  using them to improve poker
 ...
Neuroethics 2009;2:75-87.
Bioethics and taking CPEMs
Marijuana in
poker culture

  Use and
 emphasis

 Relative to
  general
 population
Limitations




Respondent characteristics
such as adult eligibility and
poker playing status were
not verifiable
Results of this study may not reflect
     the use of CPEMs by the 50
million US and 100 million worldwide
        casual ...
However this segment also includes
  those least risk averse and most
 susceptible to issues with CPEMs
Conclusion
Use of CPEMs
  was relatively
 proliferate with
over a quarter of
  players using
   prescription
medications and
most usi...
Future considerations

 Additional research and
   possibly educational
  initiatives are merited
based on the frequency o...
Initial results presented via poster at the




   College of Psychiatric & Neurologic
    Pharmacists 2010 Annual Meeting...
Images
•   http://www.army.mil/-images/2007/04/22/3578/army.mil-2007-04-20-164929.jpg



•   http://www.nosumo.com/pics/mu...
@kevinclauson
Use of cognitive and performance enhancing medications in poker players
Use of cognitive and performance enhancing medications in poker players
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Summary results of survey research of CPEM use in poker players; preliminary results presented at the College of Psychiatric and Neurologic Pharmacists 2010 Annual Meeting.

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Use of cognitive and performance enhancing medications in poker players

  1. 1. Use of cognitive and performance enhancing medications in an international sample of self-identified poker players Kevin A. Clauson, Pharm.D.
  2. 2. Acknowledgments Co-authors Joshua Caballero, PharmD, BCPP Jose A. Rey, PharmD, BCPP Barron I. Gati, MS
  3. 3. Background
  4. 4. Emerging area of neurocognitive enhancement in cosmetic psychopharmacology Neurology 2004;63(6):968-74. Perspect Biol Med 2006;49(4):515-23.
  5. 5. Camb Q Healthc Ethics 2007;16(2):129-37. Increasing interest in drugs for enhancing brain function parallels evolution of plastic surgery after World War I
  6. 6. Poll in Nature revealed one in five (self-identified) scientists reported having used neuroenhancers Nature 2008;453(7195):674-5.
  7. 7. Neuroenhancer use by students has been studied for exam preparation and in classroom situations Nat Rev Neurosci 2004;5(5):421-5.
  8. 8. The use of performance enhancing agents has also been studied in professions ranging from pilots to classical musicians…and even in nervous public speakers Neurology 2002;59(1):123-5. Psychopharmacologia 2000;150(3):272-82.
  9. 9. One population neglected in these studies is poker players
  10. 10. Objective To characterize use of and perceptions about cognitive (e.g., methylphenidate, modafinil) and performance enhancing (e.g., propranolol) medications, dietary supplements (e.g., guarana), and other substances to improve performance in poker
  11. 11. This study did NOT examine the use of steroids, HGH, etc.
  12. 12. Methods
  13. 13. Survey development A survey tool consisting of 38 questions was created in order to: 1) assess the use of cognitive and performance enhancing medications (CPEMs), dietary supplements, and other substances by respondents to improve their performance at poker 2) explore methods of acquisition and motivations for poker players to use or avoid using CPEMs 3) characterize perceptions of poker players regarding CPEMs
  14. 14. Pilot administered during WSOP
  15. 15. Pilot yielded suggestions by poker players to add products they use as CPEMs but are not widely seen in other studies including alcohol, hydrocodone, and marijuana
  16. 16. After pilot and revision, adult study participants were recruited via invitations posted on Internet poker forums
  17. 17. Invitations linked with informed consent process and survey online
  18. 18. Survey flow was accelerated by skip logic and piping which reduced the total survey question burden for each participant
  19. 19. Reminder posts were used during survey administration and to announce closure on forums Dillman 2009
  20. 20. Statistical analysis Descriptive statistics (e.g., frequency counts, standard deviation) were used to characterize results Logistic regression analyses and Pearson‟s correlation coefficient were used to determine CPEM predictors SPSS version 16
  21. 21. Results
  22. 22. Survey response Of the submissions received, 198 poker players fully completed the online survey Data are reported on an item- level basis and rounded
  23. 23. Most poker players were from USA (59%), EU (24%), and Canada (11%) 96% of responders were male with an average age of 26
  24. 24. Which best describes your poker playing STATUS? o Professional (i.e., poker is your main source of income) o Semi-professional (i.e., poker represents a substantial source of income) o Amateur (i.e., poker is a hobby, but you study and prepare to compete) o Recreational (i.e., poker is a leisure activity that represents a way to have a good time)
  25. 25. Respondents self-identified poker playing status included amateur (37%), semi- professional (35%), professional (25%), and recreational (3%) No-limit hold’ em was the most commonly played form (68%)
  26. 26. Respondents played poker online (67%), live (18%), or an even mix of both (15%)
  27. 27. 28% of those surveyed took at least one prescription medication to improve poker performance
  28. 28. Use of CPEMs to improve performance in poker Primary purpose was to focus/concentrate (73%), calm nerves (11%), stay awake (11%), improve memory (2%), or other (3%)
  29. 29. Which medications have you taken to improve your performance in poker? [Please select all that apply; hold down the Ctrl button and click to choose multiple answers] None Amphetamine/Dextroamphetamine (Adderal, Dexedrine, Dextrostat) Armodafanil (Nuvigil) Atomoxetine (Straterra) Benzodiazepines (Valium, Xanax, Ativan, Klonopin, Restoril, etc.) Other (if applicable)
  30. 30. Prescription Medication Use (%) (N=55) Amphetamine/ 62 Dextroamphetamine Benzodiazepines 20 Hydrocodone 18 Methylphenidate 18 Lisdexamfetamine 7 Beta blockers 4 Modafinil 4
  31. 31. Methods used by poker players to obtain prescription medications Via a physician 38% Given to by players 26% Purchased from players 26% Purchased online 10%
  32. 32. 80% of poker players took some type of „other substance‟ to improve performance
  33. 33. What other substance(s) have you taken to improve your performance in poker? [Please select all that apply; hold down the Ctrl button and click to choose multiple answers] None Alcohol (beer, wine, liquor) Caffeine Cocaine Crystal Meth Other (if applicable)
  34. 34. Other substance Use (%) (N=158) Caffeine 71 Energy drinks 51 Marijuana 34 Alcohol 30 Nicotine 29 Sports drinks 25 Cocaine 8
  35. 35. 46% took a dietary supplement to improve their poker performance
  36. 36. Which dietary supplements have you taken to improve your performance in poker? [Please select all that apply; hold down the Ctrl button and click to choose multiple answers] None Bitter orange Ephedra Ginkgo biloba Guarana Other (if applicable)
  37. 37. Dietary supplement Use (%) (N=92) Vitamin B12 30 Guarana 23 Ginkgo biloba 8 Ephedra 7 Panax ginseng 7 Fish oil 3 Melatonin 3
  38. 38. Respondents (n=105) reported they knew/heard others used marijuana to improve poker performance
  39. 39. Survey comments: marijuana Many poker players (n=96) chose to write comments in the optional text box at the end of the survey A quarter of all comments written involved marijuana
  40. 40. Marijuana comment examples “Marijuana is by far the most safe and effective substance used to aid in poker performance, though amphetamines such as adderal are among the top as well insofar as it is among the most widely used and most effective.” “I am a tilt monkey, then I smoke weed. I then stop being a tilt monkey.” “I know many people who claim they play better on Marijuana but I don't believe it.”
  41. 41. Most common influence for WHY players started taking medications to improve poker performance was… …previous use to improve performance in a non-poker related area (e.g., studying for exam, staying awake for a long drive)
  42. 42. Predictors for use of CPEMs* Negative Positive Live poker Residence in (p=0.045) USA (p=0.003) Previous CPEM use r=0.548 (p<0.001) *Values statistically significant at p<0.05
  43. 43. Alcohol consumption for any purpose in this population was 86% Players reported drinking an average of 9 days/month with 5 drinks consumed on drinking days
  44. 44. Discussion
  45. 45. Unmonitored use of CPEMs and methods of acquisition highlight safety concerns in this cohort of poker players
  46. 46. Consequences of use can include addiction, psychosis, and sudden death (with structural cardiac abnormalities)* *These are the most extreme safety issues seen with CPEMs
  47. 47. Reproduction of an original (counterfeit) drug is more likely to be bought online European Alliance for Access to Safe Medicines
  48. 48. Recent American Academy of Neurology (AAN) Ethics, Law, and Humanities Committee guidance now states off-label prescribing for neuroenhancement is legally and ethically permissible Neurology 2009;73(17):1406-12.
  49. 49. Impact of AAN guidance Could help the majority of poker players who are not currently getting their CPEMs from a physician or benefitting from monitoring by a pharmacist
  50. 50. British Medical Association “…universal access to enhancing interventions would bring up the base-line level of cognitive ability, which is generally seen to be a good thing” Ethical aspects of cognitive enhancement. BMA 2007.
  51. 51. CPEM users in this study typically had tried them for reasons other than poker prior to using them to improve poker performance Up to 16% of college students have tried psychostimulant study aids J Am Coll Health 2006;54(5):261-8.
  52. 52. Neuroethics 2009;2:75-87. Bioethics and taking CPEMs
  53. 53. Marijuana in poker culture Use and emphasis Relative to general population
  54. 54. Limitations Respondent characteristics such as adult eligibility and poker playing status were not verifiable
  55. 55. Results of this study may not reflect the use of CPEMs by the 50 million US and 100 million worldwide casual poker players . Players who participated in this survey may be a more serious segment of the poker playing population
  56. 56. However this segment also includes those least risk averse and most susceptible to issues with CPEMs
  57. 57. Conclusion
  58. 58. Use of CPEMs was relatively proliferate with over a quarter of players using prescription medications and most using some agent to improve performance
  59. 59. Future considerations Additional research and possibly educational initiatives are merited based on the frequency of CPEM use in this subset of poker players
  60. 60. Initial results presented via poster at the College of Psychiatric & Neurologic Pharmacists 2010 Annual Meeting http://cpnp.org/ed/meeting/2010
  61. 61. Images • http://www.army.mil/-images/2007/04/22/3578/army.mil-2007-04-20-164929.jpg • http://www.nosumo.com/pics/muscleMan.jpg • Opinio survey tool [screenshots, various] • http://upload.wikimedia.org/wikipedia/commons/0/0a/PokerTableOpenSource.jpg • http://www.smbc-comics.com/index.php?db=comics&id=1853 • http://www.frontiersin.org/conferences/test.php?src=images/conference_images/cpnp.jpg Unreferenced images are licensed stock photography
  62. 62. @kevinclauson

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