Use of cognitive and performance enhancing medications in poker players

Use of cognitive and performance enhancing medications in an international sample of self-identified poker players Kevin A. Clauson, Pharm.D.

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. Perspect Biol Med 2006;49(4):515-23.

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

Poll in Nature revealed one in five (self-identified) scientists reported having used neuroenhancers Nature 2008;453(7195):674-5.

Neuroenhancer use by students has been studied for exam preparation and in classroom situations Nat Rev Neurosci 2004;5(5):421-5.

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.

One population neglected in these studies is poker players

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

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 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

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 including alcohol, hydrocodone, and marijuana

After pilot and revision, adult study participants were recruited via invitations posted on Internet poker forums

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 Dillman 2009

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

Results

Survey response Of the submissions received, 198 poker players fully completed the online survey Data are reported on an item- level basis and rounded

Most poker players were from USA (59%), EU (24%), and Canada (11%) 96% of responders were male with an average age of 26

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)

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%)

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%), stay awake (11%), improve memory (2%), or other (3%)

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)

Prescription Medication Use (%) (N=55) Amphetamine/ 62 Dextroamphetamine Benzodiazepines 20 Hydrocodone 18 Methylphenidate 18 Lisdexamfetamine 7 Beta blockers 4 Modafinil 4

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%

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 Ctrl button and click to choose multiple answers] None Alcohol (beer, wine, liquor) Caffeine Cocaine Crystal Meth Other (if applicable)

Other substance Use (%) (N=158) Caffeine 71 Energy drinks 51 Marijuana 34 Alcohol 30 Nicotine 29 Sports drinks 25 Cocaine 8

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 the Ctrl button and click to choose multiple answers] None Bitter orange Ephedra Ginkgo biloba Guarana Other (if applicable)

Dietary supplement Use (%) (N=92) Vitamin B12 30 Guarana 23 Ginkgo biloba 8 Ephedra 7 Panax ginseng 7 Fish oil 3 Melatonin 3

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 survey A quarter of all comments written involved marijuana

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.”

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)

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

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

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)* *These are the most extreme safety issues seen with CPEMs

Reproduction of an original (counterfeit) drug is more likely to be bought online European Alliance for Access to Safe Medicines

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.

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

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.

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.

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 poker players . Players who participated in this survey may be a more serious segment of the poker playing population

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 using some agent to improve performance

Future considerations Additional research and possibly educational initiatives are merited based on the frequency of CPEM use in this subset of poker players

Initial results presented via poster at the College of Psychiatric & Neurologic Pharmacists 2010 Annual Meeting http://cpnp.org/ed/meeting/2010

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

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Use of cognitive and performance enhancing medications in poker players

by Kevin Clauson on May 03, 2010

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Use of cognitive and performance enhancing medications in poker players Presentation Transcript