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.

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

2. Acknowledgments
Co-authors
Joshua Caballero, PharmD, BCPP
Jose A. Rey, PharmD, BCPP
Barron I. Gati, MS

3. Background

4. Emerging area of
neurocognitive enhancement in
cosmetic psychopharmacology
Neurology 2004;63(6):968-74.
Perspect Biol Med 2006;49(4):515-23.

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

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

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. One population neglected in these
studies is poker players

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. This study did NOT examine
the use of steroids, HGH, etc.

12. Methods

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

15. Pilot administered during WSOP

16. 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

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

18. Invitations linked with
informed consent process
and survey online

19. Survey flow was accelerated by skip logic
and piping which reduced the total survey
question burden for each participant

20. Reminder posts
were used during
survey administration
and to announce
closure on forums
Dillman 2009

21. 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

22. Results

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

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

25. 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)

26. 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%)

27. Respondents played poker online (67%),
live (18%), or an even mix of both (15%)

28. 28% of those surveyed took at
least one prescription
medication to improve poker
performance

29. 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%)

30. 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)

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

33. 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%

34. 80% of poker players took
some type of „other substance‟
to improve performance

35. 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)

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

37. 46% took a dietary supplement to
improve their poker performance

38. 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)

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

40. Respondents
(n=105) reported they
knew/heard others used
marijuana to improve
poker performance

41. 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

42. 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.”

43. 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)

44. 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

45. 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

46. Discussion

47. Unmonitored use of
CPEMs and methods of
acquisition highlight
safety concerns in this
cohort of poker players

48. Consequences of use can include
addiction, psychosis, and sudden death
(with structural cardiac abnormalities)*
*These are the most extreme safety issues seen with CPEMs

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

50. 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.

51. 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

52. 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.

53. 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.

54. Neuroethics 2009;2:75-87.
Bioethics and taking CPEMs

55. Marijuana in
poker culture
Use and
emphasis
Relative to
general
population

56. Limitations
Respondent characteristics
such as adult eligibility and
poker playing status were
not verifiable

57. 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

58. However this segment also includes
those least risk averse and most
susceptible to issues with CPEMs

59. Conclusion

60. Use of CPEMs
was relatively
proliferate with
over a quarter of
players using
prescription
medications and
most using some
agent to improve
performance

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

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

63. 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

64. @kevinclauson