Virtual games, real drugs

The stakes are high in the final rounds of major Counter-Strike tournaments. The teams face hours of competition, they have to think strategically and show skill. They still have the battles of the last rounds in their bones, not to mention the hours of daily training to prepare. If even one player loses concentration, the glory of victory may be gone - and with it prize money and lucrative sponsorship and advertising contracts. It's no wonder that it's tempting to give your brain a boost. Ritalin gives your gray cells the decisive kick, you hear behind closed doors. Or: Take Adderall instead, it makes you fit.

The games are virtual, but the drugs are real. The sporting competition in computer games like Counter-Strike or League of Legends on PCs and game consoles has become extremely professionalized in recent years. The prize money is skyrocketing and in some cases even runs into the millions. Thousands of spectators attend the tournaments, and millions of people around the world are captivated by the action on their screens. And just like traditional sports, the e-sports scene now has a doping problem.

Doping players are less concerned with forcing the body to perform at its best than with brain doping or neuroenhancement: the brain is to be brought up to speed, concentration is to be promoted, fatigue is to be suppressed. At present, no one knows exactly how widespread this practice is. Studies and reliable figures are scarce. And as far as doping tests in competitions are concerned, e-sports are lagging behind traditional sports. In many countries, such as Germany, e-sports is not even recognized as a sport. How the issue of drugs is handled depends on the individual leagues in which the competitions take place. At least one top league, the Electronic Sports League, has strictly banned drugs, alcohol, or other performance enhancers. Violation can result in expulsion from the league. The fact that drugs are actually used is more likely to be learned under the table. Only occasionally do individual players make public statements about this. In 2015, for example, an interview with Counter-Strike player Kory Friesen caused a great stir in the press, when he admitted openly and with a smile that he and his team had been on Adderall during a tournament.

E-sports hardly have anything in common with leisurely gaming on the PC at home. In infractions of a second, players have to translate information on the screen into targeted and coordinated muscle reactions. Nuances of muscular movement can distinguish the winner from the loser. In addition, spatial orientation, understanding of the game, tactical action, and forward- thinking are required. The training is not without its challenges either: to prepare, professionals have to train for many hours a day, fight fatigue and memorize dozens of moves of the next opponents, among other things.

Drugs of choice are well known

Therefore, the list of drugs that players reportedly resort to is not surprising: Methylphenidate, better known under the brand name Ritalin, which is used to treat ADHD; amphetamines or Adderall as a mixture of different amphetamine salts, which also helps people with attention deficit disorder; modafinil, a stimulant that is actually used for sleep disorders such as narcolepsy; and in some cases also antidementia drugs, which players hope will increase their memory, for example, to remember strategies and moves of the opponent in preparation. All these substances were developed to treat sick people. Does the beneficial effect transfer at all to healthy people? "Psychostimulants like amphetamines, modafinil, or methylphenidate don't make you smarter or more creative," says Isabella Heuser, director of the Clinic and University Outpatient Clinic for Psychiatry and Psychotherapy at Berlin's Charité hospital. "In this respect, the term 'smart drugs' used by the Americans is also misleading. But they can increase vigilance, alertness, and attention."

The substances achieve their effect by interfering with the brain's messenger systems. They ensure that neurotransmitters such as dopamine and norepinephrine are increasingly available in the brain. In this way, they trigger a chemical reaction, very similar to a startle reaction that suddenly makes you wide awake.

The increased alertness makes reaction times shorter. "From that point of view, amphetamine would be the ideal drug for e-sports," says Heuser. It can also delay signs of fatigue and keep concentration levels high. And by being able to hold attention longer, memory performance also improves, Heuser says. But of course, that only works for a certain amount of time: "At some point, you collapse, exhausted."

Hardly any studies on healthy people ...

The situation is different with antidementia drugs, which usually aim to increase the availability of the neurotransmitter acetylcholine. Some e-athletes hope these drugs, which were developed for people with mild dementia, will also improve memory. But studies - which, however, have not been conducted specifically on computer game professionals - give little reason for this: in healthy people, these substances have no clear benefit.

Anti-dementia drugs are not alone in this. Very often, scientists investigating brain doping in healthy people find only moderate efficacy. This is shown, for example, in a 2017 review in which researchers led by Barbara Sahakian of the University of Cambridge reviewed the literature.

Ritalin, for example, has long been known to help people whose baseline performance is rather poor. Those who perform well before taking the medication may not only fail to improve it but even end up worsening it. In addition, the drugs interfere with different neurotransmitter systems at the same time. Anyone who wants to supply one system with the optimal dose may have to overdose another, Sahakian and colleagues warn. The complex mode of action of the substances in the brain is not easy to understand.

A large part of the effect is also due to placebo effects. Those who take these drugs associate positive expectations with the active ingredients. "However, a similar effect can also be achieved with caffeine," says Klaus Lieb, director of the Department of Psychiatry and Psychotherapy at the University Medical Center Mainz. "Unlike the drugs mentioned, it's legal and would probably be allowed in competition even if e-sports were recognized as a sport and there were a list of banned substances."

... and even less on healthy e-sports players.

All of this knowledge so far comes only in general terms from studies on healthy people. "Whether the performance itself is improved by the drugs is not easy to answer," says Klaus Lieb. At least the drop in performance due to overtiredness could be delayed by taking some drugs. But here, too, there is a lack of studies specifically for the case of e-sports. In a 2017 study, Lieb and colleagues were able to prove that chess players performed better by taking methylphenidate and modafinil - at least when they were not under time pressure. Of course, he said, that's not entirely comparable, since chess isn't about quick reactions. "But it's possible that in e-sports you also benefit from the drugs."

The benefits, which are at least not entirely clear, are offset by clear risks. "The most important undesirable effect with all the psychostimulants - not with sick people, mind you, but with healthy people - is the danger of dependence," says Isabella Heuser. But the danger should not be overestimated. Not everyone who drinks alcohol becomes dependent. In addition, the substances can increase blood pressure. And modafinil, for example, can lead to cardiac arrhythmias. "But overall, they are well tolerated," Heuser said.

Dependence and side effects are the biggest problems

Klaus Lieb takes a much more critical view of the use of substances by healthy e-athletes: "There is definitely a potential for dependence." He says it is growing from modafinil to methylphenidate to amphetamines. It is particularly easy to become dependent on amphetamines if you snort them or even inject yourself. "Because in this case, the substances rise quickly in the brain and provide a euphoric effect that promotes the development of dependence." If, on the other hand, one takes methylphenidate via sustained-release tablets, one can benefit from the wakefulness effects, but the euphoric effect remains absent. "There, the risk of addiction is not quite as great," Lieb says. But because e-sports are comparable to fun sports, he also sees the danger of people continuing to take the substances even after they've finished playing at parties, which further increases the risk of addiction.

The list of side effects also sounds more dramatic to Klaus Lieb: the active substances could trigger insomnia as well as states of agitation and restlessness, even aggression. One thing he sees as particularly problematic: "They can trigger mental illnesses such as depression or psychosis if you have a predisposition to them." With methylphenidate, he said, there have also been deaths from cardiac arrhythmias resulting from overdoses. "Modafinil is available by prescription, and methylphenidate and amphetamine preparations are even narcotics - all for a reason."

For these very reasons, e-athletes who want to dope their brains have to go illegal routes to get the substances - via the black market or the Internet. And just like with all other drugs, the problem is that in this case they can't be adequately controlled. "In that case, the users probably don't get the necessary education, for example about contraindications," says Isabella Heuser. And she names another problem. "We don't know at all what the consequences are when healthy people take such drugs for a long time: The studies are simply still lacking."

And last but not least: If you order the drugs over the Internet from international pharmacies, you could face criminal proceedings for illegally importing substances that are not freely marketable. It may be tempting to get your brain going under the pressure of hard training and nerve-racking tournament matches - that it proves to be the best winning strategy is more than questionable.