27 October 2007

Sleepy ... so sleepy

One of the things I love about this blog, is that a lot of my readers, like me, work odd hours. I enjoy seeing the timestamps on the emails and comments; a surprising number of them originate between 0100 and 0400 hours. I guess a lot of ER types get bored and read blogs on the night shift.

One of the things I don't like about my job is that I have to work nights. Don't get me wrong -- I worked nights exclusively for a few years before I had kids, by choice. I like the pace of night shifts, I like the occasional down time, I like the camaraderie that the night staffs always seem to enjoy, and I even learned to like the traditional post-night shift team meal of pancakes and beer. That was when I was working all nights. Now I just work the same fraction of nights as the other docs in our group, a handful per month, and I find them much harder. It's easier to flip the sleep/wake cycle when you're going to work five nights in a row. One or two stand-alone night shifts are a lot more disruptive to my biological rhythms. And it's well known that as you get older, your ability to handle the sleep deprivation gets less and less.

This is why I was interested to hear a lot of buzz recently about a medication called Provigil (Modafinil). It apparently is FDA approved for the treatment of "Shift Work Sleep Disorder," a disease which I am pretty sure did not exist before the good folks at Cephalon decided to market the drug to shift workers. It is basically a stimulant which is more effective than caffeine, milder than amphetamines, and with a lower side effect and dependence profile than other stimulants. I attended a few lectures at ACEP's Scientific Assembly which addressed this issue -- both from a quality of life perspective as well as a physician performance and patient safety perspective -- and I was surprised to hear an almost evangelistic level of enthusiasm for this drug from the speakers. I have personally known a few ER docs who have tried it and they also rave about its virtues. They say that you are just blissfully awake for that awful first night up, without the jitters from caffeine, without feeling edgy or off-kilter, and you are able to sleep the next day -- there's no hangover.

It's got me wondering. I have never self-medicated (other than with coffee or booze or the occasional antibiotic), and I am not about to start. If nothing else, it is a schedule IV med. (It's also on the FAA's list of forbidden drugs for a pilot to take, which is ironic since apparently the Air Force uses it to improve pilot alertness on long missions.) But I am tempted to take the commercial's advice and "ask my doctor about a free trial..."

I'd be interested to hear any experiences any of my readers might have with this medicine -- especially any of the under-reported down sides. It sounds too good to be true, which means it probably is.

EPILOGUE

I wrote this post in a slow moment of an overnight shift. I hadn't thought I was particularly tired, but once I was on my way home a wave of fatigue broke over me and really took me by surprise. I almost fell asleep at the wheel and drove off the road several times. Scary -- thank God for rumble strips on shoulders! Fatigue impairs your judgment; I should have gotten the hell off the road but I was afflicted with a severe case of get-there-itis. I managed to focus myself after the second or third time it happened and made it home without incident.

I don't think it makes a compelling point for or against Provigil, but it's a disturbing irony to occur three hours after writing a post on sleep issues...

17 comments:

  1. Shift worker syndrome is a real phenomenon, but has not had meds like this to treat the fatigue. The depression rate among employees doing swing shifts has long been known to be much higher. I have always advocated set shift schedules over swing shifts for factory workers - most seem to do it better than they did 10 years ago.

    Regarding the Provigil, I agree that you should hesitate. I would generally only say to use it for significant problems with function due to fatigue. Just being tired is not enough, there needs to be some more measurable harm that the abnormal sleep patterns are causing. I have yet to prescribe it for someone for anything other than narcolepsy.

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  2. I have a lot of experience with this drug recently. My original reasons for trying it were for my mild attention deficit which was getting in the way of my boards studying and the arrival of call nights during my 3rd year clerkships. At 37 years of age, I was worried I would not hack them as easily as the 26 year olds!

    Although modafinil has been used mainly for narcolepsy and SWD. There are some people out there trying it in kids for ADD and one doc published a paper on using it in epileptics to help with the sedative effects of the anticonvulsants. This is an important clue that it has a very different mechanism for alertness than amphetamines which lower your seizure threshold.

    My experience has been 80% benefit, 20% drawback. It has done wonders when I have taken it for both my attention and ability to focus as well as keeping me alert for long hours at odd times. It is not a stimulant feeling as much as an "awake and alert" feeling. Hard to describe. No jitters like the 8 cups of strong coffee, just the desire to focus and work. I found half the dose (50-100mg) worked great for about a 12 hour stretch. During this time you simply feel alert & awake and want to get busy. After about 8 hours the effect is still there but if I chose to take a nap I could close my eyes and sleep. It is hard to explain, but if I open my eyes and decide to be awake I simply am, but if I chose to sleep I could. I also noticed that I woke more easily the NEXT morning and although I was not stimulated I was more easily alert upon waking.

    Now, the down sides. If I take it for more than 2 days in a row I find I get very tense shoulders & neck and after three days I can start to get a headache. The headache is somewhat like a cluster headache and not too severe but noticeable enough. If I take it 3 days in a row I find it takes about a day or two for these side effects to wear off. So, my recommendation, start on a low dose (50mg) and see what it does for you. I would not take more than 2 days in a row. If needed, perhaps 2 on, 1 off, 2on would get you through a long week. I like having it for the occasional call night that is killing me and occasional weekend where I need to cram for an exam. Other than that I try and exercise and sleep right.

    Summary: I think this is a good medication with real benefit, but it does not cure all and it does have side effects but for short term needs it is very effective and I have NEVER felt a dependence or craving. If anything, the headache & shoulder tension makes me want to stop after 2-3 days no matter how much I think it might help. As a jump start for a series of night or a boost near the end of a series of nights I think it would be great.

    The med is super expensive, so I recommend getting the 200mg pills as the price is better and then just break them in half or thirds PRN. Email me if yo uhave any other questions...

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  3. I work day/night rotating and oftentimes I'll get the lone night shift or 2 nights in a row in a sea of days, and the effects can be seen for 4 or 5 days later. Sometimes when my time stamp says "0334", it doesn't mean I'm bored at work, it means I'm scheduled to work days and fell asleep at 7pm after struggling to keep going. I did that for about 4 shifts in a row last week, in fact. Once you fall asleep at 7 pm once (in your scrubs, contacts, and makeup), it's hard to break that pattern without a stimulant like coffee, but then, usually, the coffee keeps me up longer than i want, like until 4 am, so I'm always screwed one way or another.

    mmmm...coffee.

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  4. I read about this stuff a few years back and it really intrigued me. I used to be a Resident Assistant at a Big Ten university and when I had to be on duty at night I was always completely drained the next morning. Waking up has always been hard for me, but waking up without a consistent sleep schedule was nearly impossible. Although I'm no longer an RA, I still have a job that requires me to work painful night shifts so I'll be interested to know how modafinil works out for you.

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  5. I've taken Provigil when I needed to stay awake and alert without the teeth-grinding, jitters, and complete decimation of appetite that other stimulants can cause.

    It worked beautifully--I felt as rested and alert as someone who'd slept eight hours, and I was able to write and then go out to dinner and actually eat something. When it was time to sleep, I drifted off without any problems. That said, it was a once-in-a-while thing, thus I can't speak to any ill effects one might experience when taking it for days in a row.

    I would take it again, if I were exhausted or jet-lagged but circumstances called for me to be bright-eyed and bushy-tailed, but no, not repeatedly and yes, it is expensive.

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  7. Magic. Pure Freakin' Magic.

    It's like going through life having just woke up from the Best. Nap. Of. Ever.

    I tend to get a raging headache about eight hours after I take it. Nothing two Tylenol won't kill, and I usually take them prophylactically.

    It's not just "awake" like "too much coffee". It's "clear", like in "I could find Waldo in a Moonie wedding photo with one eye tied behind my back".

    Another clue to safety; the TI is huge - there are people taking 1200mg/day for degenerative neurological conditions, with no ill effects. Note that it *IS* a 3A4 inducer, and it induces its own metabolism, so there's a non-linear dose effect at some point.

    There has to be some hideous downside for regular users, but it hasn't appeared in the 20-year marketing history of Provigil, Olmifon (the prodrug of modafinil, never submitted for approval in the US, but popular in France) or Nuvigil (the newly-approved variant). The "Dear Doctor" letter that went out in the last few weeks was over VERY scattered reports of Stevens-Johnson Syndrome and psychiatric side effects. Seeing as how I still have my skin and haven't spent my life savings in Vegas on a weeklong binge of pai gow, buffets and hookers, I'd say I'm safe for the moment.

    Try one tablet on some random weekend day. If you don't like how it works, it's gone by morning. I will *never* be jet-lagged again.

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  8. You know thinking about it makes me think about a lot of things pertaining to "human enhancement," steroids, impending genetic modifications, etc. Scientific American reviewed a pair of books with opposing viewpoints on the matter here.

    Seems like taking this med is extending human capabilities beyond what they "should" be. But then you examine that and wonder, should there be a limit? Kind of interesting question. I'll have to think more about it...

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  9. hmmm... maybe I *should* talk to my doctor about getting some. Wonder if it would help with the occasional 30 hour call shift? I, too, have almost fallen asleep at the wheel countless times. It's amazing to me that if I were still at the hospital, I would be expected to operate in that condition.

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  10. please note the *correct* address to my blog... ::shakes head:: freaking intern move.

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  11. I've taken it practically every day for the past two years or so. I take it two hours before my shift starts, preferably on an empty stomach. If I take it after a meal it just takes a little longer to kick in with a flatter curve of alertness. There is a little rush from about the 3 to 6 hour mark, but it isn't really very euphoric, just an awake feeling without the jitteriness or nausea of an equivalent dose of caffeine. There is a slight mood-enhancing effect.

    Taking a double dose isn't really particularly helpful; the awake feeling isn't linearly increased, but the side effects seem to be. The only time I've felt jittery with it is when I've tried a double dose.

    Taking one the day after a night shift to try to stay awake doesn't help much. I can stay awake for a while longer, but I still feel awful. Awake, but fatigued and miserable. I can easily go to sleep on it.

    The only drawbacks are the cost (about $10 per pill), an occasional subtle feeling of anxiety when it first starts to take effect (only lasts a few minutes, I think of it as really just your brain kicking in to a higher gear), and perhaps a slight increase in blood pressure.

    I don't see why it's classifed as a "controlled substance" at all, really; it doesn't seem very abusable in my opinion because the mild mood-enhancing effects don't seem to be dose-related like other controlled substances.

    It's a miracle drug, and I can't wait for the price to come down. But it's well worth the $10 per pill. And yes, I have an official diagnosis of shift work sleep disorder and the medication is prescribed by another physician. Without pre-approval by insurance and an official diagnosis, most plans won't cover it.

    Although it's widely available via overseas pharmacies without a Rx for 1/8 the cost in America.

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  12. The House Whisperer10/28/2007 11:54 PM

    I took it once several years ago and will not take it again. I felt a little more scattered than usual on the night shift, and couldn't nap at all in the morning. I much prefer coffee, which is cheaper and, in my opinion, easier to titrate.

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  13. I have taken it frequently and note an increased level of alertness without side effects. Not hangover and no difficulty in getting to sleep.

    It is also indicated for OSA.

    We also use it as an adjunct for anti-depressants. We have found better efficacy when used in combination form.

    We have also found it helpful in Alzheimer pt's to boost their energy level.

    Yes, it is expensive - but like many others have said - worth every penny.

    It is interesting to note that the AMA issued a statement about 2 years ago forbidding it's use by residents while on duty. But the question is what if a resident in question has the proper dx and is offically prescribed the med? Double standards?

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  14. Lets see, I took it some time ago, when dealing with "the mystery illness" that caused seizures, excessive daytime sleepiness, migraines, and internal bleeding. I was on a very high dose , because it would work for a time, and then need to be increased. However, at a certain point it was not effective, but the next dose up made me wacko. When it worked and i was alert, that was good, but it did not keep me awake.I'd say stay away from it if you can.

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  15. Dazzled by this pharmaceutical 'wonder', my doctors jumped to prescribed it as a 'cure' for my insomnia (the thought being if I was alert during the day, I'd sleep naturally at night). The result was a heart rate nearing two hundred, a hospital stay, and a very un-amused patient.
    That said, my dad takes it occasionally and finds that it works as promised.

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  16. Perhaps a reason to not consider Provigil:
    http://content.nejm.org/cgi/content/full/357/21/2167


    CardioNP

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