24 September 2010

Friday Flashback - 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.


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...

Originally Posted 27 October 2007


  1. I take provigil and it doesn't feel like a stimulant at all -- it just keeps you awake. And I've noticed no side effects whatsoever either.

    Other people report nausea and other effects, so your mileage may vary.

    The only downside I've had is that it is ludicrously expensive, and you have to jump through a ton of hoops to get it and keep it.

  2. Nuvigil is the isomer of Provil that they're now marketing to get the most bang for their buck before Provigil goes generic.

    I haven't found it to be all that expensive...10 bucks for 30 pills with my insurance. And all I had to do was tell my doc I was working weird shifts and thought it would help.

  3. Hmmm, I took this for "excessive daytime sleepiness" when my neuro couldn't figure out what was wrong with me. If I remember correctly, I kept needing higher doses, it was a short acting drug, and then when I got to a certain point I was like a bunny on crack. I guess at lower doses, it is probably fine, but it seems like there has to be a better solution than schedule IV stimulants.

  4. I have tried it-not for shifts but for the first day after a stretch of nights. I asked my MD about it and he writes a fair amount of it "a lot of physicians"-not just night shift people.

    I've been really pleased with the effects- alert, awake, no shakiness or tachy, dry mouth, etc.

    apparently the FAA has approved it for long-haul pilots too.

  5. Count me as a fan; the one downside is that I tend to be more prone to tension headache when I take it - nothing that a couple of tylenol or naproxen won't cure, but a headache nonetheless. It doesn't seem to make me any more susceptible to migraine, which I was initially concerned about.

    My insurance only covers it for the narcolepsy indication and as an adjunct to CPAP therapy, so I'm stuck paying what is now, I think $14/tablet for Provigil and $9 for Nuvigil. That said, *never* getting jet-lag or having a grim day after working until midnight and having an 0800 meeting that requires leaving the house at 0600? TOTALLY WORTH IT.

    What's funny? I gave up caffeine other than one Diet Coke before 1300 a few years ago. I don't like the jittery buzz of caffeine or conventional stimulants, even a little. This is just a smooth "eraser" for the effects of a sudden phase shift or lack of sleep.

  6. I was prescribed it for being MS and it caused nausea for me. I have a whole bottle that I haven't used... and a husband that really likes it. I hide it. :)

  7. What I would have given for a scrip for these when I was on rotating shifts... 7 days graveyard, 2 off, 7 swing, 1 off, 7 days, 5 off. It was brutal and I did it for 3 years straight; never again.

  8. Also forgot so say "managing to focus after second or third time" is not good enough The third time regularly will be too far gone to pull the car back on the road. Even the the first time could have been fatal if someone had the bad luck to be changing a tire a the spot you went over the rumble strips. You are underestimating what your body can demand. It is just like putting off urinating two or three times. When you ignore your body it stops giving you fair notice.

  9. I took modafinil for several months before my doctor put me on thyroxine. It kept me quite awake, but it did not relieve the horrible sensation of tiredness from sleep deprivation that I occasionally put myself through. However, it was a miracle at the time. I did notice, once I d/c'd it, that my moods felt lighter and more cheerful, and that I laughed more easily than while on it.

    Also it was exorbitantly expensive, but it was worth it not to constantly fall asleep in classes.

  10. I've tried it and I wasn't particularly happy with it. During the period of time that I needed to be awake I still found it too easy to nod off. It felt similar to caffeine to me in that respect: I can tell something is *trying* to keep me awake and making me zippy/crabby, but I'm going to fall asleep at the wheel anyway.

  11. Anonymous at 10:30AM has a good point. For myself, since I don't have the organizational skills to keep up with a methylphenidate prescription (there's an ADD joke in there somewhere, I'm sure), if I find myself nodding off on the road I stop and take a nap. It sucks to take the delay in getting where you're going, but not as much as it would to cause a wreck.

  12. Provigil works very well for me. I usually work nights (2100-0500),have been for more than 20 years by preference, and don't use it to stay awake at work. I use it stay awake during the days when I'm not working -- and then only when I need extra levels of alertness. I have Cigna insurance, and a month's supply is a $10 copay. It costs them $300-something. The only side effect I've noticed is a buzzy-high-chattiness about 20 minutes after I take it, that lasts for about 15 minutes. Then I'm just awake and alert, I suppose like "normal" people. No side effects. I can take it irregularly, and it still works as advertised.

  13. I heard about this stuff weeks ago, on the radio!! I was blown away too. Here's my post on the subject!


    ps, keep posting, I'm a huge fan!


  14. Headache & a certain level of grumpiness others can see, but you're not aware of.

    When stopped, the headaches go away & as Emily said - a lightness of mood that others notice & comment on.

  15. Mother's little helpers, 2010 style.

    I'm sure its a wonderful idea to take the latest drug that big pharma is peddling to keep you awake. Then you can take some Ambien to fall asleep.

    Some Lyrica for your fibromyalgia too of course.

    How about some good old fashioned sleep hygiene for shift workers. Works for me and my husband.

    What is especially alarming is the people that think taking uppers is a good idea on the days when they're not working but sleep deprived from working nights. Just keep your ass in bed if you're tired and not working.


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