Source: The Ottawa Citizen
Date: 11 October 2003

New drug may help soldiers stay awake
Doctors unsure of long-term effect

Tom Spears

miltary modafinil?

U.S. soldiers are staying awake for days and nights on end in Iraq, and many are almost certainly benefiting from military research into pills that let them work for 40 hours straight, without feeling "wired" and without crashing afterward.

Soldiers in past wars have taken stimulants when they can't afford to fall asleep, but these have all had side effects: poor judgment, jumpiness and the need for extra sleep as soon as the soldier stops popping them.

But the new stay-awake pills appear to have no side effects, at least in the short term.

U.S. military studies found that soldiers can stay awake and function alertly for 40 hours, get eight hours of sleep, and then stay awake for 40 more, all without the impaired judgment of old-fashioned uppers.

That's beginning to scare some doctors, who say that modafinil, sold in Canada as Alertec and in the U.S. as Provigil, might threaten the health of people who abuse it.

Modafinil is designed to help people with narcolepsy stay awake. These people, 150,000 of them in the United States, sometimes fall asleep suddenly in the middle of the day. Some doctors also prescribe modafinil to patients with multiple sclerosis to help them feel less tired.

Modafinil is not addictive. But what happens when a student or an office worker starts popping modafinil to stay awake for the next 30 or 40 hours for a deadline project? And what happens if the cycle continues?

Increasingly, Americans who feel the need to stay awake, and who don't have a serious sleep disorder, are getting "off-label" prescriptions for modafinil.

That's why there are 150,000 Americans with narcolepsy, but as many as 250,000 are using modafinil. The drug was first approved for use in Canada in 1999.

"I'm sure it's being used that way. You can understand how hard it would be to study such a situation, particularly when it's intermittent," says Dr. Tom Scammell, a sleep expert at Beth Israel Deaconess Medical Center in Boston.

"Most clinicians I talk to are really down on that."

Less than a year ago, the U.S. supplier of the drug posted a patient summary on its Web site, Dr. Scammell recalls, showing one-quarter had narcolepsy, while others had multiple sclerosis and some had depression.

"And then there was a large category of 'Other.'"

These include people taking the drug just because they want to stay awake, not because they need it. And while the drug itself might not be hurting them directly, he believes that lack of sleep might be dangerous.

"In a nutshell, we do not know all of the consequences of sleep deprivation. However, there are some consequences that are very clear. When somebody is sleep deprived they become sluggish. Their reaction times are slower than usual. They become clumsy. Somebody who's been sleep-deprived for just one night drives as badly as somebody who is legally intoxicated.

"If you look at the number of cars accidents (as a rate) it's highest between 2 and 5 a.m. because people are sleepy."

People who are tired sometimes show blood-sugar levels similar to people with diabetes.

A Washington Post reporter who sat up for 30 hours on the drug happily wrote he felt fine, adding: "Modafinil may have the power to change Washington, D.C., and other high-powered cities."

Doctors fear the that modafinil, while not a "feel-good" drug, is one that people may take if they're under heavy pressure.

"It's just one of these misuses, in my view, of a medical application. You could probably get the same thing with 20 cups of coffee, but you wouldn't like it," says Dr. Judith Leech, a respirologist who sees patients with sleep disorders at the Ottawa Hospital. "Get some sleep! Don't use a pill to stay awake! Does that make good medical sense?

"I think sleep is a good thing. The healthy thing to do is to sleep more if you're tired, right?"

"Compared with other stimulants that have been prescribed, such as dexedrine and ritalin, it (modafinil) doesn't work the same way so it doesn't have the same side effects," she adds. It doesn't cause high blood pressure or feeling wired, all the effects that are part of the nervous system's "fight or flight" reflex.

"On the other hand we don't really know which brain chemical it does work on. Personally I'm not really big on stimulating people's brains with things I'm not sure of, unless there's a medical indication."

Dr. Leech notes that soldiers have been offered drugs before to keep them awake: if it isn't modafinil, it may be something worse, such as amphetamines.

"On the other hand, what I use in somebody whose life is totally impaired by a brain chemistry disorder is different from what I think you should use in an army person" or other healthy people.

"It's bad to use drugs for bad reasons. There's a reason why we get sleepy." Sleep helps the brain store memories and recuperate from work, and helps the body build its immune system. "And you deprive yourself of those things if you use a stimulant to overcome it."




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