Gettysburg Medical News
The Clinical View
By P.E. Hoffsten, M.D.
15 August 2007

DRUGS FOR SLEEPINESS

            In May of 2003, I wrote an article on “Tired All the Time.”  I made the point that there are three words we use to describe the concept of tired.  The first word was sleepiness.  This can be depicted as what happens at about 2:00 in the afternoon after lunch and you are not that interested in what you are doing.  People tend to get the yawnies at this time.  This is not a disease state. 

            The word tired might be applied to what you feel at 8:30 to 9:00 at night after a long day, the kids are in bed, and you sit down in the easy chair or the sofa for the first time of the day.  You have just done as much as you are going to do that day and you are “tired”.  Again, this is not a disease state.

            The third condition to describe is fatigue.  This is what a person feels the next morning after they have slept all night and they are still not rested.  This is not good.  This can lead to a disease state. 

            Two people recently came to the clinic for what might have been considered similar problems.  In fact, the problems were very, very different.  One person had a special kind of sleepiness that is a disease state.  The other was tired/fatigued and he did not have a disease.

            The first person had a disease called narcolepsy.  If not constantly stimulated, he would fall asleep.  It was unsafe for him to drive a car because he would consistently fall asleep at the wheel.  After seeing a sleep specialist, he was diagnosed as having narcolepsy.  Of all things, the sleep specialist started him on dextroamphetamine which is a legitimate treatment for the condition.  With an adequate dose, he functions very well.  Dextroamphetamine is a popular but illegal “street-drug” used as an upper but does also have legitimate medical uses.

            The second person presented with quite a different problem.  He described really not liking his job and having trouble meeting the deadlines that were placed upon him in his occupation.  He wanted something to stimulate him to get his work done.  He indicated that he had used coffee for years, but it was really no longer doing the trick.  He described having four cups a day of very strong coffee that he brewed himself.  A “normal” cup of coffee has about one hundred milligrams of caffeine.  Estimates were that he was probably taking 600 milligrams of caffeine per day and it was probably interfering with his sleep since he drank it in the late afternoon in addition to in the morning.  He acknowledged that the coffee was “hard on his stomach” and that it often made him jittery and irritable.  He probably was physiologically dependent on caffeine. 

            Caffeine characteristically has an onset of action within about 15 minutes of its consumption.  It does lead to increased alertness.  In spite of many condemnations and disease- causing accusations, it really does not seem to cause heart disease, hypertension, cancer, or irregular heart rhythms.  It is certainly the most widely used drug in the world and quite remarkably safe from the standpoint of intoxication.  Estimates are that it would take 10,000 milligrams of caffeine to kill half the people that took that much.  Since a cup of coffee has about 100 milligrams of caffeine, it would take approximately 100 cups of coffee to kill somebody and they would probably have drowned rather than die of caffeine intoxication.

            The young man said that he had heard about a drug called Provigil (modafinil).  This is a medication that was introduced to the market in 1998.  It is touted by our armed forces as being the medication that can let a person function for extended periods of time (24 to 48 hours) without sleep.  This is valuable to the military in crisis situations.  It has also been used to help keep pilots alert when they have long flights halfway around the world.  A new product called Nuvigil is now approved by the FDA but not available in our pharmacies yet.  Nuvigil is a purified form of modafinil and is said to have fewer side effects. 

            In 1998, modafinil was introduced to the market as a drug for narcolepsy like the man described above.  It is nowhere near as effective as dextroamphetamine.  Modafinil now has medical indications for people that have obstructive sleep apnea which leaves them so tired that they fall asleep during the day.  Modafinil is also used to help with shift-work-sleep-disorder.  This is a condition related to a person’s occupation where their shift changes from day to night  periodically and their sleep pattern is disturbed.  This medication can be taken before going on to the regular shift and does help keep a person alert instead of being fatigued and nonfunctional. 

            The young man asked if this wasn’t a drug that might be helpful for him.  I instructed him that there are no long-term studies done on the effectiveness of using this medication to enhance normal function.  I indicated to him that it was not approved and I was not willing to prescribe it for the problem he was describing.  It was strongly suggested that he needed a change in life style and occupational goals.

He then asked about other drugs he could try.  He mentioned something truck drivers used to buy over the counter to stay awake for long drives; that was ephedrine which is now illegal.  Multiple other very illegal drugs are used as “uppers”.  These include methamphetamine and cocaine, which are not legal to be prescribed at all.  Methylphenidate is a drug that is used to help attention deficit disorder in adults and in children.  But again, these drugs are not prescribed to help with daytime sleepiness in people that do not have specific medical diagnoses and indications.

            In summary, I told the young man that he needed to readjust his occupational expectations and sleep pattern. There is, unfortunately, no safe, well tested agent to create “super-humans” other than caffeine.  Modafinil is still in development but is available to maintain wakefulness in crisis situations in the military.  But it is not approved as a medical indication for that purpose for the general public at this time.