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Viewpoint

Viewpoint: An Answer to Shift Work Sleep Disorder?

Ostermayer, Daniel MD

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doi: 10.1097/01.EEM.0000455728.37997.bd
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    Shift work and chemical augmentation go hand-in-hand. Usage has ranged from the extremes — the military prescribing amphetamines as “go pills” for night combat and pilot alertness — to mundane caffeine and energy drinks during an overnight shift. The latest drug in the fight against sleep, Provigil (modafinil), may already be in use in your emergency department.

    The U.S. FDA approved modafinil in 1998 for narcoleptics. Five years later, it extended that approval to shift work sleep disorder, making the medication easy to prescribe to residents and emergency physicians. Shift work sleep disorder, as defined by the American Academy of Sleep Medicine, is development of sleep disturbances and impairment of waking alertness and performance. (Sleep 2007;30[11]:1460.)

    Modafinil promotes wakefulness but not through the classic receptors such as norepinephrine, dopamine, serotonin, GABA, melatonin, and phosphodiesterase inhibition. Pharmacists place modafinil in an entirely separate category from amphetamine-like stimulants, and often label the medication as a wakefulness-promoting agent. (Neurosci Lett 1998;241[2-3]:95.) Modafinil did not cause any behavioral excitation in a feline model, unlike amphetamines. (Brain Res 1992;591[2]:319.) Metabolism occurs via the P450 system, and the drug may alter the metabolism of other medications, such as oral contraceptives, via the same pathway.

    Popular culture has compared modafinil with the Bradley Cooper movie Limitless, citing cognition improvement, increased focus, and unmatched productivity. Wall Street executives and high-profile CEOs report improved cognition especially during time zone travel or under strict deadlines. (NY Magazine 2013 Mar 31; http://nym.ag/1mcwmjY.) Not surprisingly, college students pulling all-nighters have flocked to the medication as well. (Huffington Post 2014 Jan 31; http://huff.to/1tazaE5.) Residents in surgical and medical specialties at my former small LA County hospital are using modafinil to make a night shift or 30-hour call more bearable, with the hope of improving alertness and subsequently patient care. Users report that sleepiness vanishes and the mind slowly awakens without the spikes and crashes of stimulants such as caffeine. No data have quantified the use among physicians, but a quick survey of your department will no doubt turn up one or two residents or attendings who have at least tried the medication.

    Headaches were the most frequently occurring side effect during the phase 3 clinical trial; others included insomnia and depression. (Cancer 2010;116[14]:3513.) The Journal of Medical Toxicology reports 87 California poison control calls from excessive ingestion, the most common being tachycardia and agitation. (J Med Toxicol 2010;6[3]:307.) No arrhythmias or deaths were reported, but all of the other clinical effects seemed to relate to a level of increased sympathomimetic drive even though modafinil has no direct sympathomimetic pharmacology. The majority of patients were managed at home over the phone with poison control guidance, and 44 percent received ED care. Treatments were generally supportive, including fluids, benzodiazepines, Haldol, and occasional charcoal administration. The anonymous forum, www.erowid.org, describes many user experiences with the medication, the most notable anecdote being agitation and hallucinations associated with 200 mg (a standard daily dose) and alcohol usage. An anonymous physician reported discontinuing the medication because of blood pressure elevations and persistent tachycardia. (http://bit.ly/Xv97w2.)

    As a young white man with no medical problems, I had a somewhat anticlimactic response to what the media often portrays as a pill for instant enlightenment. I switched from a day shift to a night shift with six hours of interrupted sleep, so I took the medication an hour before work. I purposely avoided caffeine, and did not feel fatigued eight hours into a 12-hour shift. I would describe it as feeling rested. Time of onset is reported at 30 minutes, with elimination half-life being 15 hours. I could never pinpoint a time-to-effect because there are no feelings of euphoria or excitability. Taking the medication only provided me an absence of sleepiness rather than a feeling of being extraordinarily awake. Falling asleep was not a problem because I took modafinil more than 15 hours before my planned sleep. Repeating the dose a few more times over the course of a month in similar shift change situations did provide a subjective perception of better schedule adaptability with no experienced side effects.

    Emergency physicians worldwide recently took pause when hearing of the association between zolpidem and sudden death, mainly because many within our community use the medication to help fall asleep. (BMJOpen 2012;2[1]; doi:10.1136/bmjopen-2012-000850.) Modafinil, however, has had no long-term scrutiny. The verdict is out on the absolute benefit to shift work, and I only speak from personal experience. I still hold a prescription for modafinil, but do not use it regularly. I believe that spending effort preparing a quiet dark uninterrupted space for sleeping and good sleep hygiene confers much better longevity in a career of perpetual shift work sleep disorder.

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