Gemma is a recent Oxford University graduate. As a student of experimental psychology, she wrote three essays a week, in addition to spending 40 hours in lectures and labs. At night she worked for the student newspaper. In her final year things began to pile up but the 22-year-old was reluctant to drop any of her activities. She started taking Modafinil to make possible a life that was fast becoming impossible.

Modafinil is a stimulant most commonly prescribed as a prescription drug to treat sleeping disorders, particularly narcolepsy. But increasingly this drug, and two other stimulants, Ritalin and Adderall, are being bought illegally over the internet by high-achieving, overstretched students in British universities to sharpen their focus, concentration and memory.

Like many other high-flyers who use so-called “study” or “smart” drugs, Gemma felt a desire to be on top of her game all the time. Modafinil helped her to stay awake long enough to complete her assignments.

“I had a few American friends who regularly used Ritalin and sang its praises but I was suspicious of it,” she says. “But my friend bought some Modafinil online, said it was fantastic and could keep you awake for ever so I bought some from him.

“Taking Modafinil meant that I could just keep working. It didn’t make me any more gifted but it meant that my day lasted anything up to 36 hours.”

The other popular stimulants, Ritalin and Adderall, are legally prescribed for children who have been given a diagnosis of attention-deficit hyperactivity disorder (ADHD). But since it has been demonstrated in scientific trials that these drugs can boost cognitive performance, their unofficial use has rocketed.

Yet, even as students pop the pills and brag about their advantages in chat rooms, some experts are asking how much damage they are doing to their bodies. Others are speculating that, if the risks are found to be slight, the use of such drugs could become the norm for the brightest, most competitive young people in our society.

Like many users Gemma soon discovered the downsides. She describes feeling shaky, although “this might just have been me not going to sleep. I didn’t feel tired and I didn’t feel hungry. It stopped my body clock. I lost all track of time and whether I was meant to be eating or not. I would have long bursts of concentration”.

More worryingly, she also experienced bouts of obsession. “One night I made 10 Facebook photo albums for no good reason other than the fact that I was set on doing it,” she says.

Tackling the problem is difficult. Figures that reveal who is taking what are not readily available. Last year the scientific journal Nature published the results of an online survey of 1,400 adults. It showed that 20% of readers had taken “smart drugs”, but no definitive figures exist on the extent of their use in British universities. Research at the University of Michigan in the United States reveals that 8% of American undergraduates have used such drugs at one time or another to improve alertness. Other studies suggest the figure could be as high as one in six.

Emmanuel Akpan-Inwang, a student union welfare officer at the London School of Economics, says that as students approach their exams at the end of the year many are experimenting with “anything that will enhance their performance. “Adderall is the most popular drug at the moment,” he reveals.

Such people include Claire, a 22-year-old final-year Cambridge University philosophy student. She opted to try Adderall, a drug that is composed of mixed amphetamine salts, in the run-up to her second-year exams last year. She had no difficulty getting hold of it.

“I was sitting around in our college rooms with friends and someone mentioned that the engineering students had this drug that they used to help them study,” she says. “A friend who was in the year above had a lot of it, which he had bought on the internet, and so he gave me some.”

She took a capsule the next day before going to the library and was delighted to sail through a highly productive session of study. “I really found my concentration levels went up,” she says. “I thought, oh wow, I’ve been sitting in the library for five hours and haven’t been distracted by people walking around like I usually am. It was very helpful.”

With her finals coming up in a few weeks, she is planning to use Adderall again to keep her concentration at peak levels. Nor are the prices prohibitive: Ritalin costs £290 for 150 10mg pills, Adderall £230 for 120 30mg capsules and Modafinil £75 for 100 200mg doses.

Information on the risks of such drugs is highly anecdotal. Users report side effects such as headaches and depression, but no definitive research has been done on the long-term effects of their use on healthy people. This in itself is worrying many, including Barbara Sahakian, professor of neuropsychology at Cambridge University. Sahakian first became interested in the drugs when, arriving jet lagged at a conference in the United States, she was offered Modafinil. After speaking to her colleagues she discovered the extent to which it, and other similar drugs, were in circulation, both among her academic peers and their students.

In a paper entitled Professor’s Little Helper, she spelt out her concerns. “The trouble is that people in the UK are getting these drugs off the internet,” she says. “That’s worrying, because you are not really sure what you are getting. And even if the drug is pure, you may have another medical condition that means you shouldn’t take it. A person having a bad reaction to one of these drugs is, I think, a horrible accident waiting to happen.”

For other academics, such as John Harris, professor of bioethics at Manchester University, it is only a matter of time before smart pills are available, without prescription, on the high street. “If these drugs are shown to be safe, I can see a time when bright, competitive people will be able to access them as easily as you can get the morning-after pill now,” he says.

Some names have been changed

http://www.timesonline.co.uk

“About 20 percent of adults in the United States report a level of daytime sleepiness sufficient to interfere with daily activities, and excessive daytime sleepiness is the leading symptom of patients presenting to sleep clinics,” writes J.F. Pagel, MD, MS, from Rocky Mountain Sleep Disorders Center in Pueblo, Colorado.

“The prevalence of excessive daytime sleepiness is highest in adolescents, older persons, and shift workers, but assessment of its true prevalence is difficult because of the subjective nature of the symptoms, inconsistencies in terminology, and a lack of consensus on methods of diagnosis and assessment,” Dr. Pagel writes. “Some persons use subjective terminology (e.g., drowsiness, languor, inertness, fatigue, sluggishness) when describing symptoms of excessive daytime sleepiness.”

Excessive daytime sleepiness is one of the most prevalent causes of sleep-related patient symptoms, affecting approximately 20% of the population. Persons with excessive daytime sleepiness generally have poorer health vs adults of similar age. The Stanford Sleepiness Scale and the Epworth Sleepiness Scale are useful tools to screen for excessive daytime sleepiness.

The consequences of excessive daytime sleepiness can be varied and sometimes serious or even fatal, largely because of increased risk for motor vehicle crashes and work-related injuries. Sleep problems contribute to more than 100,000 motor vehicle crashes, resulting in 71,000 personal injuries and 1500 deaths annually, with more than half of single-vehicle crashes involving heavy trucks being fatigue related. Adolescent and young adult male drivers are involved in most sleep-related crashes.

Sleep deprivation, obstructive sleep apnea (OSA), and sedating medications are the most common causes of excessive daytime sleepiness. Other potential causes may include certain medical and psychiatric conditions and sleep disorders, such as narcolepsy, periodic limb movement disorder, and restless legs syndrome. Neurologic causes include head trauma, stroke, brain tumors, encephalitis, and genetic and neurodegenerative conditions.

OSA is a frequent cause of excessive daytime sleepiness, as well as the potentially most dangerous and physiologically disruptive cause. Polysomnography should typically be used to confirm the diagnosis. In patients diagnosed with OSA, possible comorbid conditions of hypertension, diabetes, and coronary disease should be identified and managed. Current prevalence of the risk for, or presence of, OSA is estimated to be 26% to 32% of adults, but this is anticipated to increase.

Sedating medications that may cause excessive daytime sleepiness include alpha- and beta-adrenergic blockers, antiepileptic drugs such as hydantoins and succinimides, antidiarrheal agents, antiemetics, antihistamines, antimuscarinics and antispasmodics, antiparkinsonian agents, antipsychotics, cough suppressants, genitourinary smooth muscle relaxants, opiate agonists and partial opiate agonists, and skeletal muscle relaxants.

Antidepressant medications with sedating effects include monoamine oxidase inhibitors, tricyclics, and selective serotonin reuptake inhibitors. Sedative-hypnotics and anxiolytics include barbiturates, benzodiazepines, and other drugs acting on γ-aminobutyric acid receptors.

The cornerstone of evaluating and managing excessive daytime sleepiness is to identify and treat OSA and/or other underlying conditions. In some patients, the appropriate use of activating medications may be indicated.

Most patients with OSA will experience reduction in symptoms of daytime sleepiness when treated with positive pressure devices, such as continuous positive airway pressure (CPAP) during sleep. There is less evidence supporting effects of medications, dental appliances, surgery, and other treatments of OSA.

For the treatment of excessive daytime sleepiness, modafinil is considered to be the first-line choice of activating agent because of its generally benign adverse effect profile. Because it is pharmacologically distinct from the amphetamines, it has a much lower potential for abuse (schedule IV). In addition to its indication for the treatment of persistent sleepiness associated with OSA in patients already being treated with CPAP, modafinil is also indicated for the treatment of daytime sleepiness in patients with shift work disorder.

As schedule II prescription drugs, the amphetamines are thought to have a high potential for abuse and must therefore be used with caution to promote alertness in sleepy patients. These include dextroamphetamine, methylphenidate, and pemoline. Personality changes, tremor, hypertension, headaches, and gastroesophageal reflux may be associated with amphetamine use.

“The use of activating agents is inappropriate in hypersomnolent patients with untreated OSA — although daytime sleepiness may be improved with these agents, the patient remains at risk from the pathophysiologic consequences of untreated OSA,” Dr. Pagel writes.

Specific clinical recommendations for practice, all rated level of evidence B, are as follows:

• Treating patients who have OSA with CPAP therapy is associated with decreased daytime sleepiness and a reduced risk for motor vehicle crashes.
• In patients with OSA who are already being treated with CPAP, modafinil therapy has been associated with reduction in symptoms of persistent sleepiness. Modafinil also appears to reduce daytime sleepiness in patients with shift work disorder.

“The physician treating patients with excessive daytime sleepiness (or patients using drugs likely to affect driving performance) has the responsibility to make a clinical assessment of the patient’s overall risk of unsafe driving, and to document driving recommendations and precautions,” Dr. Pagel concludes. “A physician should report patients who fail to comply with treatment, particularly high-risk persons such as airline pilots, truck, bus, and occupational drivers, and those with a history of recent sleepiness-associated incidents.”

http://www.medscape.com