Monday, December 08, 2008

With Speed As With So Much Else, All That's Old Is New Again.

Awhile back I wrote a little amateur book review of On Speed: The Many Lives Of Amphetamine, mostly because they flattered my ego by sending me a free copy. I did like the book though, and gave it mostly a thumbs up. Today I'm going to change my opinion a little:

Read the book. Especially if you are a medical professional. Buy it, borrow it, find the words Nicholas Rasmussen wrote somewhere my friends, because the many lives of amphetamine are far from over. From Sunday's AP wire:

NEW YORK – Healthy people should have the right to boost their brains with pills, like those prescribed for hyperactive kids or memory-impaired older folks, several scientists contend in a provocative commentary.

College students are already illegally taking prescription stimulants like Ritalin to help them study, and demand for such drugs is likely to grow elsewhere, they say.
"We should welcome new methods of improving our brain function," and doing it with pills is no more morally objectionable than eating right or getting a good night's sleep, these experts wrote in an opinion piece published online Sunday by the journal Nature.

Now, to be fair, the actual Nature commentary is a little more nuanced than the impression of it being left by the popular press, but here's the thing, to your average American, reading the AP article alone would constitute scholarly activity. Far too many people are gonna see only "Taking Ritalin is like eating right!!" Far too few people, including far too few doctors, are gonna read the actual Nature article. Or even the part of the AP story, at the end, that says:

Dr. Nora Volkow, director of the National Institute on Drug Abuse, said she agreed with the commentary that the nonprescribed use of brain-boosting drugs must be studied.

But she said she was concerned that wider use of stimulants could lead more people to become addicted to them. That's what happened decades ago when they were widely prescribed for a variety of disorders, she said.

Addicted and psychotic and dead of heart attacks and strokes. We've seen all this before. If you're not old enough to remember, read the book.

In addition to adjusting the plane to the needs of the aviator, war research also worked on modifying the man to fit the machine. Special suits to prevent blackouts under major forces were one major project. Another was biological enhancement of fliers: vitamin supplements were studied, as was testosterone for its reputed strength-building powers. However, the steroid hormones of the adrenal gland commanded the greatest attention......amphetamine seemed another likely possibility for high altitude performance enhancement.....

The military eventually cooled to the idea of speed as "biological enhancement", settling on a small role for it in keeping pilots awake. Today though, we have this:

Many of the medications used to treat psychiatric and neurological conditions also improve the performance of the healthy. The drugs most commonly used for cognitive enhancement at present are stimulants, namely Ritalin (methyphenidate) and Adderall (mixed amphetamine salts), and are prescribed mainly for the treatment of attention deficit hyperactivity disorder (ADHD). Because of their effects on the catecholamine system, these drugs increase executive functions in patients and most healthy normal people,

I wonder if by "increase executive functions in most healthy normal people" the authors of that Nature article meant "make healthy normal people want to mow the lawn at 3 in the morning" 'Cause I've seen Ritalin do that.

The authors pay lip service to safety concerns, but not nearly enough. They talk of a new medical paradigm of better living through amphetamine, which has been talked about before. It did not end well before, and it won't end well this time if it's allowed to take root. Machines and lifestyles need to be modified to meet the person, not the other way around.

Unless maybe you're really into lawn care.


Anonymous said...

i believe german soldiers were pumped up on speed...there's a good endorsement for better living thru drugs

Eric, AKA The Pragmatic Caregiver said...

Sympathomimetic amines are passe. Provigil/Nuvigil/Olmifon are where it's at.

My parents use caffeine to start the day. I don't like the side f/x, I don't like the wear-off and I don't like the snarly dependency.

I like Provigil. I like not ever having jetlag. I like having mental clarity the day after a poor night's sleep. I like DDAVP before boring conference sessions - I retain more information and I'm not fidgeting because I have to get up to pee.

Feeling fatigued is one of the top drivers of primary care visits for adults. People spend BILLIONS on addictive/habit-forming/dangerous (read, benzo/Ambien/Benadryl) sleep aids - why not solve the symptom (I'm tired during the day/can't focus/feel draggy) during the day than masking the sleep problem at night?

In a perfect world, we'd all eat right (right things, right amount, right times), get enough high-quality sleep and exercise, but you know what? We still wouldn't be at peak mental performance. Here's something that gives me a pleasant edge, is pretty well-understood (20 years of use of Olmifon, which is the prodrug of Provigil and the prodrug of the racemate of Nuvigil) and doesn't leave me mowing the lawn at 0300.

Let's say that pharmacists got a special dispensation to use Nuvigil with impunity - free, courtesy of Cephalon. What would happen? They'd be more alert to catch medication errors, they'd be more awake when shifts change or they have to cover for someone, they'd be more up on their professional reading. Some of them would have more energy after work for things like exercise and paying attention to the kids. Aren't these all *good* things? Shouldn't I be demanding that my overworked under-slept, underfed retail pharmacist swallows one an hour before he fills my Rx? Something to think about.

I *HAVE* done eight loads of laundry in a row the day I got back from a trip. While reading journal articles that had piled up. At midnight.


Anonymous said...

Don't think so. Dependency is dependency. It's not the drug that does the 8 loads of laundry and the yardwork at 3AM, it's a human body with human limits. Tell us of no limits and we hear about physicians at the north pole doing their own surgical procedures and jealous cosmonauts that drive 18+ hours straight through wearing Attends. People are not robots even if they think their intelligence places them on the same level.

DrugMonkey, Master of Pharmacy said...

Thank you Cephalon, for sending one of your sales reps over.

"Here's something that gives me a pleasant edge"

No doubt.

"is pretty well-understood"

Really? Maybe you should tell the people who put together the Provigil package insert:

"The precise mechanism(s) through which modafinil promotes wakefulness is unknown"

We do know this though:

"Modafinil has wake-promoting actions similar to sympathomimetic agents like amphetamine and methylphenidate, although the pharmacologic profile is not identical to that of sympathomimetic amines."

Translation: Not quite speed, but close.

"Let's say that pharmacists got a special dispensation to use Nuvigil with impunity - free, courtesy of Cephalon. What would happen? They'd be more alert to catch medication errors"

Says who? Not The New England Journal of medicine:

"For one of the drug’s three approved uses, to treat people on shift work, the key study comparing modafinil to a placebo in such workers found that treated workers still experienced worrisome levels of sleepiness. The study was accompanied by an editorial in the New England Journal of Medicine stating that “workers would still be considered greatly impaired regarding vigilance and wakefulness during the nights they would need to remain awake and alert", and that “the current study does not adequately assess the clinical value of this particular drug in shift-work sleep disorder, nor does it justify writing more prescriptions for modafinil.'"

Not my good friends at Public Citizen:

"Very tired people who take a stimulant, such as modafinil, may misinterpret the effect as improved cognitive ability. In pilots kept awake for 37 hours, while their performance with modafinil improved overall, it did not return to normal levels, and did not improve all flight maneuvers."

You can keep the free Provigil, thanks.

Wait. I'm sorry.You were offering free Nuvigil, the *cough* new drug Cephalon will be shoving down people's throats so they can get as many as possible switched over before the patent expires on Provigil. That's totally not a sign you're a sales rep or anything.

"I *HAVE* done eight loads of laundry in a row the day I got back from a trip. While reading journal articles that had piled up. At midnight."

Which isn't anything at all like mowing the lawn at 3 in the morning.

You're on speed my friend. The only thing that keeps Provigil out of the public consciousness the way Ritalin and Adderall are is the $300 a month it costs to maintain a Provigil habit.

So you're not only on speed, you're getting ripped off. Unless Cephalon gives it to their sales reps for free.

Now get some sleep.

Elizabeth said...

That is so funny that you mentioned the book. I just finished reading it about a month ago, and started reading this blog not long after. It was GREAT!

Anonymous said...

If I recall correctly, you used to be quite preoccupied with lawn care yourself, back when you owned a lot of land. Don't know if it had anything to do with the use of stimulants, though.

Anonymous said...

I love how the illegal actions of college students are used as support in that article.

I'm bipolar and struggle with ADHD symptoms. (Comorbid much?) For me, the balance between "just enough so I can function" and "not so much that I go batshit manic" is a very fine line. And I laughed at your question about Abilify, the same way I shook my head in shame with the results to your "fat or crazy" poll months ago. I wish to GOD I could answer "What the Hell is Abilify?" Instead, my answer is, "Oh, that expensive as fuck drug that made me scratch my skin off my arms because it wasn't 'the drug for me' according to my psychiatrist?" While I'm thankful for my meds and all- fucking pharmaceutical companies never give a SHIT about the actual patients. Trying to sell Abilify as an antidepressant, when there are a billion places to go first, should be illegal. Do these people not have souls? Abilify is an atypical antipsychotic! Yeah, that's the first place I'd go for a boost to my AD.
And the "performance enhancing" benefits of stimulants. Yeah, that's a new concept. WTF are people thinking? Some of us who have NO CHOICE agonize over the choices we face and the risks we take daily. Lamictal: great mood stabilizer, could give me a sudden, deadly rash. Seroquel: awesome drug that I believe keeps me alive, but makes me fat and could give me diabetes. Half of the people that want to throw a few adderall back to get more done are the same people who eat organically and pride themselves on never taking asprin. Idiots.

Anonymous said...

I love how you called out that drug rep!

I was prescribed Provigil once because I was falling asleep driving, hell I fell asleep everywhere. I was sleeping about 20 hours a day on my days off, only working 3 days a week. I had a sleep study done and all kinds of blood work--no answers. So prescribe me some Provigil, that'll fix the problem. NOPE! Didn't change a thing. I was like this for more than a year, only took Provigil for a month when I realized it was useless.
One day I stumbled across a study that Lilly had supressed about side effects of Prozac, it mentioned the people who take it and become extremely aggressive and then the ones, who like me, couldn't stay awake. I had doctors trying to increase my dose (only on 20mg), because I MUST be depressed to sleep so much when there wasn't anything wrong with me. I found that article, quit cold turkey and within weeks was living a normal life again...and I lost 10 pounds within 6 months, I thought I was gaining weight from getting older.
Now I find it hard to take ANY drug, because we just don't really know enough about them, and I am a supposed drug expert! I find it hard to work in a field where I am at odds with dispensing drugs like candy--I want to warn people but they don't want to hear it. I can't even convince parents not to give their toddlers cold medicines--even when the FDA has said they shouldn't.
Boston Legal just had an episode about using these drugs to boost SAT's--I didn't realize it was one of those "ripped from the headlines" stories. UNBELIEVABLE!

Stavros said...

My fatigue was diagnosed as severe sleep apnea. A CPAP machine was prescribed. No drugs and I feel great.
My sympathy to the drug companies. Pills are not always the answer.

I noticed the mention that normal people should be given the opportunity to take brain enhancers. My questions is how long will they remain normal after taking the drug?

There is also a crazy idea that intelligent people will not suffer the consequences of using the drug. They just learn to mask the symptoms for a longer period of time before they crash and burn out.

kim possible said...

30% increased use of Ritalin derivatives in teens in the richest suburban area of Seattle. Parents overwhelmed with ADHD (it must be in the water?) or wanting their kids to have that competitive edge? Hey parents, it's normal for children to me distractable and need breaks and task transition, it's part of the learning process... It's called developing good study habits!!

Anonymous said...

when i was in college went to the doc because of fatigue and was promptly prescribed ritalin which was great because white crosses were hard to forward to 15 years ago where same prescribing doc was arrested for illegal gun possession and intent to distribute illegal scripts....the ritalin was long gone for me..couldn't stand grinding my teeth coming down and bedisdes ginger baker scared the crap out of me.

Hartvig said...

We knew "speed kills" in the 70's fer christsakes... I suppose some of these morons are just going to have to learn the lesson the hard way.

Stavros69 said...

The problem that we are experiencing is global. There is no respect for the knowledge gained by the elder generation. Everything is youth orientated. It is not on in USA My friend in China told me that if he lost his job at age 38 he will never get hired by another company.

What we know about speed will be learned over again by the "know it all" generation.

Speed has been killing in more ways now than ever. In my job I have been in several meth labs, after they blew up. Can you imagine what happens, when a high school drop out runs an organic chemistry lab in his apartment or home. One lab put 70 people out in the street. The whole apartment building was damaged.

In addition there is this thing called common sense. Stanford University did a study and found that common sense is really not that common. The explains why a government official would allow the gun to be called a medical device or even suggest that meth should be OK for "normal people."

Anonymous said...

Well....Master of All Things Pharmacy

I got prescibe Ritalin and Provigal (not at the same time).

Tiny pediatric/homeopathic doses.

Can we say power barfing? Like food poisoning power barfing?

My heavens, I could never be a speed freak.

My friend openly wept that I flushed the Provigil. "How could you do that?"

Easy, the shit doesn't work.

Speed freaks are like alcoholics. They can't see how stupid they are acting.

Also lmao about the people who eat all organic food/bottle water/unbleached clothing and pop Provigil, then Xanax to deal with their children.

LD 50 Lab Rat

Anonymous said...

Loved how I went to drug talk put on by Provigil couple years ago and the psychiatrist speaker was touting use of that melatonin-derivative ? Ramelteon, back-to-back with Provigil for shift workers. I say, if ya need drugs to work in the critical areas, then ya don't need to be working them there hours.
The only night shifter I knew that actually used Provigil attempted suicide after too many weekends and night shifts in a row. Not saying that Provigil causes suicide, but the set-up for pushing body beyond limits is not healthy. There should be no reason that the employer 'makes' a worker do the night shift if it takes drugs to get through the days. Fundamentally wrong--infringement on personal freedoms, I say.