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I’ve had that feeling at 2:30am: the phone rings and I have to drag myself in to A+E to see a patient with an acute stroke. ‘Time is Brain’, so I have to hurry in to get the most out of clot-busting thrombolysis, definitely not enough time for a nice cup of English Breakfast (my usual morning caffeine boost – must be made in a teapot, I’m very fussy about this). Actually, the decision is often not too difficult. I know the inclusion and exclusion criteria and most of my job is hurrying up the CT scan, blood tests, blood pressure measures etc. But on my way home I can usually think of about 3 or 4 minor things I’ve forgotten to check, or forgotten to write in the notes. What if I had to do a 3 hour operation? What if I had a clinic the next morning? What if you woke up on the morning of an exam and felt a bit dozy?

Well, I was involved in a study to try and work out whether cognitive enhancing drugs might be an alternative to that cup of tea or coffee.

You might have seen something about modafanil on Newsnight a little while ago, a brilliantly inconclusive n=1 trial. This study published here was a little more rigorous, taking 64 subjects in a blinded study (ie neither the participants or us knew whether they were taking placebo or modafanil) and testing them on various cognitive tests after taking modafanil. It doesn’t aim to answer the above question, but it does give us an idea of what modafanil might do. The main results (copied straight from the abstract) were as follows: “Improvements under modafinil were seen on spatial working memory, planning and decision making at the most difficult levels, as well as visual pattern recognition memory following delay. Subjective ratings of enjoyment of task performance were significantly greater under modafinil compared with placebo, but mood ratings overall were not affected. The effects of modafinil on creativity were inconsistent and did not reach statistical significance.”

Working memory task

Outcomes of the working memory task. You can see the modafanil subjects make less errors than the control subjects.

I have to be honest and point out this is the first study I’ve been involved with in disease-free people. It’s easy to say that if you have a disease and a drug addresses a ‘symptom’ then you should take it. But the ethics of taking cognitive enhancing medications if you’re otherwise well is difficult. Where do you draw the line? Is modafanil any different from taking a cup of coffee (the argument goes that it has a similar effect, but without the shakes)? We point out in the conclusion that modafanil has never been tested outside the laboratory, which is enough for me not to recommend it for the minute.

I’m generally against taking drugs for things you can do well enough without, like exams. But what about airline pilots, surgeons, etc? Could these sort of drugs save lives? I would love to get off the fence about this issue, but I find it very difficult. I think I’m going to have to think about this a little more. I don’t think any more evidence of efficacy either way is going to help. If modafanil for some unexpected reason doesn’t have the right effect, there’ll be another drug along behind it that does. At the moment I can’t overcome my gut reaction that taking a drug to fix a problem if you don’t have a ‘disease’ isn’t quite right. But who knows, I may well change my mind yet…

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