Thursday, February 7, 2008

New Diagnosis: Excessive… Sleepiness?

Think you’ve heard it all?

Well, I thought I had. Until today, when I opened up the Baltimore Sun and learned something new. There is a new medical disorder… and I may have it! Thank goodness, there’s also a drug to treat it.

What’s my diagnosis? ES.

No… not Ewing’s sarcoma (which is what ES used to mean to me). ES is the new acronym for Excessive Sleepiness. I kid you not. But our friends in the pharmaceutical industry have a solution: Provigil.

Now… I’m not anti-medication at all. Heck, I use harsh medicines on my patients every day, and then have to give them more medicines to treat the side effects of the first medications. I’ve even put some of my own patients on Provigil. Kids who required so much narcotic to control their pain that they have a hard time staying awake to be able to interact with family members in a meaningful way… these patients benefit tremendously from Provigil.

But if you think about it, that’s not much of a market. Even if you add in patients with obstructive sleep apnea, who have badly disrupted sleep patterns and often have a hard time functioning during the day, there still isn’t a big market for this drug. Not even the addition of patients with narcolepsy (which is excessive daytime sleepiness even after a good night’s sleep, and is characterized by sudden uncontrollable bouts of sleep, with sleep paralysis and hallucinations) makes the market for this drug very large. BUT… if we make a new medical diagnosis, give it a clever name and acronym… and if that condition is tremendously common… well NOW there’s a market for your drug.

Please don’t misunderstand. Obstructive sleep apnea and narcolepsy are a big deal, and the excessive daytime sleepiness associated with these diagnoses can have a significant impact on patients’ lives. The sleep disturbances associated with shift work is also a significant problem for many people. Provigil plays an important role in the care of people with these problems. My concern is that the creation of a specific “disorder,” especially if it is given a name with such common use, combined with direct-to-the-patient marketing, feels like another example of the overmedicalization of our society. Do people who don’t sleep at night because of OSA benefit from a medication to help them stay awake? Certainly. Do people like me, who don’t sleep at night because they work too hard, need to “ask their doctor if Provigil is right for them”? No. We need to get more sleep.

OK. I’m going to bed.


Elizabeth Munroz said...

Since Provigil is fairly expensive, I wonder if insurance companies would even cover prescriptions for those who might want it for this new (off label?) purpose. Doesn't going without sleep cause serious psychological problems?

Doctor David said...

Going without sleep causes serious psychological problems, yes... and physiological ones, too. These problems underlie the efforts to limit resident work hours, for example. Of course, the solution is to get more sleep if the cause is voluntary sleep deprivation (as in my own case). Provigil certainly plays a role when the cause is OSA or other sleep disorders.

Dee said...

I completely agree with you.

And tbh, I know, I am well aware that I don't get nearly enough sleep, especially for somebody in my 'condition', but I also know I'd never feel okay with popping pills to get sleep. I think people are too...quick to jump and have a pill fix their issues then really assess what their issues are. Just because you have simliar symptoms doesn't mean you need the medication for the disorder. Maybe the reason you aren't sleeping is stress, caffeine, sugar, diet, lack of exercise, the list could go on and on...

Why does everybody want a pill to fix what 65% of the time, a really good solid look at yourself and your life, would do the same thing?

Doctor David said...

Thanks, Dee. You're so right... everyone wants a pill to fix what ails 'em, when sometimes a pill just isn't the answer.

Lori B said...

Ahhh! In the days before being innundated with commercials for prescription medication I had never known of these conditions or new these catchy drug names. Scary! Now we can begin making up our own diagnosis and look for drug fit. I have restless hand syndrome (I type too much). I also have GMS (gluteous maximus spread) from sitting too much. I think there is a pill for that. Ha!

outre said...

Hmmm... I think I have ES. Yep, I do... sometimes I have to take a nap on my office couch.

Too many people don't know what a drug does beyond the dribble said on direct to consumer commercials. It makes me cringe.

I work in the pharma related industry and frequently have to create patient education materials... Almost had to do something for RLS and gladly it didn't amount to anything. I'd rather read about heparin induced thrombocytopenia than semi-pseudo conditions being used as a marketing tool.

Joy Logan said...

First of all let me say,you sound very sensitive and have feelings about your patients. This is stronly lacking in the hospital world now days. Secondly, I can sleep all day and then again all night,sounds like Provigil is my answer? I was tested for sleep apnea it's not that. I keep thinking it's just me.

Doctor David said...

Thank you for your kind words, Joy. I hope you enjoy my blog.

Eric, AKA The Pragmatic Caregiver said...

Dr. Smak sent me over here, and I just had to open my mouth....

I'm a huge fan of Provigil; I sleep a reasonable amount of time most of the time (eight hours), I practice scrupulous sleep hygiene (I never read in bed, it's perfectly dark and quiet, etc) and I eschew caffeine like you wouldn't believe. My sleep study showed I was ridiculously good in bed. ;0)

Yet, there are times when, due to work issues or dealing with two terminally ill parents, I don't feel as mentally clear as I should during the day, and a nap is vaguely out of the question. More importantly, I deal with a bunch of things that, if not handled in an error-free manner, could result in death or disability to someone else. I owe it to the people who are counting on me to be at my absolute sharpest, and Provigil does just that, very effectively.

I've decided the problem people have with Provigil is the "something for nothing" aspect of the compound; you don't get the issues you get from the sympathomimetic amines (peripheral activation, sleeplessness, jitters, etc) - you just spend $8 and go through your day feeling like you've just had the best nap of ever. It strikes me as vaguely Calvinist that people think there should be consequences for supraphysiologic performance. If I fly all night on the red-eye, I should not be bright-eyed and bushy-tailed at my 0900 meeting that is really happening at 0600 per my body clock.

It's not *natural* to be able to run effectively on near-zero sleep, which you can *totally* do with correctly-timed doses of Provigil. The military has a curious interest in this application. Then again, non-caloric soda, G-CSF and nitrogen mustard aren't natural either, but I'm thankful in some way or another that they exist, too.


Doctor David said...

Hi Eric,

Thanks for coming over and reading my blog!

Don't get me wrong, my problem is not with Provigil. As I wrote, I've prescribed the drug myself and agree it has its uses. Your use, for example, seems like a good one.

My problem is with the pharmaceutical companies "inventing" illnesses where none exist in order to market products. In order to boost sales, new conditions are manufactured, followed by a direct-to-the-consumer ad campaign, urging people to "ask their doctor if Drug X is right for you!"

I suppose one could argue that without convincing people that there is a disorder called "Excessive Sleepiness", Cephalon would not be able to sell enough Provigil to continue to manufacture it, so there is some greater good, but in my mind this just contributes to the overmedicalization of our society, and our tendency to want to solve all of our problems with a pill.

As an aside, my research nurse told me that she interviewed for a job with a company whose purpose was to invent these illnesses. Thankfully she decided being an oncology research nurse was a better use of her training.

Eric, AKA The Pragmatic Caregiver said...

Oh, absolutely. "Shift Work Sleep Disorder" was Cephalon's first BS medicalization of a societal problem. Part of me wants to scream, but part of me goes "hey, there are medical consequences of daypart shifting, and treatment seems like a good idea".

Here's the part that had me head-scratching. . . sleep is undervalued in American society (and, really, elsewhere as well, but we seem especially bad). The market size for hypnotics/sedatives is *massive* - huge OTC market (inferior agents, anticholinergic actions that sure aren't part of the marketing hype), ginormous Rx market (questionable science (why increase half-life of a hypnotic? Oh. Yeah. Patent-busting), high prices, wacky risks like sleepeating a jar of mayo....). Which is worse? Selling people either OTC antihistamines with known cognitive impacts the next day, selling them expensive Rx drugs to get them to sleep earlier (with effects on REM quality *and* next-day cognition) or selling them a compound with desirable side effects like improved alertness and modest mood/cognition elevation?

I agree that behavioral interventions and reprioritization to support better sleep are the most important, but if people *are* going to medicalize their sleep issues, I think I'm more comfortable with dealing with the awake side of the equation rather than chemically-induced sleep. I find Cephalon upper management to be a bunch of scheming, gouging neer-do-wells on their *BEST* days, but I'm not sure pushing an alternative to hypnotics is their biggest failing as human beings.

(That award goes to their scummy patent payoff scheme currently being investigated by the FTC).


Nima D. M said...

It takes only the 2nd largest industry of the world to come up with a disease and yeh here's the treatment for it. In the world of medicine nowadays docs don't cure disease because they don't know the etiology in the first place. But thanks to our big pharma they know exactly what the cure is for their invented disease. And did i mention there's a difference between disease and illness? Of course it's their born right to label what constitutes disease and what not, even if the person feels alright. I wonder if they're shifting from drugging young American with met to a morphed met. But then It's America, where people get taken advantage of (there's a better word for it but I keep it professional) when they don't educate themselves in medicine. Let's not forget where we live . Stand up for the genuine patient care where you can. Thanks for sharing this.

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