Managing modafinil

For the last year or so I have been deliberately experimenting with a psychoactive, nootropic drug.

You have to know me personally (much better than most of my blog audience does) to realize what a surprising admission this is. I’ve been a non-smoking teetotaller since I was old enough to form the decision. I went through college in the 1970s, the heyday of the drug culture, without so much as toking a joint. I have been open with my friends about having near enough relatives with substance-abuse problems that I suspect I have a genetic predisposition to those that I am very wary of triggering. And I have made my disgust at the idea of being controlled by a substance extremely plain.

Nevertheless, I have good reasons for the experiment. The drug, modafinil (perhaps better known by the trade name Provigil) has a number of curious and interesting properties. I’m writing about it because while factual material on effects, toxicology, studies and so forth is easy to find, I have yet to see useful written advice about why and how to use the drug covering any but the narrowest medical applications.

Before I continue, a caveat that may save both your butt and mine. In the U.S., modafinil is a Schedule IV restricted drug, illegal to use without a prescription. I use it legally. I do not – repeat, do not – advise anyone to use modafinil illegally. I judge the legal restriction is absurd – there are lots of over-the counter drugs that are far more dangerous (ibuprofen will do as an example) – but the law is the law and the drug cops can flatten you without a thought.

Another caveat: Your mileage may vary. This is a field report from one user that is consistent with the clinical studies and other large-scale evidence, but reactions to drugs can be highly idiosyncratic. Proceed with caution and skepticism and self-monitor carefully. You only have one neurochemistry and you won’t like what happens if you break it.

The first thing I should cover is why I get to use this drug legally. Many of you know that I have congenital spastic palsy. Our first weird fact about modafinil is that it is the only drug – indeed, the only medical intervention of any kind – that has improved the motor control of CP patients in controlled trials. This is a more interesting effect than drugs like Baclofen that are merely muscle relaxants.

Yes, modafinil helps me walk better – that’s why I can get it prescribed. I’m not actually very impaired as a normal thing, but it is of medically significant use in the circumstances when I am worst off – mainly, when I’m fatigued or under stress. Modafinil greatly reduces the likelihood that when I am tired or strained I will become extremely clumsy, barge into things, break them, and hurt myself.

Nobody knows how this works. (This is a phrase you will hear a lot in descriptions of modafinil effects.) CP is thought to be actual damage to the brain’s motor control circuitry. For a drug to be able to counteract or override that is bizarre – like observing a broken watch to work better when you pour butter into it – and nobody has any plausible theory about it.

Eppure, si muove. It really works. I have no explanation.

Modafinil has a much better known role as a wakefulness and pro-concentration drug. While on it, you will feel much less need or desire to sleep, and your ability to single-focus concentrate will go way, way up. Furthermore, there is no crash when the drug effect dissipates. And clinical studies indicate the drug has very low toxicity and addictive potential.

Nobody knows how this works. Pretty much all other wakefulness drugs exact a heavy price – they’re toxic, addictive, psychotogenic, derange your sleep cycle, and known or suspected to have baleful long-term effects on your neurochemistry even if you don’t have one of those short-term bad things land on you.

How do we know the drug is benign? Because there is actually decades of field experience with modafinil (and adrafinil, which is what it turns into when you metabolize it) in various military organizations. These drugs were first seriously investigated as go pills for pilots and SpecOps personnel on long-duration missions. They proved an effective (and unexpectedly non-injurious) replacement for dexedrine and other amphetamines.

This isn’t to say the military experience didn’t reveal any problems at all. I am reliably informed by a source close to the field military that in a few cases heavy modafinil users developed a kind of manic Superman syndrome – neglecting self-maintainance, going without sleep for months, overdriving themselves and their units into psychological and physical collapse. Later in this report I will suggest some lessons to be drawn from these incidents.

The things I read about the military experience were a major factor in convincing me to try modafinil. Nothing less than decades of toxic/addictive/psychotogenic effects not showing up at a level above statistical noise would have done for me, personally; I’m extreeeemely protective of my gray matter. I didn’t know of the Superman-syndrome outliers when I began using it; had I known, I would have found it obvious that this is not a problem with modafinil itself but with stupid people interpreting the drug as a license to be stupider.

I should also note that there have been a very few (as in about 5 cases per million) reports of a very nasty necrotic skin disorder called “Stevens-Johnson syndrome” being brought on by modafinil. But this also occurs as an equally rare side effect of a wide range of other drugs, and the incidence pattern suggests to me that the victims have a rare karotype that responds badly to all of them. Just as stupid people gonna stupid, fragile people gonna fragile. This means less than meets the eye.

(After writing the above I learned that my conjecture is correct. There’s a list of SNPs associated with susceptibility with Stevens-Johnson. The source also lists classes of other drugs that are likely to trigger it: antibiotics, analgesics, cough and cold medication, NSAIDs, antiepileptics, antigout drugs, cocaine and phenytoin.)

There have been an even tinier collection of reports (as in, countable on the fingers of one hand) of psychotic breaks in people introduced modafinil with no previous history of mental illness. Again, the incidence pattern creates a strong suspicion that these were fragile people whose neurotransmitter balance could have been messed with by any number of stimuli, and that modafinil was an accidental but not essential cause here.

Earlier I said “you will feel much less need or desire to sleep”, and that is true. However, modafinil does not actually abolish physical fatigue. What it does is (a) reduce your sleep need by about 2/3rds, sometimes more, and (b) sever the link from physical fatigue to drowsiness, distraction, and brain-fog. If you pay attention to your body while on the drug, you will notice that (after a longer time than usual) it is getting sore and clumsy from physical fatigue – but that will present as a sort of neutral mechanical fact that affects nothing about your mental state; your mind will stay clear, sharp, and focused until the dose dissipates.

Now to the last big thing about modafinil: there is clinical evidence of significant increases in IQ while on the drug. To what extent this can be separated from the large boost in ability to single-focus is not clear, and one 2005 study found a boost effect that decreased with increasing IQ. However, recent studies and a 2016 meta-analysis suggest a stronger and more consistent effect than did earlier ones, with significant gains in both executive function and learning capacity. But nobody knows how this works.

I can’t say as much about this from personal experience as I’d like to, because I don’t know how I’d tell if my IQ were elevated. It’s certainly not something one can notice as easily as “Hey! I can really concentrate.” Also, if it’s really true that the effect decreases with increasing baseline IQ, I’d be poorly positioned to notice it.

However: there is practical field evidence that backs up the more positive studies. I am reliably informed that demand for modafinil from STEM students at top universities and people in cognitively-demanding jobs has created a large underground around the drug. If this is true, the drug cops must be practicing benign neglect; to date, modafinil-related criminal charges in the U.S. can be counted on the fingers of one hand and all seem to have been a sort of decorative garnish on more serious indictments.

(Of course, this cannot be relied on to continue. Moral panics have been ginned up on even slighter causes in the past and doubtless will be again.)

I will also say that I notice some differences in my affect while on the drug that are at least consistent with it jacking up my IQ. It makes me feel calm, cerebral, and in control – the exact opposite of the jittery, volatile effect from caffeine or (I’m told) other conventional stimulants. Emotions aren’t gone but they’re a little damped, a little muted. Except, interestingly enough, for my sense of humor; that is fully operational or possibly even enhanced.

Related point: I find the onset bump when the adrafinil crosses my blood-brain barrier quite noticeable.

(I’ve heard that one of the commoner street names for modafinil is “zombie”. That makes a lot of sense if you think about how that slight damping of emotional swings is going to register to a person who lives in their emotions most of the time and barely even knows what “calm and cerebral” is like.)

Again, I’m probably not the best person to report on changes in affect. While doing web searches related to this topic I discovered several articles on the theme “ZOMG makes me a different person!”. That’s not my experience at all – rather, modafinil makes me more like me. It chemically pegs my affect to the same place I go naturally when I’m at the top of my game.

And am I actually more productive? Oh hell yes. I can tell by the amount of code and text I get written while on modafinil. Many users report productivity outside their normal range; I don’t get that, but I do get consistent performance at or near my normal peak level for as long as I’m on it.

You may be thinking modafinil sounds too good to be true. You have company; everybody who knows anything about drugs that mess with neurotransmitter balance has the same reaction when they learn the facts. Nobody knows how this works.

Before getting to management strategies, I will report another thing: Some but not all modafinil users develop a tolerance to the drug and require increasing doses to collect the effects they want. Odds of developing tolerance seem, unsurprisingly, to increase with frequency of use.

For the rest of this report, I am going to assume that you are either a U.S. citizen with a narrowly valid medical reason to use modafinil (such as spasticity or narcolepsy) and a legal prescription, or you live in a non-U.S. jurisdiction that does not restrict the drug, or you have other means of legal access. I will further assume that you want to maximize the nootropic and other benefits of modafinil while minimizing the risks.

Let’s inventory the risks:

First: Stevens-Johnson syndrome.

Second: Lifestyle dependency. While the clinical studies suggest very low potential for either physical or psychological addiction, you don’t want to go anywhere near subtler, functional versions of addiction either.

Third: Acquired tolerance requiring increasing doses.

Fourth: Self-damage through ignoring physiological cues partially suppressed by the drug (manic-Superman syndrome would be the extreme example of this).

Now the mitigation methods:

Against Stevens-Johnson, don’t have a fragile karotype. OK, there’s not much you can do to prevent that. So learn the symptoms of Stevens-Johnson syndrome and if you think they’re developing, stop taking modafinil and see your doctor immediately. One bit of good news is that you only have to pass this gate once – if they’re not triggered the first time you take it, they’re not going to be second and later times.

To avoid lifestyle dependency, plan your modafinil use around specific, non-recurring, slightly unusual challenges. Like: you need to not be clumsy and fatigued for a particular martial-arts test. Or, you need to put two or three working days’ worth days of peak effort into a project all at once.

To avoid tolerance buildup, don’t use it often. I seem to have a steady rate of about 1 200mg dose a month. I’m most likely to use it to handle unusual events where I want to be functioning at peak and perhaps expect to get less sleep than normal – SF conventions, for example. I will, as mentioned, also take it before a kung fu test for prophylaxis against palsy effects,

To avoid self-damage, self-monitor. In particular, stay aware of your physical fatigue level. Sometimes when I’m on modafinil and my muscles start getting fatigue-sore after hour 20 or so, I take a hot shower and a short nap to make the muscles happier even though my brain doesn’t need the rest yet.

That’s it, really. The last part, self-monitoring, is I think the most important. The drug will expand the envelope of what you can do; take those gains but treat yourself gently – no need to push the expanded envelope to collapse.

Modafinil is actually a mix of two enantiomers, only one of which is active. Once I use up my last few doses, I will be switching to a variant called armodafinil that is just the purified active enantiomer. I’m told it has a gentler onset and a longer dwell time,

A use for which I can certify it is combating fatigue on long drives. The effect I have seen in this application is so dramatic and benign compared to riskier drugs like amphetamines that I think this is in itself a sufficient argument for making modafinil and its variants over-the-counter drugs rather than prescription – they would would rapidly displace much more harmful substances and probably significantly decrease highway fatalities.

The drug also has much to recommend it for medical personnel, search & rescue people, police, and anyone else who has to work odd shifts under potential stress. The calming, anti-jitter effect is significant here and an improvement over large doses of caffeine, which promotes wakefulness without being particularly pro-concentration.

Finally, of course, there’s flow-state maintenance for programmers. Frankly, I don’t understand why steady use of modafinil is not already so dirt-common among people who code for a living that everyone takes it for granted. The pro-concentration effect is hugely helpful for productivity, and after a year of use I have experienced no downside at all, not even the jitters and wakefulness I would expect from deploying caffeine for similar purpose.

Nevertheless, I’m still wary of taking it more often, because I don’t want to develop that lifestyle dependency. On the other hand, I’ve seen a reason I might want to relax about this more as I get older. A recent study out of Italy suggests that modafinil improves centrality of neural function in elderly people, in effect mitigating or even partly reversing the effects of physical senescence on the brain.

Er, so, anti-senescence on top of everything else? Seems way too good to be true. But the positive results keep rolling in. I shall continue experimenting, self-monitoring, and perhaps occasionally reporting on it here.