Thinking Fast and Slow

Modafinil’s tightening hold over students

01 June 2018

ON A FRIDAY EVENING in November 2016, a 20-year-old medical student sat behind a mound of papers in a crowded college library, cramming for an upcoming examination on pathology and forensic medicine. The student, in his second year at DY Patil Medical College in Pune, was panicking about the amount that he had left to study. Later that night, he complained to a friend about the formidable syllabus. The friend gave him a small, white pill, insisting that it would help with concentration. He took it on Saturday evening and revised through the night, then took another one on Sunday evening, and studied all of the following night as well.

The student managed to make it to the examination hall on time on Monday morning, but blanked out when the question paper was placed in front of him. Despite having spent the weekend reviewing incessantly, there were substantial parts of the syllabus that he could not remember, and he was seized by another bout of panic. “His hands started trembling and it looked like he was having a fit. He submitted an almost blank sheet of paper and ran out of the examination hall,” a 22-year-old classmate of the student later recounted to me.

“He had to keep studying all the time,” his classmate said, adding that, in the lead-up to the exam on Monday, the student had grown “obsessive” and pored over his textbooks with an almost manic absorption. While revising the microscopic features of specimens that he would have to identify on slides in the examination, he revisited the same paragraph repeatedly to assuage his anxiety about having missed any minor details.

Even after the ordeal of the examination, the student was unable to catch up on the sleep that he had sacrificed to study. His eyes would not close, and “he was anxious, irritable and restless through the day.” Despite refraining from taking more of the pills, he was unable to sit still, his hands continued to tremble and he fidgeted constantly. Conversing with him became almost impossible. He would “suddenly start a third topic while I was talking. He had sudden bursts of anger and tantrums.” For example, the classmate told me, “he got very angry if a person didn’t pick up his call.”

Many of modafinil’s frequent users take
it to ward off exhaustion while working incessantly. Researchers on cognitive enhancers have speculated about whether it induces a single-minded focus that is antithetical to the creative process.

His anxious state continued well after the exam—on Tuesday evening, two friends suggested that he accompany them on a walk around the university grounds. They strolled to the campus gate, which was surrounded by spring flowers. But the student agitatedly declared that he was overpowered by the pungent smell of garbage, even though everyone around him was enjoying the fragrance of the flowers.

The pills the student had taken—and which his friends were convinced had caused his uncharacteristic behaviour—were of Modalert.

“Modalert” is one of the Indian trade names for the cognitive enhancer modafinil. The drug belongs to a category of substances called “nootropics” or “smart drugs,” which purportedly improve mental focus and alertness. Modafinil is also a “eugeroic,” a drug that helps users evade sleep, stave off fatigue and work with singular concentration.

The classmate of the medical student admitted to having taken the drug before his second-year examinations. “It was either that or failing,” he stated grimly. His friend’s adverse experience, he said, deterred him from ever taking it again, but he estimated that around 140 of the 160 students in his batch use modafinil. “Around 50 are daily users who take mod to study every night,” he said. For the others, it is a desperate last resort during examination time.

Modafinil was originally developed in France in the 1970s, as a treatment for narcolepsy, attention deficit disorder and attention deficit hyperactivity disorder, and first commercially launched in the country in 1994. The primary researcher behind its discovery, Michael Jouvet, was an eminent neurophysiologist and sleep researcher who claimed in 1989 that modafinil had the potential to “keep an army on its feet and fighting for three days and nights with no major side-effects.” The Indian company Ranbaxy, which had been acquired by the multinational company Sun Pharmaceuticals Industries, launched modafinil in India in 2004, under the trade name Provake. It is currently manufactured by around five companies, and sold in India under various trade names, including Modapro, Modatec, Modfil and Modalert. For the students interviewed for this story, Modalert was the brand of choice.

Modafinil is often described as an alternative to Adderall—a stimulant widely used to combat ADHD and improve wakefulness and cognition. The New York Times reported that as of 2012, approximately 16 million adults between the ages of 20 and 39 in the United States had an Adderall prescription, and that the drug has a thriving off-label life on college campuses. Likewise, modafinil is popular among many who have not been diagnosed with any of the ailments it was originally used to treat. Many of its frequent users, who include corporate and tech professionals, air-force personnel, surgeons, truck drivers and students, take it to ward off exhaustion while completing seemingly insurmountable amounts of work. Four years ago, a survey of 2,000 students in the United Kingdom revealed that usage of the drug was widespread across academic institutions in the country, where one in five people had consumed it in order to stay awake and study. Similar research has not yet been conducted in India.

“The main culprits are medical students,” JD Mukherjee, a neurologist at Delhi’s Max Hospital in Saket, told me, noting that the drug had become increasingly popular over the last five years. A fifth-year student at the All India Institute of Medical Sciences in Delhi also said that the consumption of modafinil was rampant and normalised in medical institutions, and attributed it to the combination of an awareness of pharmacological innovations and intense academic pressure. Estimating that around 20 people in his batch of 70 are regular users, he enacted a typical conversation during the end of the year, where one bleary-eyed student tells another, “Neend aa rahi haiI am feeling sleepy—to which the other person promptly replies, “modafinil le lo”—Take modafinil. “You don’t understand,” he said, shaking his head furiously, “We have to be on top of our game every night. You feel guilty for taking a five-minute nap.”

While statistical data on modafinil’s usage in India is sparse, anecdotal evidence from my interviews with 12 students, two young professionals and four doctors suggests that the consumption of the drug is not confined to medical colleges. Its ubiquity in academic institutions across India might be a consequence of the ease of access to the drug in the country. Unlike several other places—such as the United Kingdom, where it is a prescription-only medicine, Russia, where it is banned for personal possession, and the United States, where it is a controlled substance—the drug can be bought over the counter in India, at approximately Rs 13 for a single pill (although prices vary for different brands). With such ease of access, it is likely that the use of modafinil will escalate, raising ethical questions about whether the common use of smart drugs poses a disadvantage to those who do not take them, and about the likelihood that these drugs grant their users a cognitive edge. There are other immediate health concerns to be contemplated as well, relating to the side effects that consumers of modafinil could experience.

SEVERAL MODAFINIL USERS I spoke with had dealt with a range of unpleasant side effects, including paranoia, a waning appetite and the temporary loss of certain creative faculties. A student at St Stephen’s College in Delhi mentioned an unquenchable thirst after ingesting the pill. A final-year Delhi University student who took the drug before his examinations said, “Modalert made a bit of a mess”—listing pre-examination paranoia, snappiness and a complete loss of appetite as side effects. A second-year student at the All India Institutes of Medical Sciences in Delhi was unsurprised when he experienced palpitations after ingesting the pill. “All stimulants increase heart rate, which is not a good thing,” he told me, adding that he had tried the drug because he was “very, very tired and had to study.”

Shwetank Bansal, a psychiatrist at the Delhi-based clinic Better Me Healthcare, told me over email that he had witnessed a considerable rise in modafinil consumption among adolescent and young-adult patients who did not have prescriptions for it. Describing the craze as a “ticking time bomb,” he explained that the drug “can have serious side-effects when used indiscriminately. These can range from the common ones such as headache, anxiety, nervousness, insomnia, raised blood pressure and palpitations to potentially life threatening side effects (though rare) such as transient ECG changes and cardiac disease.” Due to the paucity of research, there is little consensus on several aspects of modafinil, including whether it is addictive. Bansal told me that “modafinil is not considered habit-forming in clinical practice.” RS Bhatia, an Ahmedabad-based neurologist, also told me that its “addiction potential” was not very high. According to a 2009 paper co-authored by the director of the National Institute on Drug Abuse in the United States, however, modafinil may raise levels of dopamine—a neurotransmitter associated with feelings of pleasure—in critical areas of the brain associated with addictive behaviour. The paper cautioned that modafinil could be particularly dangerous for people who were already vulnerable to addiction.

At the opposite end of the spectrum are modafinil’s host of alleged positive effects. Barbara Sahakian, a neuropsychologist and a leading researcher on cognitive enhancers, has written extensively about its capacity for improving decision-making, working memory, motivation and cognition in cases of depression. In an interview with The Guardian, however, she suggested that the drug could have an adverse effect on chronic users’ sleep patterns, particularly those of students who tend to take additional doses once the first dose wears off. Sahakian remained apprehensive about the lack of knowledge about modafinil’s lasting effects on healthy people. “We just don’t have any long-term studies,” she said. “That’s why it’s so inadvisable to use them”—smart drugs—“until that’s done and that’s why I’ve been pushing the government to work with the pharmaceutical industry to do that.”

Sahakian’s recommendations for regulatory scrutiny would be useful to act on in India. As Chinu Srinavasan, the co-founder of a Vadodara-based general pharmacy, told me recently, modafinil is not on India’s lists of Schedule-H, Schedule-H1 and Schedule X drugs, amended in March 2018. (These categories mandate varying degrees of regulation, such as requirements for a doctor’s prescription for all three categories and a requirement for a second prescription to be retained by the retailer in the case of the second and the third.) In a 2012 report on the functioning of the Central Drugs Standard Control Organisation, the Parliamentary Standing Committee on Health and Family Welfare noted that “modafinil can cause serious skin reactions,” and recommended that the CDSCO regularly update information on marketed drugs. But although each strip of Modalert warns that the drug is “to be sold by retail on the prescription of a neurologist/ psychiatrist/ specialist,” none of its potential health risks feature on the packaging.

Several modafinil users I spoke with had dealt with a range of unpleasant side-effects, including paranoia, palpitations, unquenchable thirst, a waning in appetite and the temporary loss of certain creative faculties.

The office of the Drugs Controller General of India, or the DCGI—responsible for approving pharmaceutical drugs—did not respond to my phone calls and emails. I filed an RTI request with the CDSCO this March for documents pertaining to any complaints about the usage of modafinil, and about its possible inclusion among Schedule H drugs. The response stated that “there is no information available to furnish.” Sun Pharma also did not respond to my emails requesting information about modafinil.

In June 2017, I met with Alok Sarin, a psychiatrist at Sitaram Bhartia hospital in Delhi. He told me that he does not prescribe modafinil to patients without a history of narcolepsy, ADHD or a related disease, and appeared slightly surprised that modafinil is not a Schedule H drug. After looking it up on the internet, however, he remarked that the omission was perhaps not so anomalous, pointing out the inconsistency of regulations. “For instance donepazine, a dementia drug, is on the list, but many anti-psychotic drugs are not Schedule H,” he said. Methylphenidate, a sister drug of Adderall that is sold abroad under the trade name Ritalin, falls in the Schedule X category in India. Sarin added that the absence of regulation is also usually the outcome of a strong “pharmacological push,” a “subtle but very effective tactic of pharmaceutical companies” to boost their sales, and added that “the pushing of modafinil for severe mental illnesses”—such as dementia or depression—“where evidence of efficacy is iffy at best, is very much a part of this.”

As we were talking, Sarin turned abruptly to the telephone on his table and called the hospital chemist. He asked whether Modalert was available, and, if so, whether he could order a strip of ten tablets. Putting the receiver down, he told me that the chemist had reported that he had “standing orders from the DCGI” that any drugs which affect the cardiovascular or central nervous system—such as modafinil—not be sold without a prescription. Although this reaction appeared incongruous with the drug’s absence from scheduled lists, several modafinil customers in India have told me about similar encounters with informal, if erratic, forms of regulation.

The student of DY Patil Medical School, for instance, told me that the institution’s chemist shop does not allow students to buy modafinil without a prescription, and one attempt to buy Modalert at the shop without a prescription prompted a serious lecture from the attendant to stop relying on drugs and “try doing yoga instead.”

At an upmarket, well-stocked Fortis chemist shop in Delhi’s Green Park market, in June 2017, I was given modafinil in a matter of minutes by the attendant. I asked to speak with the manager of the outlet, and asked if they sold the drug. He insisted that it is only sold with a prescription. When I explained what had just transpired, he appeared confused for a few seconds, then hastily added, “You must be a Fortis member.” I said that I was not. He proceeded to show me a digital catalogue sent to them by the company’s head office—a sheet with a long list of drugs, some of which were highlighted in red—and claimed that modafinil lay in a class of drugs that required a prescription to be sold. The attendant who sold me the drug offered me an alternative after he saw me talking to the manager. “Take Stress Nil instead, it is better than modafinil. It is an Ayurvedic medicine.” As he spoke, he pointed to a box of pills with an illustration of barks and leaves on the cover. The box was labelled “Pure Nutrition: Natural Treasures” and claimed that Stress Nil could “Support Cognitive Functions.”

At a smaller chemist shop in the same market, the attendant insisted after selling Modalert that he required a prescription for the drug, and that he had a letter from the DCGI mandating it, though he said he could not find it now. He, too, appeared unable to reconcile this position with his previous sale a few moments ago, and finally conceded that he sometimes relaxes the rule, particularly in the cases of “call centre-wale log jo raat bhar jaage rahten hain”—people who work in call centres and stay up all night.

A similar sequence of events took place when I visited five chemists in Delhi’s Yusuf Sarai market, all of whom handed me modafinil without a prescription and later insisted that they normally only sell the drug after seeing one. The fifth chemist estimated that an average of a hundred customers visit his shop each month to buy Modalert, but said that they all come with prescriptions. At the fourth chemist, the manager jokingly turned to his attendant and said, “Mujhe bhi neend aa rahi hai, Modalert de diyo”—I am feeling sleepy too, give me some Modafinil.

At Sitaram Bhartia hospital and in the chemist shops I visited, it appears that a few chemists do exercise some degree of caution, either of their own accord or in obedience to an often ambiguous source of authority. “Some method of oral instruction is working as a preventive mechanism. Nevertheless, the weakness in the system is clear,” Sarin said resignedly.

Several students I spoke to had found ways to procure the drug. The DY Patil medical student, for instance, told me that because of the restrictions at the local chemist, students at the college “become friends with the MD students, who write us a prescription for ADHD.” I also spoke with a master’s student of cognitive science at IIT Gandhinagar, who said that he unwittingly became “the go-to-guy” for modafinil during his final year as an undergraduate—although he claimed to have only shared the drug with a small group of friends who were as enthusiastic about “mind alternation” as he was at the time.

The widespread presence of the drug and information about it in elite academic establishments suggests that the efficacy of informal forms of regulation is minimal, and that more stringent regulation needs to be introduced to monitor its circulation.

Unsurprisingly, it also appears that the easy access to modafinil in India is helping modafinil users in other countries with more stringent regulations obtain the drug. A 27-year-old Delhi resident, for instance, told me that he was recently contacted by an elderly friend of his parents living in Cambridge in the United Kingdom. She asked him to help her procure Modalert, which she “needed to stay awake” and could not buy in the country without a prescription. He was reluctant to risk couriering the drug, and instead sent it with a relative who was going to England. He had previously witnessed other family members exporting modafinil: his maternal uncle, a psychiatrist in Birmingham, routinely “takes modafinil for a psychiatrist friend of his who cannot have it prescribed.” His uncle, he said, buys it from a “friendly neighbourhood chemist” in Gurugram, who “always hands the pill over without questions.”

IN THE SUMMER OF 2017, I met Ritwik Agrawal, a PhD candidate in philosophy at the University of Missouri-Columbia in the United States, at a cafe in Delhi’s Kailash Colony market. He observed that it is likely that upper-class students at elite institutions across India hear about the drug through their “informal networks,” such as friends abroad and particular social-media groups. “The mystique around modafinil needs to be countered with strong research for it to lose its status as a ‘wonder drug,’” he said. Bringing the drug properly into the legal framework might help uncover more data about whether it offers a cognitive edge to its users, which, according to Agrawal, is a fundamental ethical concern.

Arudra Burra, an assistant professor of philosophy at IIT Delhi, considered the ethical dilemma posed by smart drugs from a different angle. “Like many other technical solutions to essentially non-technical problems,” he told me, “the nature of the intervention provided by these drugs masks the structural problem which causes students to turn to them in the first place.” For Burra, the use of modafinil as a way in which to tackle academic pressure is problematic because it sidesteps the issue of whether current levels of academic competition are sustainable in the first place. “Smart drugs might have a legitimate role in intellectual life—the great mathematician Paul Erdös famously used amphetamines to fuel his work in mathematics. But using them in pursuit of a deep intellectual commitment is quite different from using them to beat the competition in an exam.”

The final-year Delhi University student I met appeared entirely unperturbed about boosting the brain for furthering academic careers. He compared it to “drinking at a party.” He said that “many people just didn’t study through the semester, it was a chilling scene all the time.” The student recalled attending parties every week, taking impulsive road trips and regularly using alcohol, caffeine, cocaine and psychedelics. In the lead-up to examinations, however, his fellow students were engulfed by a sense of hopelessness and mounting panic, and his syllabus for upcoming examinations appeared unmanageable. Despite recounting the negative side effects he experienced after taking the drug through his final semester, including paranoia and snappiness, he told me that he did not think students should be discouraged from taking modafinil. “It’s not against the law of the university, it’s not against the law of the land, so what’s the problem?” he said.

Other students were similarly defensive. The fifth-year student at AIIMS was deeply offended at the moral censure that surrounds the rampant use of neuro-enhancers on his campus. “You’re talking about ethics, but what about coffee? Or Mom’s chooran,” he said angrily. “They are not Schedule H drugs, but it’s no crime,” he said. “We think anything we eat is good. But as soon as we use the word ‘drug,’ there’s a stigma. Why don’t you judge me for drinking coffee?”

Neuro-enhancers also appear to have permeated the lives of young people in India beyond the spheres of academic institutions, with mixed effect. A web-designer at a design consultancy in Delhi described to me his experience with what he called “brain hacking.” He was drinking with a friend one evening when he first heard of modafinil. His friend promised him that his workday would improve vastly, but warned him to draft a list of things to do in advance, because modafinil could make you focus on anything. “I was more efficient than I’d ever been” he said, shaking his head in wonder. “Mundane work suddenly seemed so interesting.” But he found that too much focus was not always helpful. He could only do the task immediately in front of him. If a colleague asked him to comment on any other project, he found himself unable to break out of his present work. What he referred to as “context-switching” was hampered, but that was not the only problem. “I could do the mundane, mechanical tasks that I usually avoided,” he said, “but in the evening, a senior colleague came to draw a creative mind-map with me. I couldn’t do it, I couldn’t think of ideas. It went to shit.”

A student recalled attending parties every
week, taking impulsive road trips and regularly using alcohol and psychedlics. In the lead-up to examinations, however, his fellow students were engulfed by a sense of hopelessness and mounting panic.

The inability to get outside your mind also posed problems for a graduate of IIT-Madras, who now works in a major bank as a financial analyst. He highlighted the concentration that modafinil induced, describing a surge of confidence under the spell of which “it’s actually frustrating not to work.” On a typical day, he said, he would feel inclined to take a coffee break after a long meeting. On modafinil, he raced back to his desk and continued working. “I can literally skip breakfast-lunch-dinner, work non-stop from 9 to 6,” he said. Yet, he claimed that while the work suddenly became interesting, it drew him away from everything else. “Life feels meaningless, uninspiring ... I am unable to talk to people, understand things from others’ perspectives. I feel... un-empathetic,” he said, trailing off.

The Delhi University student also told me that there would be times during the exam where his mind would become “static, like a black-and-white TV.” On one occasion, he wrote three pages in English for a Hindi exam. Modafinil, it seemed, foregrounded the task alone, while the personal and the environmental contexts become inconsequential, even disposable. But he insisted confidently, “It’s not a big deal. Take it, become a weasel for two weeks, forget about it.”

Some researchers and commentators expressed concern about whether cognitive enhancers induce a single-minded focus that is antithetical to the creative process. A 2015 review by a pair of researchers from Harvard Medical School and the University of Oxford of the cognitive effects of modafinil in healthy, non-narcoleptic people found that, especially when more complex methods of assessment were used, modafinil induced an improvement in attention, decision-making, learning capabilities and executive function—defined as the ability to manipulate and effectively mobilise external information. Since participants reported no significant side effects or mood alteration, one of the researchers stated that “Modafinil seems to be the first ‘smart drug’ that is reasonably safe for healthy people,” and urged a wider debate on the ethics of cognitive enhancement among scientists, politicians and the public.

But the researchers noted that one study reported that the use of modafinil had negative effects on creativity for some people who were creative to begin with. For many, such as the students and young professionals with whom I spoke, the capacity for a kind of expansive, divergent thought process, in which the chaos of thinking is not funnelled into the service of a single solution, was made difficult by consuming modafinil. These knotty questions, as well as others about the drug’s long-term effects, likely have no conclusive answers at the moment.

For all the normalisation of the drug among young people, none of the drug’s users whom I interviewed were comfortable with their identities being disclosed. Many admitted that they do not always feel comfortable sharing their experiences on the drug with their peers. “Nobody wants their intelligence to be reduced to a pill,” the fifth-year AIIMS student said, and added that even partially attributing a person’s success to a drug such as modafinil could lead people to dismiss their accomplishments.

As we concluded our conversation, he once again expressed his frustration that the academic pressure in medical schools compels students to consume neuro-enchancers. “People think us doctors are gods, which is not right,” he said. “We do party, we have our fun, we smoke, we drink, and yes, we take modafinil.”

Uttara Chintamani Chaudhuri is a Delhi-based writer and a recent graduate of Ashoka University.

Keywords: Drugs education Health