Due to its dopaminergic activity and low abuse potential, Modafinil has been used in treatment of cocaine [ 7 ] and methamphetamine [ 8 ] abuse and correction of disturbed cognitive functions in alcohol dependent subjects [ 9 ]. Even though Modafinil abuse is not frequent, it’s still possible to encounter patients abusing the substance [ 1 ]. There are rare reports of Modafinil abuse in literature. In two of the three case reports that we encountered, subjects with Modafinil abuse concurrently had history of alcohol and benzodiazepine dependence, whereas a case who had schizoaffective disorder did not have history of alcohol or drug abuse. Maximum amount of Modafinil intake of the cases in these reports was 3,000 mg/day [ 10 12 ].

Modafinil is a non-amphetamine type stimulant used in narcolepsy, obstructive sleep apnea syndrome and circadian rhythm disorder [ 1 ]. Modafinil has also been tried for diseaserelated fatigue, attention-deficit disorder, Alzheimer’s disease, age-related memory decline, depression, cognitive impairment in schizophrenia, idiopathic hypersomnia, myotonic dystrophy, post-anaesthesia grogginess and everyday cat-napping [ 2 ]. Even though the action mechanism is not clear, it is thought to be distinct from other stimulant drugs [ 3 ]. Modafinil is known to act via its effects on noradrenergic (activation of alpha-1 receptors) [ 4 ] and dopaminergic [ 5 ] neurotransmission. Its wakefulness and activity-promoting properties are mostly related to its effects on these neuromediators [ 6 ].

CASE

Twenty-four years old male, single student, living in county town with his parents stated, in his own words that; he had been facing difficulty in listening to classes since primary school, had issue in concentrating, difficulty in making friends, had low academic success, had coerced particularly during transition to higher education and due to performance anxiety had clinical psychologist visits. Developmental and past psychiatric history, corroborated by his parents confirmed these complaints. During childhood he was obviously more active than peers, and he was easily distracted by external stimulus. The parents reported that, when he was 10 years old, they admitted to a child psychiatry policlinic complaining of inattention, difficulty in completing school work, organizing activities, following instructions, committing frequent mistakes, losing belongings and forgetting daily routines. He was diagnosed with ADHD by the child psychiatrist and stimulant medication was indicated. However, parents refused medical treatment due to concerns related to side effects. No further treatment was searched.

Patient reported that approximately 5 years ago, he begun consuming omega 3-6-9 preparations and vitamin supplements in order to increase his social and academic performance. Subsequently approximately 3 years ago, without any doctor suggestion, he commenced taking Modafinil in 50 mg/day dose, and gained improvements in attention, self-reliance, academic success and social activity. After a while, in order to be able to maintain initial effects, he necessitated increasing the dose and went on using Modafinil at 300-400 mg/day dose during 2 years. It was ascertained that since his ailments were not totally resolved and his exam load increased, 1 year ago he presented to a different psychiatry clinic than ours, where 20 mg/day short-acting Methylphenidate was initiated for attention deficiency and hyperactivity disorder diagnose. It’s realized that, as an addition to Modafinil he used short-acting Methylphenidate 60 mg/day. The patient stated that, even though he benefited from the Methylphenidate treatment, he did not use regularly and discontinued the drug. During the last year, he increased the Modafinil dose, in order to achieve the initial effects Modafinil and resulted in consuming 100 mg tablets, 5 times a day and 10 tablets most of the time. Whenever he quit using Modafinil or diminished the amount, he experienced irritability, anxiousness, sweating, tremor and an urge to take excessive Modafinil. The case presented to a different psychiatry clinic with a desire to quit Modafinil, where Modafinil was stopped and Venlafaxine at 75 mg/day, Risperidone 2 mg/day, Propranolol 80 mg/day and Olanzapine 5 mg/day were initiated. After discontinuation of Modafinil, he experienced fatigue, vivid and unpleasant dreams, sleeping irregularities, anxiousness, and functionality impairment, as previously. Since, despite the given treatment his complaints did not subside, he abandoned treatment and revert using Modafinil.

Modafinil that could be purchased over the counter before, became a prescription medicine with recent regulations in Turkey. Therefore the patient encountered difficulty in accessing the drug and presented to our polyclinic. During his anamnesis he presented his complaints as necessity to consume usurious doses of Modafinil, to be able to achieve the initial effects, difficulty in obtaining the medicine, irritability, tremor, anxiety, sleep disorder, fatigue, and unpleasant vivid dreams when he did not use the drug. It was realized that he was consuming 5,000 mg/day Modafinil since 1 month. After evaluation, he was admitted to our psychiatry ward with the initial diagnosis of “stimulant use disorder” according to DSM-5 classification.

During mental state examination performed in our clinic, he appeared at his age, was self-sufficient, his associations were normal, his speaking rate and amount was partially increased, and was anxious. He did not have active psychotic thought content, evaluation of actuality was normal. He had irregular sleeping pattern, decreased appetite and normal libido.

Family history revealed that his elder brother previously had alcohol addiction.

In our psychiatry ward, the patient was introduced Lorazepam 2.5 mg/day, Risperidon 1 mg/day and Ketiapin 25 mg/day. Following abandoning of Modafinil, cravings, pschomotor agitation, sweating, tremor, fatigue were observed. Therefore his treatment was modified to Diazepam 15 mg/day, Ketiapin 100 mg/day, Risperidon 2 mg/day. On the third day of his admission, the patient was discharged from the ward upon his own will. During his first control in outpatient clinic, it was realized that, although he had some benefits from treatment, his compliance to medication was poor. He requested prescription of Modafinil, and he did not attend to further control visits.