Hope in the form of a sleeping pill

Need to sleep? Have you tried Ambien?

In a coma? Have you tried Ambien?

Doctors on the cutting edge of brain injury rehabilitation are finding that a sleep aid can bring some coma patients to a more wakeful state – sometimes years after the initial injury.  But is it a miracle or a mystery or a little of both?

Researchers and physicians are familiar with what a drug was developed to treat, but much less is known about exactly how it works and whether it has more than one use.  Some drugs may be found to have multiple uses although officially only labeled for one specific condition.

Discoveries, such as the case of Ambien, are often accidental.  Prescribe a drug to ease a patient’s sleep and the patient regains consciousness – even minimally.

Determining whether the drug actually works in ways other than approved by the FDA means methodically sorting out coincidence from actual indicators.  This takes time and money – and often involves dozens of variables – both known and unknown.

And even if effective off-label use is indicated that doesn’t mean drug manufacturers automatically do clinical trials, ramp up production or that insurance companies will pay for the off label usage.  Ambien costs very little comparatively, but some drugs run in the tens of thousands of dollars per year.

In the case of Ambien, N=1, perhaps better known as a case study, provides a starting point.  In this case the clinical progress of one person, then combined with reports of similar documentation, provided the impetus necessary for researchers to explore further.

Why does Ambien work with some coma patients and not others? Why do some patients initially improve and then drift back into unconsciousness?  Doctors and their families want to know this too.

Whether this and other treatments work hinges on a key decision. Many families are asked to consider terminating life support soon after the patient slips into a coma.  The decision must be made rapidly before the patient stabilizes enough to where it is more than refusing artificial ventilation or choosing to allow the patient to succumb to common infections. If there is the chance that the patient can be “brought back”  it may not be known immediately.

In “A Drug That Wakes the Near Dead,” a fascinating blend of hope, uncertainty and medicine by science writer Jeneen Interlandi, these questions are explored in the context of real lives.

The writer tells of patients who wake or regain near conciousness weeks, months, or years after the initial injury. Although communication may be sporadic and minimal, monitoring the brain with electrodes indicates that the patient has awareness.

How long should friends and family cling to hope? When is hope an illusion and when is it a realistic possibility? When will you know and can you know with certainty? Do you risk terminating the life of someone who is aware, but locked inside their body? Or is the soul long gone leaving only a husk behind? Medicine is always a case of we know in part, and a sleep aid may help scientists pick the lock on the puzzle of brain trauma.

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