Modafinil and Zolpidem Use by EmergencyMedicine ResidentsBrian D. McBeth, MD, Robert M. McNamara, MD, Felix K. Ankel, MD, Emily J. Mason, MD, Louis J.Ling, MD, Thomas J. Flottemesch, PhD, and Brent R. Asplin, MD, MPH

AbstractObjectives: The objective was to assess the prevalence and patterns of modafinil and zolpidem useamong emergency medicine (EM) residents and describe side effects resulting from use.

Methods: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationallyin the context of the national American Board of Emergency Medicine in-training examination. Dataregarding frequency and timing of modafinil and zolpidem use were collected, as well as demographicinformation, reasons for use, side effects, and perceived dependence.

Results: A total of 133 of 134 residency programs distributed the surveys (99%). The response rate was56% of the total number of EM residents who took the in-training examination (2,397 ⁄ 4,281). Past mod-afinil use was reported by 2.4% (57 ⁄ 2,372) of EM residents, with 66.7% (38 ⁄ 57) of those using modafinilhaving initiated their use during residency. Past zolpidem use was reported by 21.8% (516 ⁄ 2,367) of EMresidents, with 15.3% (362 ⁄ 2,367) reporting use in the past year and 9.3% (221 ⁄ 2,367) in the past month.A total of 324 of 516 (62.8%) of zolpidem users initiated use during residency. Side effects were com-monly reported by modafinil users (31.0%)—most frequent were palpitations, insomnia, agitation, andrestlessness. Zolpidem users reported side effects (22.6%) including drowsiness, dizziness, headache,hallucinations, depression ⁄ mood lability, and amnesia.

Conclusions: Zolpidem use is common among EM residents, with most users initiating use during resi-dency. Modafinil use is relatively uncommon, although most residents using have also initiated use dur-ing residency. Side effects are commonly reported for both of these agents, and long-term safetyremains unclear.

ACADEMIC EMERGENCY MEDICINE 2009; 16:1311–1317 ª 2009 by the Society for Academic EmergencyMedicine

Keywords: substance-related disorders, physician impairment, graduate medical education

M any emergency physicians (EPs) work clinicalschedules that disrupt circadian rhythms.Fatigue during shifts and insomnia after shifts

can be significant problems for EPs. Shift scheduling hasbeen cited as an important reason for EP attrition.1 Inaddition, there may be long-term health risks as a resultof chronic sleep deprivation and changing sleepcycles.2–4 Studies have examined circadian rhythm–based shift scheduling, sleep hygiene recommendations,and napping during overnight shifts.5–7 In addition tobehavioral and administrative changes, the issue of phar-macologic aids has also come to the fore in the past sev-eral years. With the development of new agents thatenhance wakefulness and an increasing array of sleepaids, there is potential for both benefit and harm for EPswho are attempting to regulate their sleep–wake cycles.

The industry surrounding sleep aids is vast. It is esti-mated that in 2005, more than 42 million sleep aid pre-scriptions were filled in the United States.8 One of thenew agents used increasingly for excessive sleepiness ismodafinil (marketed as Provigil by Cephalon, Inc.,Frazer, PA). Zolpidem (marketed as Ambien by SanofiAventis, Inc., Bridgewater, NJ) is a popular agent usedto combat insomnia. The use of these mediations andother sleep regulators may not be benign, and with

ª 2009 by the Society for Academic Emergency Medicine ISSN 1069-6563doi: 10.1111/j.1553-2712.2009.00586.x PII ISSN 1069-6563583 1311

From the Department of Emergency Medicine, Regions Hospi-tal (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Departmentof Emergency Medicine, Temple University Medical Center(RMN), Philadelphia, PA; the Department of Emergency Medi-cine, Hennepin County Medical Center (LJL), Minneapolis,MN. Dr. McBeth is currently with the San Francisco GeneralHospital, San Francisco, CA. Dr. Mason is currently with theSacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currentlywith the Mayo Clinic, Rochester, MN.Received April 13, 2009; revision received June 24, 2009;accepted July 14, 2009.Presented at the American College of Emergency PhysiciansScientific Assembly, New Orleans, LA, October 2006.This work supported by an internal grant from the Healthpart-ners Research Foundation, Bloomington, MN.Address for correspondence: Brian D. McBeth, MD; e-mail:brian.mcbeth@emergency.ucsf.edu. Reprints will not be avail-able.

increasing prevalence of use by the general population,EPs are likely to turn to these agents for aid with theirdemanding and fluctuating schedules.

There is little published literature on the use ofpharmacologic agents to regulate sleep–wake cyclesfor EPs. A recent study examined the use of modafinilon cognitive performance for EPs.9 A single recentWeb-based survey examined sleep aid use by EM resi-dents, but suffered from a very low response rate(16%).10 EM residents, with typically longer shifts andmore total clinical hours, may be especially susceptibleto circadian disruption and resulting sleep impairment.Residents represent the future of medical practice inthis country, and it may be that patterns of chemicaluse among physicians in training reflect futurechanges in substance use prevalence among physiciansas a whole.

The primary objective of this investigation was toassess the prevalence and patterns of modafinil andzolpidem use among EM residents. As a secondarygoal, this study aimed to describe side effects resultingfrom use of these medications.

METHODS

Study Design and PopulationThis was a voluntary, anonymous written survey studyof EM residents. Respondents were assigned a randomidentification number and were not identified by nameor residency program. The institutional review board of

the Healthpartners Research Foundation approved thestudy, with waiver of informed written consent to pre-serve the anonymity of study participants. Residentscompleting the American Board of Emergency Medi-cine (ABEM) national in-training exam in February2006 were asked to participate. There was no monetaryor other incentive to residents or programs to completethe surveys.

Survey Content and AdministrationResidents were questioned about the use of 15 differentsubstances (results previously published).11 The entiresurvey was limited to two double-sided sheets and wasdesigned to be completed in less than 10 minutes.

Residency directors were contacted in advance tosolicit their support and encouragement of residentparticipation. Reminder e-mails and phone calls follow-ing the in-training exam were used to encouragereminders to residents to complete and return thesurveys.

Questions regarding the use of modafinil and zolpi-dem were presented as a separate survey addendum(Table 1). Only residents who had previously usedmodafinil and ⁄ or zolpidem were asked to completethese questions, and the addendum was designed totake less than 5 minutes to complete. Frequency of usewas quantified by asking whether a resident had usedeach substance ever in their lifetime, in the past year, inthe past month, and ⁄ or daily. They were also askedwhether they felt impaired by or dependent on any of

Table 1Survey Questions

Questions Answer Choices

ModafinilHow often do you use this on night shifts? Every, most, occasional, rare, do not useWhat SAME-DAY strategy(s)do you use when takingit for a night shift?

I nap ⁄ sleep before shift and then take, I do not napbefore shift ⁄ just take modafinil

What NEXT-DAY strategy(s) doyou use when taking it for asingle or your last night shift?

I stay up all day after taking it,I nap ⁄ sleep right after the night shift

Do you ever take a second dose thatday after a night shift to keep you going that day?

No, <1 time ⁄ month, 1–2 times ⁄ month,3–4 times ⁄ month, >4 times ⁄ month

Do you ever take it for sleepinessother than on night shifts?

No, <1 time ⁄ month, 1–2 times ⁄ month, 3–4 times ⁄ month,>4 times ⁄ month

How do you feel it affects your clinical performance onNIGHT SHIFTS as opposedto before you started using modafinil?

Much better, slightly better, no change,slightly worse, much worse

Have you experienced anyside effects from modafinil?

No, minor side effects (list), major side effects (list)

ZolpidemHow often do you use this tofight insomnia or help fall asleep?

Every day, most days, occasionally, rarely, never

What strategy(s) do you employ to help sleep? I use zolpidem to help nap earlier in the day before a shift,I use zolpidem to help transition back to days after a series ofnight sifts

Do you feel it affects your clinicalperformance the day following using zolpidem?

Much better, slightly better, no change, slightly worse,much worse

Have you ever taken more than10-mg dose in a 24-hour period?

No, <1 time ⁄ month, 1–2 times ⁄ month, 3–4 times ⁄ month,>4 times ⁄ month

Have you experienced anyside effects from zolpidem?

No, minor side effects (list), major side effects (list)

Modafinil = Provigil, Alertec, Vigicer; Zolpidem = Ambien.

1312 McBeth et al. • MODAFINIL AND ZOLPIDEM USE BY EM RESIDENTS

the substances in the study survey and whether theyhad first used modafinil or zolpidem during residency.They were questioned about their reasons for using anyof the substances in the survey. General demographicinformation was also collected such as age, sex, maritalstatus, and geographic location.

The survey was distributed with an addressed,stamped envelope for easy return to an independentsurvey center, where the data were compiled, assuringblinding and participant anonymity.

Data AnalysisTo identify factors corresponding with modafinil andzolpidem use, a series of contingency tables stratifyingpatterns of substance abuse by the covariate of interestwas constructed. Depending on the properties of thevariable of interest (e.g. nominal, binary, or ordinal), atraditional chi-square test, McNemar’s test, or CochranArmitage test of trend was used. To determine if oursample was representative of all EM residents, we com-pared the age and sex distribution of our sample todata published by ABEM using a chi-square goodness-of-fit test.

Because of the relatively small number of reporteduses of modafinil (57) and zolpidem (516), certainresponse levels as listed in Table 1 were combinedwhen attempting to identify potential mitigating factors.For the question, ‘‘How often do you use …,’’ ‘‘every’’and ‘‘most’’ were combined to ‘‘most to every shift,’’while ‘‘rare’’ and ‘‘do not use’’ were combined to‘‘rare’’ (‘‘Do not use’’ would indicate respondents whohave used at least once previously, but indicate thatthey do not actively use now). For the question, ‘‘Doyou feel it affects your clinical performance …,’’ the cat-egories of ‘‘much better’’ and ‘‘slightly better’’ werecombined to ‘‘better’’ while the categories of ‘‘slightlyworse’’ to ‘‘much worse’’ were combined to ‘‘worse.’’For questions regarding levels of use, the responses‘‘No’’ and ‘‘<1 time ⁄ month’’ were combined to ‘‘<1time ⁄ month,’’ while ‘‘3–4 times ⁄ month’’ and ‘‘>4 time-s ⁄ month’’ were combined to ‘‘>2 times ⁄ month.’’ Wealso explored possible associations between modafiniland zolpidem and the use of other substances (caffeine,tobacco, cocaine, amphetamines, alcohol, marijuana,and benzodiazepines) using Kendall’s tau, which is anonparametric measure ranging from –1 to 1 reflectingthe degree of correspondence between two rankings,with 1 being perfect agreement and –1 being perfectdisagreement. Thus, a value of 1 implies the reportedlevel of zolpidem and ⁄ or modafinil use was associatedwith a similar level of another substance. Due to thesmall number of users of zolpidem and modafinil, theresponses regarding rates of use of these substanceswere collapsed to three categories: ‘‘never,’’ ‘‘rarely’’(past year or ever use), and ‘‘frequently’’ (past month ordaily).

Analysis was performed using the SAS 9.1 (SASInstitute Inc., Cary, NC). All statistical procedurestested a null of no significant differences using a two-tailed test at the 5% level. According to assumptions ofpower analysis performed prior to the start of thestudy, a response rate of 56% provided a traditionalchi-square test of association 86.3% power to detect a

10% differences in the distribution of responses acrossdiscrete covariate levels.

RESULTS

The surveys were distributed to all 134 of the EM resi-dency programs in the United States at the time, andthere was a 99% residency participation rate, with allbut one program agreeing to distribute the surveys totheir residents. Of the 4,281 U.S. EM residents who satfor the 2006 ABEM in-training examination, 2,397(56.0%) returned the primary survey. These 2,397 resi-dents comprised 54.7% of the total 4,385 EM residentsin U.S. training programs in 2006.12 Demographic char-acteristics of respondents are described in Table 2.

For each demographic variable, a chi-square test ofassociation was performed. The results indicatedrespondents were most likely to be male, be from eitherthe Northeast or the Midwest, married, and have grad-uated in the top 33% of their medical school classes. Itis uncertain how many residents actually received thesurvey, because distribution was performed by individ-ual residency directors and coordinators. The age(p = 0.46) and sex (p = 0.89) distributions of respondentsin this survey are nearly identical to published nationaldata (65% male; 63% ages 21–30 years; 34% 31–40 years).12

A total of 2,372 respondents indicated whether or notthey had used modafinil. Of these, 57 (2.4%) reportedpast modafinil use, with 66.7% (38 ⁄ 57) of those havinginitiated their use during residency. Frequency ofmodafinil use is shown in Figure 1. Of residents using

Table 2Demographic Characteristics of Survey Respondents

Characteristics n (%)

SexMale 1,520 (63.7)Female 867 (36.3)No response 10

Geographic locationNortheast 843 (35.8)Southeast 380 (16.2)Midwest 768 (32.7)West 361 (15.4)No response 45

Postgraduate year of trainingPGY1 709 (29.8)PGY2 745 (31.3)PGY3 715 (30.0)PGY4 211 (8.9)No response 17

Marital statusSingle 1,021 (42.9)Married 1,176 (49.5)Cohabitating 135 (5.7)Divorced ⁄ separated 46 (1.9)No response 19

Medical school performanceTop 10% 498 (21.6)Top 11%–33% 1,137 (49.4)Bottom 67% 666 (28.9)No response 96

Mean (±SD) age = 30.3 (±3.8) years.

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modafinil, 25.0% (9 ⁄ 36) reported that they have used asecond dose at least once after a night shift to remainawake, and 50% (18 ⁄ 36) reported using it for sleepinessnot associated with working night shifts. Twenty-threeof 36 (63.9%) felt that clinical performance was ‘‘muchbetter’’ or ‘‘slightly better’’ following modafinil use, andthere was an association between better perceived clini-cal performance and frequency of use (p = 0.033).Significant side effects were reported by 31.0% (13 ⁄ 42),most commonly including insomnia, agitation or rest-lessness, palpitations, and nausea or anorexia. Therewas no association between pattern of scheduling(circadian, blocked, random) and frequency of modafiniluse (p = 0.64). Denominators for these data are lessthan total modafinil users (n = 57), due to variance inresponse to individual questions.

A total of 2,367 respondents indicated whether or notthey had used zolpidem. Of these, past zolpidem usewas reported by 21.8% (516 ⁄ 2367), with 15.3%(362 ⁄ 2367) in the past year and 9.3% (221 ⁄ 2367) in thepast month (see Figure 1). Three-hundred twenty-fourof 516 (62.8%) residents reporting zolpidem use initi-ated use during residency. Of zolpidem users, 57.3%used the drug ‘‘rarely’’ to fight insomnia, while 37.2%were ‘‘occasional’’ users. The reported use on ‘‘mostdays’’ was 4.9%, and 0.6% of users reported use ‘‘everyday.’’ Of those respondents indicating a strategy forzolpidem use, 80.1% (213 ⁄ 266) indicated that they usedthe drug to help transition back to days after a series ofnight shifts, whereas 19.9% (53 ⁄ 266) used it to help napprior to a night shift. Seven percent of zolpidem usersreported using multiple doses within a 24-hour period(25 ⁄ 355). Again, denominators are less than total zol-pidem users (n = 516), due to variable responses toquestions.

Most residents (60.1%; 197 ⁄ 328) felt that zolpidem didnot significantly affect their clinical performance (seeFigure 2). Ninety-nine of 328 (30.2%) felt that their clini-cal performance was ‘‘much better’’ or ‘‘slightly better’’following zolpidem use, while 9.8% (32 ⁄ 328) felt that itwas ‘‘much worse’’ or ‘‘slightly worse.’’ There was norelationship between better perceived clinical perfor-mance and increased frequency of use (p = 0.088). Sideeffects were reported by 22.6% (79 ⁄ 350) and most

commonly included drowsiness, dizziness, headache,hallucinations, depression ⁄ mood lability, and amnesia.There was no association between pattern of schedul-ing and frequency of zolpidem use (p = 0.26).

Table 3 compares reported levels of zolpidem usewith reported levels of caffeine, tobacco, cocaine,amphetamine, alcohol, marijuana, and benzodiazepineuse. There did not appear to be any associationbetween the level of zolpidem use and these substances,with Kendall’s tau ranging from 0.05 to 0.18. Similarly,there did not appear to be any association between

Figure 1. Frequency of modafinil and zolpidem use by resi-dents (% of residents reporting use).

Figure 2. Perceived impact of zolpidem on clinical perfor-mance.

Table 3Association of Zolpidem Use with Other Substances

Substance Never Rarely Frequently Kendall’s Tau

Caffeine 0.07Never 77 7 3Rarely 114 12 7Frequently 1,660 276 211

Tobacco 0.13Never 1,072 122 94Rarely 535 116 76Frequently 244 57 51

Cocaine 0.11Never 1,738 257 193Rarely 109 34 24Frequently 4 4 4

Amphetamines 0.12Never 1,736 247 193Rarely 102 45 22Frequently 13 3 6

Alcohol 0.05Never 151 8 9Rarely 240 30 18Frequently 1,460 257 194

Marijuana 0.18Never 1,110 114 84Rarely 658 161 119Frequently 56 20 18

Benzodiazepines 0.13Never 1,736 247 193Rarely 102 45 22Frequently 13 3 6

1314 McBeth et al. • MODAFINIL AND ZOLPIDEM USE BY EM RESIDENTS

modafinil use and these substances, with Kendall’s tauranging from 0.04 to 0.13.

DISCUSSION

Proper sleep hygiene is important for EPs and othernight-shift workers. Sleep disturbance and schedulingdifficulties have been correlated with job burnout anddissatisfaction among EPs.1,13 Practice patterns may beestablished during residency, and if they includeunhealthy sleep habits, this has the potential to affectjob satisfaction, career longevity, and personal health.14

With increasing availability of pharmacologic sleepmodifiers, it is not surprising that some EPs and EMresidents are turning to these agents for assistance.Modafinil is a central nervous system (CNS) stimulantthat is related to the amphetamine class.15 It wasapproved by the U.S. Food and Drug Administration(FDA) in 1998 for narcolepsy and then in 2004 forobstructive sleep apnea and shift work sleeping disor-der (SWSD). The mechanism of action is unclear, butCNS activation occurs in the hypothalamus and otherareas of the brain that regulate sleep and seems to bemore selective compared to amphetamines, whichresult in more global activation of the brain.16,17 It isprimarily used to promote wakefulness in people withexcessive sleepiness.18 There is also significant‘‘off-label’’ use for attention deficit and hyperactivitydisorder, fatigue, and depression. It is metabolized inthe liver by the CYP3A4 pathway. Its side effect profileincludes cardiac dysrhythmias and hypertension.19

Modafinil affects mood, perception, thinking, and feel-ing, which has raised concern about the potential forabuse. Recently, the FDA added warnings to modafinil’sside effect and safety profile, including severe hyper-sensitivity reactions (Steven Johnson’s syndrome)and severe psychiatric symptoms (psychosis, mania,suicidality).20

Zolpidem is a nonbarbiturate hypnotic that wasapproved by the FDA in 1992 for short-term insomniause.21 The extended-release formulation, Ambien CR,was approved by the FDA in 2005. Zolpidem is thoughtto selectively bind the omega-1 subunit of the GABA-Areceptor complex in the CNS.22 Stimulation of thisreceptor subunit may be involved with sedation, anxiol-ysis, myorelaxation, and anticonvulsant activities. Itsproposed benefit is to enable an individual to get tosleep faster and sleep through the night. Zolpidem isgenerally recommended for only short-term use, aschronic use may diminish efficacy. It is metabolized bythe liver and cannot be dialyzed. Its side effect profileincludes worsening of psychiatric illness (particularlydepression), somnolence, dizziness, and headache.There are also case reports of amnesia, withdrawal sei-zures, and sleep walking.22–25

Modafinil use by EM residents appears to be rela-tively uncommon. Although uncommon, most usersappear to have initiated use during residency. It has notbeen available as long as zolpidem, and only over thepast few years has it become known and approved fortreatment of sleepiness outside of narcolepsy. Withincreasing recognition of SWSD among EPs, increasedindustry marketing, and more prevalent off-label use,

modafinil may become increasingly popular in thefuture to combat sleepiness by EM residents andattending physicians.

Zolpidem use, in contrast, appears to be commonamong EM residents, with most users also having initi-ated use during residency. This hypnotic has been avail-able for 15 years and recently has been aggressivelymarketed as a safe and nonaddictive alternative forinsomnia, when compared to more heavily sedatingbenzodiazepines. The U.S. military has adopted its useto help pilots sleep after missions.26 However, as zol-pidem use becomes more frequent and experiencegrows, there are increasing reports in the literature ofsignificant side effects, dependence, and withdrawal.27–

30 A number of residents in this study reported signifi-cant neuropsychiatric complaints after using zolpidem,including visual hallucinations, amnesia, mood alter-ation, and oculomotor derangements. More commonlyreported side effects were daytime sleepiness, forgetful-ness, and dizziness. Examples of specific residentcomments are listed in Table 4.

Side effects from both of these medications werereported by the residents in this study, and the safetyof these agents remains unclear. A resident who experi-ences ataxia or diplopia from zolpidem may be athigher risk for fall or injury. Amnesia and neuropsychi-atric symptoms (hallucinations, depression) are veryconcerning as well, even if transient. As educators, it isimportant to be aware of the use of these agents byresidents, with regard to patient care and safety, as wellas resident wellness. If a resident were to arrive for anight shift with residual sleepiness after using zolpidemduring the day, it may have the potential to affect cog-nitive ability and, subsequently, patient care. However,it is an open question whether this drowsiness wouldbe more limiting than fatigue from presumably lesssleep had they not used the drug.

There does not appear to be significant correlationbetween the use of modafinil or zolpidem and other sub-stances examined here, including agents very commonlyused to regulate sleep, such as caffeine, alcohol, andbenzodiazepines. Although speculative, residents’

Table 4Examples of Resident Comments Regarding Side Effects ofZolpidem

‘‘Slept through three alarm clocks, have not used since’’‘‘Decreased responsiveness ⁄ alertness’’‘‘Gait ⁄ vision disturbance, drunkenness’’‘‘Reduced sexual inhibitions, amnesia’’‘‘Transient diplopia’’‘‘Dizziness, ataxia if I don’t get to sleep right away’’‘‘Impaired memory of few hours before taking’’‘‘Depression’’‘‘Lethargy, first few hours awake seem like I am intox.’’ [sic]‘‘Transient depression, emotional instability’’‘‘Slept for 14 hours then felt groggy all day. So I never tookagain’’‘‘Black out, forgot discussions’’‘‘Wacky’’‘‘Unstable on feet when awake during sleep to usebathroom’’‘‘Visual hallucinations’’

ACAD EMERG MED • December 2009, Vol. 16, No. 12 • www.aemj.org 1315

perceptions of these new agents may be different (safer,less habit-forming, etc.). Why residents may choose touse zolpidem deserves closer examination.

One area of interest that this study did not addresswas how residents were obtaining these medications.Both modafinil and zolpidem are Schedule IV controlledsubstances with some potential for abuse, and ideally, ifmedically indicated, they would be prescribed by anoffice-based physician: a primary care provider orspecialist, who could monitor the use of the medicationon an ongoing basis. The Council on Ethical andJudicial Affairs of the American Medical Associationstates that it is inappropriate to self-prescribe acontrolled substance.31 Requesting a prescription froma colleague who is not a treating physician is aninappropriate imposition, and writing that prescriptionmay contribute to an underlying substance useproblem.

Finally, it is also concerning that most residents usingthese sleep-modifying agents are initiating use duringresidency. This raises the question as to whether thereis a culture of acceptance of use among residents andwithin residency programs. Residents may be morelikely to experiment with these substances if their peersare using them, and there is an implicit acceptance ofthis practice within emergency departments. Such aresidency ‘‘culture’’ of support for substance use tocope with the stress of work and difficulties of traininghas been previously described for alcohol and othersubstances.32

LIMITATIONS

This was a descriptive study and is clearly limited byresponse rate, although response rate is comparable tosimilar surveys.10,11,33–35 One can raise the question ofwhether nonrespondents differ from respondents.There are several reasons why a resident might choosenot to participate, including the time involved to com-plete the survey, fatigue after the in-training exam, andconcern with the sensitive nature of their responses.Although every effort was made to assure residents ofthe confidentiality of their answers, it is possible somechose not to participate due to concern that positiveresponses could affect their training and career. Askingsurvey respondents to self-report compromising behav-ior is a potential source for error if participants areunwilling to disclose. Recall bias and memory errorcould have also affected residents’ reporting patterns. Ifresidents using these substances are overrepresentedamong nonparticipants, it would skew the results to anunderestimation of prevalence of use. If, on the otherhand, nonrespondents represented fewer residents whouse substances, this could lead to an overestimation ofuse patterns. The confidential nature of the surveymakes characterization of respondents and nonrespon-dents impossible. However, residents participating inthis study appear to be generally representative of thenational sample, compared to ABEM data.12

The survey used in this study has not been validated.With a nonvalidated survey instrument, it is not possi-ble to be confident about the preciseness of reportedresponses and prevalence rates.

CONCLUSIONS

Modafinil use appears to be uncommon among EM res-idents. Zolpidem, on the other hand, appears to bemuch more frequently used. Users of both substancescommonly have initiated use during residency training.Side effects are reported for both of these agents, andlong-term safety remains unclear. Given the use ofthese substances by EM residents suggested in thisstudy, further research regarding their use by practic-ing EPs and the effects of these agents on the perfor-mance and well-being of EPs is warranted.

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