August 5, 2021: Among the many advances in military medicine since 2000, one of the least noted is improvements in alertness drugs which have been used for over a century to keep soldiers, sailors and eventually airmen alert during long periods of necessary wakefulness. Most current alertness drugs are non-prescription items, the most popular being an energy drink called Rip It. This is a budget version of more expensive and widely advertised versions like Red Bull.

The military provided Rip It free to troops in Iraq and Afghanistan after 2004 by purchasing large quantities from the manufacturer at wholesale prices. While Rip It retailed for a dollar an eight-ounce can, the Department of Defense got it for less than half that and the manufacturer made a profit because of the huge quantities shipped and the many new customers obtained in the home market as troops reported how useful the always available energy drink was. Whenever supplies were delivered to troops in a combat zone they expected to see Rip It along with water and MREs (dehydrated meals ready to heat after water was added). Rip It, containing 100 milligrams of caffeine per can, was an easier to handle alternative to caffeine pills (with as much or more caffeine) and coffee. In hot climates coffee, the traditional military source of caffeine, was at a disadvantage because it may have the same or twice as much caffeine but has to be served hot to be palatable. Iced coffee is not available to troops in the field. Rip It is palatable at any temperature and contained other useful minerals and nutrients.

At the opposite end of the scale there were prescription drugs, which often came with dangerous side effects. Then came Modafinil. First available in 1998, it has always been a prescription drug because of its potential addictiveness and uncertainty about long-term effects. After 2001 Modafinil became more widely used in the military and, so far, it has proved to be effective, non-addictive and, so far, not responsible for any long-term problems. But it was not as easily available or as enjoyable as Rip It, which came to be the alertness solution favored by troops.

The enemy often chose other options. In most of this post-2001 combat the enemy was Islamic terrorists and they were never concerned about safety or harm from long-term use. While Islamic terrorists found heroin, cocaine and prescription drugs useful, the most widely used Islamic terrorist alertness enhancer was the old World War II era standby of amphetamine ("speed") pills. When shipments of Islamic terrorist weapons and ammo were seized there were often quantities of amphetamines as well as guns, ammo and sometimes medical supplies. The Islamic terrorists and rebels throughout the world considered speed an essential drug for their fighters.

Amphetamines have long been used by military personnel to remain alert during combat situations. Islamic terrorists often don’t have access to military grade amphetamine pills but instead rely on a commercial product; Captagon. This is the trade name for fenethylline, a synthetic drug that has the same effects as amphetamine but with fewer bad side effects, like increased blood pressure. Fenethylline was still pretty potent and by the 1980s most countries had either outlawed it or made it a prescription drug. Despite that it was so popular in Middle Eastern nations that illegal production became common. The most common legal form of fenethylline is Captagon, which is widely available in the Middle East. Captagon is considered a major problem in the Middle East because there is so much illegal use of it. It is the stimulant of choice among many Islamic terrorists, rebels as well as security forces.

In the grand scheme of things, Captagon is simply the latest mood control drug used by combat troops and it is not the only one. For example, U.S. Navy SEALs often use sleeping pills (Ambien) while getting ready for operations. That often involves first flying long distances in cargo aircraft, then keeping odd hours in crude accommodations as final preparations are made. All this is quite stressful, making it difficult to fall asleep, even when exhausted. Getting some sleep is essential, so the SEALS are encouraged to take stuff like Ambien if they need it. Many journalists found this shocking. Some even found it disturbing. But taking sleeping pills and stimulants is an ancient tradition. The alternative is getting killed in combat.

The big problem is maintaining alertness in a stressful environment. Once in combat American troops are issued stimulant pills and gum to help them stay alert. Back in 2007, the U.S. Army began issuing "Stay Alert" caffeine gum to combat troops, in cases where Rip It was not available. This was yet another in a long line of drugs troops have been given to keep them alert after long hours in a combat zone. This fatigue problem has existed for a long time and has become particularly acute in the last century or so, as battles became endurance contests, with forces engaged for days on end.

The U.S. Air Force had a similar problem. In the last few decades, as long-range bombers and refueling in the air became common, pilots have had to face alertness problems during very long (30 hours or more) missions. In sixty years of using "go pills" (amphetamines), the air force has never had an instance where the stimulant caused a crash or accident. In contrast, over a hundred crashes have been caused by pilot fatigue.

For over a century now one of the more popular fatigue solutions has been amphetamines. However, this drug can impair judgment, making the user more aggressive. Ambien has similar side effects. After September 11, 2001, it was noted that kinder and gentler alertness medications had become available. The most effective of these has been Modafinil (sold as Provigil). This stuff is described as "a mood-brightening and memory-enhancing psychostimulant which enhances wakefulness and vigilance." Tests showed that user performance was degraded 15-30 percent, versus 60-100 percent for those who took nothing at all after 24 hours of being awake.

While the Modafinil did a pretty good job, the dextroamphetamine was still a bit better. Because of that, amphetamines remained competitive until it was noted that Modafinil was much less addictive and appeared to have no long-term problems. Because Modafinil was not addictive for most users, there was a lot less long-term use. Another new stimulant, touted as superior to dextroamphetamine and Modafinil, CX717, was tested by the Department of Defense and found not appreciably superior to existing stimulants.

Meanwhile, the U.S. Navy continues to use coffee, and lots of it, to keep sailors on their toes during long hours of continuous duty. But for infantry and pilots, a hot mug of coffee is often not an option and Rip It or caffeine gum and pills are adequate replacements, especially Rip It, because it is mostly water with sugar and other flavorings and alertness enhancing ingredients.

Wakefulness can be a potent weapon, especially for commandos or troops engaged in prolonged combat, like the Battle of Fallujah in 2004 and similar long-term and intense operations. Without these wakefulness drugs, you would have to either pull troops out of action so they could rest or leave them in and risk having them make fatal mistakes. Either way, you have a problem because there are never enough troops to get the job done. But with the wakefulness medications, you can solve the problem, for a few days, anyway.

Prolonged use of these drugs is not healthy. But neither is being drowsy during combat. It's better to get some sleep when you can, even if you have to take more medications to help make that happen. Troops exposed to prolonged combat find the stimulants lifesavers and consider them as essential as ammunition. Islamic terrorists consider a weapons and ammo shipment incomplete if some Captagon was not included just as the American troops they faced expected to see 24-can cases of Rip It included with other essentials.