Vicodin, ketamine, and caffeine: The ingredients of a good space pharmacy

In space, no one can hear you sneeze. But if an astronaut does catch the flu, it can be a major problem. With the nearest Walgreens several hundred kilometers away, every medication an astronaut could possibly need on a space mission must be packed beforehand. It makes designing a pharmacy for space extremely complicated.

On top of that, of course, space itself poses potential medical issues. That extreme environment is known to warp the human body, shift fluids, and shrink bones, among other things. But microgravity can also affect how medications are metabolized, potentially making drugs less effective or even toxic.

Yet, despite 60 years of humanity sending individuals to space, there has been alarmingly little research into how meds work differently off-planet. While self-medicating in space has been common, there aren’t great records of who took what, when they took it, and how it did or didn’t help. There is some evidence that certain meds can be less potent in space and radiation may even degrade medications—but really, experts just aren’t sure.

“If you go to the doctor, there are basically three things they can do for you,” Dr. Virginia Wotring, a professor at the International Space University in Strasbourg, France, told Ars. “They can perform surgery, they can advise you to change your behavior—you know, stop smoking or whatever—or they can give you a medication. Which means [for space travel], a physician’s best tool is going to be the medication kit… This is something that merits attention, that astronauts deserve to know.”

The great unknowns

If all the careful preparation NASA astronauts Dog Hurley and Bob Behnken did recently to ride to the International Space Station in the middle of a pandemic doesn’t give it away, astronauts already abide by extremely strict health regimens. Even in healthier times, they quarantine for weeks before launches. Not much of their behavior needs changing. Surgery in space carries tremendous risk and luckily has never happened. Medication represents the best choice for out-of-this-world treatment by default, making the lack of research around the topic increasingly curious.

“At this point, we’re making an assumption that medications get absorbed and distributed to tissues and metabolized and excreted mostly the same way in space,” Worting said. “That might not be the truth.”

For example, a 2014 study measured sleep deprivation in astronauts aboard the International Space Station (ISS) and the drugs they took to get to some rest, such as zolpidem, brand name Ambien. The researchers, some from Harvard Medical School, found the astronauts often took a second dose in the middle of the night, presumably because the first dose didn’t provide enough relief.

But multiplying medications can mean increasing risk of side effects, or in the case of Ambien, potential grogginess during an emergency. Imagine trying to respond coherently after waking suddenly to a warning alarm while being “ambientoxicated.”

To better understand the mysteries surrounding what drugs would be effective for long-term stays in space, Wotring designed an iOS app that six crewmembers aboard the ISS volunteered to use for logging their meds in 2017. Every time they took a pill, the astronaut would record the drug name, the dose, the indication for taking the medicine, and whether they thought it worked, plus any side effects.

Wotring and her co-author LaRona Smith, a clinic administrator at Johnson Space Center, collected 5766 records of medication use—around 38 times more than the records from all previous space flights combined. “We were expecting more data,” Wotring said. “I was completely blown away when we saw how much data were coming in.” The results were published in the journal Aerospace Medicine and Human Performance this past January.

Medication use, on average, was somewhat more than on Earth, Wotring and Smith found. Sleep was the most common reason for taking a drug, but mild painkillers like ibuprofen were also frequently swallowed. “Most medications were considered partially effective,” they wrote. Even though the app apparently suffered from usability issues, causing the study to conclude early (insert Apple snark here), Wotring says NASA is in the process of adopting a similar protocol so they can better track their cosmonaut’s drug needs. Until then, a lot of unknowns remain.

“We know that there are physiologic changes to the human body in spaceflight. It makes sense that the effects of medications may be different in the altered physiology of the astronauts,” Dr. Tina Bayuse, lead pharmacist at Johnson Space Center Pharmacy Operations, said in an email. In 2002, she became the lead pharmacist for NASA’s first and only pharmacy.

“Changes in gastric motility may impact the absorption of medications,” Bayuse explained. “Fluid shift alterations may influence how medications are distributed or metabolized. The outcome of any of the known physiologic changes may result in medications that cause more side effects or are less effective.”