Did you know that barbiturates were once the most-dangerous prescription drug threat in America?
While the continuing opioid epidemic continues to dominate headlines and news stories across the United States, there are other types of prescription medications that present significant dangers that are vastly under-reported. Barbiturates fall into this category.
Many people mistakenly believe that barbiturates are obsolete drugs that are no longer prescribed. And while it IS true that they have been largely replaced by benzodiazepines, they are still dispensed far more often than you might think. Every year, approximately 300 tons of barbiturates are manufactured in the United States.
Although barbiturates have legitimate medical applications, the problem arises when they are misused recreationally for their pleasurable or intoxicating effects. Like other drugs of abuse, barbiturates have a high potential for addiction and present a significant risk of fatal overdose.
How dangerous are barbiturates?
Put it this way – they are frequently used for euthanasia, assisted suicide, or capital punishment.
In 2007, The Lancet published an analysis of the harm caused by 20 “drugs of potential misuse”. Barbiturates were ranked:
- #3 in terms of physical harm
- #4 in terms of social harm
- #5 in dependence
What are Barbiturates?
Barbiturates are once-popular prescription sedatives that have largely been replaced by benzodiazepines. Like “benzos”, opioids, and alcohol, barbiturates work by depressing the Central Nervous System (CNS).
Over 100 years ago, barbiturates were first introduced therapeutically, when barbital was marketed by Bayer as a sleeping aid, under the brand names Veronal and Medinal. At first, it was considered to be a significant improvement over the bromides used at the time.
Originally, barbital was given as a treatment for “insomnia induced by nervous excitability.” Over time, the use of barbiturates expanded as doctors prescribed them to treat not only sleep disorders, but also anxiety, epilepsy, and severe migraine or cluster headaches.
Tellingly, barbiturates are also used as general anesthetics.
Barbiturate medications are categorized by their speed of onset and their duration of effects and may include:
- Very short – Effects occur within 20 minutes.
- Methohexital (Brevital)
- Sodium Thiopental (Pentothal)
- Thiamylal (Surital)
- Short – Effects occur within 40 minutes and last up to 6 hours. This is the most-commonly abused class of barbiturates.
- Amobarbital (Amytal)
- Apropbarbital (Allonal, Oramon, Somnifaine)
- Butobarbital (Butisol)
- Pentobarbital (Nembutal)
- Secobarbital (Seconal)
- Long – Effects can last several days.
- Allobarbital (Cibalgine)
- Alphenal (Efrodal, Prophenal, Sanudorm)
- Mephobarbital (Mebaral)
- Methylophenobarbital (Prominal)
- Phenobarbital (Luminal)
Barbiturates vs Benzodiazepines
Because they have similar effects on the CNS, some people think barbiturates and benzodiazepines are the same thing. However, these are two completely different classes of drugs.
The biggest difference is in their potential for fatal overdose. Higher doses of barbiturates directly lead to respiratory depression, potentially to the point of death, but this is not the case with benzodiazepines. In fact, even though they are involved in one-third of all prescription drug overdose fatalities, when taken alone, benzodiazepines are very rarely the cause of death or even serious complications.
History of Barbiturate Use in the United States
During the first part of the 20th century – especially during the 1930s and 1940s – barbiturates were popular prescription “wonder” drugs. According to the Saturday Evening Post, there were enough users of barbiturate sleeping pills in 1939 to account for the sale of over 2.2 MILLION daily doses. By 1945, that number had nearly tripled.
Eventually, over 2500 barbiturates were synthesized and used to treat a wide variety of conditions, including:
- Melancholic depression
- Epileptic seizures
- Intravenous anesthesia
- Delirium tremens
Shortly after the end of the Second World War, US doctors were prescribing 250 tons of barbiturates annually, and by the 1960s, there were enough of these drugs in stock to give every American 18 doses.
The number of barbiturate prescriptions have decreased significantly since the 1970s. Today, benzodiazepines are dispensed as the first-line pharmacological treatments for anxiety disorders and sleep disturbances.
Barbiturates and the US Military
“And this would give them a very deep, deep sleep, sort of almost a trance-like sleep for 24, sometimes or 48 hours. And then they would– they would come out of this in, depending on the dosage, 24, 48, 72 hours, and they’d be walking around, completely numb. Sometimes they would be slipping and falling. That took a few more hours.”
~ Captain Ben Kimmelman, 103rd Medical Battalion Special Troops Dental Officer
During World War II, barbiturates were given to American soldiers to help them cope with what was then labeled “battle fatigue” – what we today call post traumatic stress disorder – so they could return to combat. These “blue 88s” were primarily composed of sodium amytal, and they had a profound calming effect of psychiatric casualties.
Service members stationed in Asia or the South Pacific were also given barbiturates. The theory was the drugs’ depressant effects would lower respiratory rates and blood pressures, thereby helping soldiers cope better with the region’s extreme humidity and heat.
Barbiturate Tolerance and Dependence
Barbiturate tolerance develops very quickly, possibly with the very first administration. This means that larger and larger doses are required for the medication to be effective. This is a significant problem, because the therapeutic “window” for barbiturates – the dosage at which the drugs work but are not harmful – is very small.
- FIRST, such a rapidly-manifesting tolerance plays a pivotal role in the subsequent risk of abuse, a potential resultant barbiturate dependence, and the development of an addiction to the medication.
- SECOND, barbiturate use turns into abuse because higher doses cause the user to experience pleasurable euphoric effects. They will feel relaxed, happy, and less inhibited.
- THIRD, because of the specific mechanism of action of barbiturates within the brain, physical dependence is far more severe than with other drugs of abuse, even alcohol and benzodiazepines, meaning withdrawal symptoms may be fatal.
Significantly, barbiturate dependence and the severity of withdrawal symptoms are “dose-dependent”. This means that heavier or long-term addicts will be affected far more than short-term or low-dose abusers.
Of special relevance, physical dependence on barbiturates can develop in as little as one month.
More about Barbiturate Withdrawal
Withdrawal from barbiturates is perhaps more dangerous than from any other addictive substance. Symptoms manifest within 8 to 16 hours after the last dose and may include:
- Extreme agitation
- Heightened anxiety, to the pint of panic
- Uncontrollable tremors
- Severe visual hallucinations
- Psychosis resembling delirium tremens—up to 60% of patients
- Dangerously-high fever
- Neurological damage
- Circulatory failure
- Potentially-fatal seizures/convulsions
Most at-risk for barbiturate withdrawal are individuals who have a history of 90 days or more of taking any barbiturate with a short or intermediate half-life, such as amobarbital, butalbital, pentobarbital, or secobarbital.
Because of these risks, a person should NEVER attempt to quit using barbiturates “cold turkey” or on their own. Barbiturate detox should ALWAYS be done under the close supervision of qualified medical personnel. The safest way to stop using barbiturates is to switch to a long-acting benzodiazepine and then gradually taper the dosage until it is low enough to be discontinued.
Why Do People Abuse Barbiturates?
As with other drugs of abuse, people misuse barbiturates for their “pleasurable” effects:
- Reduced anxiety
- Lowered inhibitions
- A euphoric “high”
A common trend among people who abuse barbiturates is to take them to counteract or prolong the intoxication from other illicitly-taking drugs. For example, because barbiturates are “downers”, they are often taken with stimulants like methamphetamines or cocaine to offset their effects.
Barbiturates are also taken with other CNS depressants to enhance their effects. This is extremely dangerous, because they do more than just add to the effects – they MULTIPLY them.
Here are some of the signs of barbiturate intoxication:
- Pronounced drowsiness
- Involuntary eye movement
- Slurred speech
- Loss of coordination
- Poor balance
- A wide-stanced, unstable, and/or heavy walking gait
- Trembling in the extremities
- Writing abnormalities
- Inability to judge distances
- Cognitive impairment
- Depressed respiration
Dangers of Barbiturate Overdose
Death due to acute barbiturate poisoning – i.e., overdose – typically occurs because of a stoppage in breathing. Like other CNS depressants, barbiturates suppress respiration. This is especially true – and especially hazardous – when they are taken in combination with other depressants.
For example, taking barbiturates in combination with opioids can lead to greatly exaggerated effects and fatal overdoses, even from relatively “weak” painkillers such as tramadol or codeine.
Finally, some barbiturates stay in the user’s system for a considerable period, even after the effects have worn off. This means that during regular use, the drug accumulates and reaches toxic levels. This can even occur when the drug is taken as directed. This is specifically how the actress Judy Garland is believed to have overdosed.
And, if the effects have worn off, the user mistakenly may think it is safe to drink alcohol, use a painkiller, or take another sedative, all the while being unaware that the barbiturate is still in their system. This can lead to exaggerated, incapacitating, or even fatal effects.
In one very specific way, a barbiturate overdose is more dangerous than one caused by opioids or benzodiazepines. While an opioid overdose can be reversed by the prompt administration of the emergency medication Narcan, and a benzodiazepine overdose is treated with flumazenil, there is NO reversal drug for an acute barbiturate overdose.
Besides Garland, barbiturates have been involved in the accidental deaths of a number of other celebrities:
- Jimi Hendrix, musician
- Pier Angeli, actress
- Dorothy Kilgallen, journalist
- Leila Pahlavi, princess
- Michael Reeves, director
- Ronnie Scott, musician
- Edie Sedgewick, model
- John Thompson, poet
- Mary Ure, actress
- Dinah Washington, singer
- Ellen Wilkinson, British politician
Barbiturates and Suicide
Roughly 1 out of every 9 men and 1 out of every 4 women who misuse hypnotic sedatives like barbiturates die by suicide. Intentional barbiturate overdose was a popular method of suicide, claiming the lives of many notable people, including:
- Marilyn Monroe, actress
- Diane Arbus, photographer
- Charles Boyer, actor
- Diana Churchill, eldest daughter of Sir Winston Churchill
- Paul Epstein, mathematician
- Margaux Hemingway, actress
- Abbie Hoffman, activist
- Malcolm Lowry, poet
- Helen Palmer, author, wife of “Dr. Seuss”
- Rachel Roberts, actress
- Lupe Velez, actress
Today, barbiturates are often associated with assisted suicide. For example, Oregon has a “Death with Dignity” law that permits physician-assisted suicides. During the first 19 years of the law, 59.3% of patients ended their life with secobarbital, and another 34.3% used pentobarbital.
Doctor-assisted suicide is legal in 5 states and the District of Columbia.
Barbiturates Street Names and Slang Terms
Like other drugs of abuse, barbiturates are often spoken of using coded slang terms, including:
- Blue Devils
- Blue Heavens
- Blue Velvet
- Christmas Trees
- Double Trouble
- Gorilla Pills
- Mexican Yellows
- Pink Ladies
- Purple Hearts
- Reds and Blues
- Red Birds
- Red Devils
- Yellow Jackets
How Is Barbiturate Addiction Treated?
An addiction to barbiturates is best treated with a comprehensive recovery approach:
- Medically-Supervised Detox
- Tapering Dosages
- Medication Assistance – anti-anxiety drugs, for example
- Cognitive Behavioral Therapy (CBT)
- Motivational Enhancement Therapy
- 12-Step Facilitation (TSF)
Depending on the personal history and needs of the individual, barbiturate rehab can be conducted on a residential or outpatient basis. Because psychological dependence on barbiturates can last for months or years, long-term support services are crucial to successful and long-lasting recovery.
Here is the biggest takeaway – if you or someone you care about is misusing ANY barbiturate, then the best thing you can do to keep yourself/them safe is to get in touch with a reputable alcohol and drug recovery program. Quite literally, reaching out may just save a life.