Barbiturates Addiction - Treatment, Symptoms and Causes

“With such non-threatening street nicknames like barbs, barbie, bluebirds, dolls, downers, sleepers! barbiturates are anything but that.”

Barbiturates are “sedative-hypnotic” class of CNS depressant drugs. Although used together, these terms are different, as, Sedatives are drugs that cause decreased responsiveness to any stimulus without inducing sleep, whereas Hypnotics refer to drugs that stimulate or mimic a state like normal arousable sleep (Not to be confused with Hypnosis- a trans like highly suggestible state of mind).

Since their introduction in 1903 by Fischer and Von Mering, barbiturates reigned supreme till 60s for anxiety and insomnia (and this was also the time of their massive abuse), until Benzidiazepines, being safer and equally potent, dethroned them and all but a few are redundant now. With decreased production, prescriptions and use, eventually their abuse and addiction also weaned off by 70s and is very uncommon now.

Instead, what’s more commonly seen is Barbiturate toxicity due to overdose of prescribed medicine OR few isolated cases of addictions that are still seen in some pocket groups like Anesthesiologists with thiopental addiction.

For this we need to understand its pharmacology…

Barbiturates are GABA Mimetics which increase the 'duration” of GABA-A Chloride Channels in CNS causing drowsy and calming effect due to global CNS depression. Benzodiazepines(BZDs) also work on similar channel to same effect but they increase 'Frequency” and thus are facilitatory in function and thus safer and less addictive.

Only two of them are majorly used and produced now:-

1. Thiopentone-ultra short acting– it is used to produce Barbiturate Coma in patients of status epilepticus and rabies; as a TRUTH SERUM in Narcotic Tests of perpetrators; and in induction of GeneraL Anaesthesia ( even this is now replaced by Propofol in that use).
2. Phenobarbitone-Long acting - is used as an anticonvulsant in Newborns and Pregnancy; or, in some cases to induce liver enzymes as barbiturates are POWERFUL ENZYME INDUCERS.

Barbiturates have an extensive list of side-effects, But the main problem with barbiturates is Anterograde Amnesia (loss of memory in forward direction)- so, as the patient takes the pill, he forgets that he/she has taken it, so takes it again and this cycle leads to overdose, a phenomenon called automatism.

Moreover, barbiturates have a very narrow Therapeutic Index (a measure of drug dose safety) and a very steep Dose- Response Curve, meaning the difference between the dose causing drowsiness and one causing death is very small, making it a highly unsafe drug and is thus NOT even preferred amongst drug abusers.

Recent reports suggest that amateur teenage drug abusers have started using barbiturates again and the main barbiturates which are on rise are older ones like Amobarbital, Secobarbital, Pentobarbital. A primary cause which compels the individual to abuse the use of Barbituarates is because of their ability to downsize the effect or 'high' which is achieved by the abuse of stimulant drugs such as cocaine, etc. That is the reason they are also called as 'downers'.

Barbiturates work like alcohol just in a more potent and drastic manner, in low doses they bring a sense of calm and relaxation and may give a 'HIT” but in just a slightly higher dose their effects may include speech slurring, disorientation, loss of response, delirium, stupor, low and shallow respiration, hypotension and flaccidity, finally leading to coma and death.

Dependency-

Barbiturates are highly addictive. If taken daily for longer than a month, brain develops an insatiable need for them, and causes severe symptoms if the drug is stopped.

There is no home based treatment for barbiturates

There is no antidote available for BARBITURATES and treatment mainly is supportive but has to be very aggressively tackled and in ICU setting. These methods are all derived from old SCANDINAVIAN REGIME proposed by NILSSON(1951)

1. ntubation and Ventilatory support with Oxygen- as major cause of death is respiratory failure.
2. Gastric Lavage with KMnO4 and activated charcoal – to take it out from mouth
3. Forced alkaline diuresis – to flush it out through urine.
4. - to evacuate it out from bowels.
5. Prophylactic antibiotics and maintaining a temperature balance.
6. Extra-Corporeal Drug Removal – Both HAEMOPERFUSION AND HAEMODILUTION are recommended for barbiturate removal.

Even after such intensive protocol of management, the chances of survival after an overdose are bleak and often the end news is bad.

Avoidance remains the only method of prevention. If someone becomes addicted to them after being prescribed, like for insomnia or epilepsy, there is a need to slowly decrease the dose (sequentially) as sudden cessation may prove fatal and then it may be switched to a better, safer alternatives like Benzodiazepines or even better are the newer NON- BZD drugs called Z Drugs eg. ZALEPLON, ZOLPIDEM and ZOPICLONE.

Most Dangerous withdrawal symptom is seizure(as the depressant effect is lost; neurons of brain go crazy and fire up in a haywire fashion precipitating a fatal seizure episode). Others include tremors, difficulty sleeping, and agitation.

BARBITURATE BLISTERS- they are often seen with barbiturate use on skin in flexural areas of armpits, knee bend or between fingers as fluid filled blisters that on rupture leave red, raw surface that dries to a brown parchment like area. They can help identify the diagnosis in a comatose patient.