What is Barbiturate Toxicity?
Barbiturates are a type of drug that cause drowsiness and can help people sleep. These drugs, which come from barbituric acid, have been around since the early 1900s. Over the past century, they’ve been used to treat a variety of issues, including sleep problems, mental health conditions, surgery anesthesia, alcohol withdrawal, seizures, and increased brain pressure.
However, these drugs have a small margin between a dose that’s helpful and one that’s harmful. They’re highly addictive and can be very toxic. Therefore, over the past few decades, doctors have started using other drugs that are safer. Despite a decrease in use, barbiturate toxicity, or poisoning by these drugs, still frequently occurs and can lead to severe health problems and even death if not treated quickly and effectively.
What Causes Barbiturate Toxicity?
Barbiturates are medications that can become toxic if not used properly. Misuse includes taking them for nonmedical reasons such as to achieve a high feeling, using them to self-treat anxiety or stress, and increasing the dose over time to maintain their effect. This kind of misuse can lead to a physical dependence and increase the risk of harmful side effects. Barbiturates can also be used purposely in attempts to commit suicide.
Barbiturates can sometimes become toxic even when taken as directed by a doctor. People with other health conditions are at a greater risk. For instance, those with lung disease can have worse breathing problems even if taking the prescribed amount. People with heart failure can suffer harmful heart effects, and individuals with liver disease can experience toxicity because their body isn’t processing the medication accurately. Other causes of problems come from doctors prescribing the medication improperly or when it’s taken alongside other drugs that enhance its effects, such as other sedatives, painkillers, and certain anticholinergic drugs.
Risk Factors and Frequency for Barbiturate Toxicity
The problem of barbiturate toxicity, or poisoning from a group of drugs called barbiturates, seems to be related to how easily people can get these drugs. Back in 1939, a hundred tons of barbiturates were sold in the United States. This number jumped to two thousand tons in the 1960s. With more people getting their hands on barbiturates during this time, the number of hospital visits and deaths due to these drugs went up as well.
Interestingly, the people who suffered the most from barbiturate toxicity were women over 45 who became hooked on the drugs and young men who abused more than one type of drug.
In the 1970s, safer drugs like benzodiazepines started to replace barbiturates in many cases. Awareness campaigns and laws were also created to help people understand the risks of barbiturates and to control the prescription of these drugs. These efforts seem to have worked, as fewer barbiturates were prescribed and fewer people were poisoned by them by the late 1980s. In 2002, only 375 cases of barbiturate poisoning and 21 deaths were recorded by the American Association of Poison Control Centers.
Now, only a small number of barbiturate drugs are used in medicine, and accidental poisoning from these drugs has gone down. Despite that, a worrying trend has appeared: more people have been trying to end their lives with barbiturates. A 2022 study from Australia showed that while hospital visits due to barbiturate poisoning have gone down, two-thirds of these visits were because of a suicide attempt. People of all ages commit suicide with barbiturates, but young people who try to end their lives this way often have mental health issues, relationship problems, or problems with substance abuse.
Older people who try to commit suicide with barbiturates usually have physical health problems, trouble dealing with death and needing end-of-life care, and the need for help with daily tasks. People being more aware of how barbiturates can be used in suicide and easier access to these drugs online have contributed to these worrying trends. Suicide attempts using barbiturates have also happened among people who have access to these drugs through workplaces like veterinary clinics, laboratories, and doctors’ offices.
Signs and Symptoms of Barbiturate Toxicity
If someone is suspected of overdosing on barbiturates, doctors will first check the person’s airway, breathing, heart and circulation, and neurological signs, which could involve their alertness and physical responses. The person might be showing signs of having taken too much of a sedative, which include less breathing, low blood pressure, abnormal heart rate, less bowel sounds, dry skin, and low body temperature.
Doctors also need to find out the patient’s medical history and the specifics of the drug use, which include what drugs were taken, how much was taken, how they took the drug, their previous health conditions, and any other prescribed drugs they might be taking. This could be difficult if the patient’s thinking is affected by the drug. If the patient can’t provide the history, the doctor will try to get the information from others, such as emergency medical staff, witnesses, family members, and any available medical or drug store records. Sometimes, the patient’s belongings may provide helpful clues.
Testing for Barbiturate Toxicity
When a patient is suspected of barbiturate poisoning, a series of tests should be done to not only confirm the diagnosis but also to identify any potential complications, pre-existing issues, or factors that may make the case more complex. For instance, liver or kidney disease and lung problems could increase the risks associated with barbiturate poisoning.
One of the first tests done is the point-of-care glucose level test, especially for patients who seem confused or disoriented. This test checks for low blood sugar levels, a condition known as hypoglycemia.
A complete blood count and comprehensive metabolic panel are also recommended. These tests can help identify liver disease, kidney problems, or other metabolic disorders that could be contributing to the patient’s symptoms.
If the patient is a woman of childbearing age, a pregnancy test should be carried out. A high lactic acid level in the blood could indicate cell damage due to low blood flow, so a serum lactic acid test can be beneficial.
Other useful tests include creatine phosphokinase, which checks for muscle damage (a condition known as rhabdomyolysis), especially in patients who are unresponsive or have suffered physical trauma. The troponin test helps assess for possible heart damage due to low blood circulation.
An electrocardiogram, or EKG, is used to check the heart rate and rhythm. It’s also useful for identifying possible ingestion of other drugs that might be affecting the heart, through symptoms such as a prolonged QTc interval which could indicate co-ingestion of tricyclic antidepressants.
Lastly, doctors will usually order tests to check for the presence of other potentially harmful substances. These tests include a blood alcohol level test, a urine drug test (which specifically looks for barbiturates), and blood tests to screen for the presence of acetaminophen and salicylates.
Treatment Options for Barbiturate Toxicity
The primary treatment for barbiturate toxicity, or poisoning from sedative drugs, revolves around supportive care since there isn’t a specific cure-all remedy for these type of drugs. Medical professionals may give naloxone, a medication commonly used to treat opioid overdoses, through an IV or nasal spray if they believe the patient has also taken opioids and is at risk of respiratory failure.
For patients who can’t safeguard their airways or those who’ve started experiencing symptoms of respiratory failure, advanced medical procedures such as placing a tube in the patient’s windpipe and providing machine-assisted breathing may be needed. If the patient’s blood pressure is dangerously low, they should receive ample amounts of fluids directly into the vein and medication that helps to raise blood pressure. If they are excessively cold, external warming methods should be used to raise their body temperature.
Despite the dangers associated with barbiturate toxicity, the likelihood of dying from this condition is quite small if proper supportive care is provided. However, some patients may need additional strategies for faster elimination of the drugs. The treatments recommended for this purpose are usually determined based on the properties of the specific barbiturate drug, clinical studies, professional experiences and expert opinions. Procedures for faster elimination are typically suggested for patients who’ve slipped into a coma due to the barbiturate toxicity, or those needing assistance for breathing or cardiovascular functions – essentially, when the benefits of these treatments would likely outweigh their risks.
Taking multiple doses of activated charcoal may help to speed up the removal of long-lasting barbiturates like phenobarbital from the body for those with severe toxicity. Hemodialysis, a procedure used to filter wastes and water from the blood, may also benefit patients overdosed on long-lasting barbiturates, as these drugs have properties that make them easier to remove from the body. Making urine more alkaline, once advised as a way to speed barbiturate clearance from the body, is not usually recommended now. This is because it might not considerably speed up the removal of these drugs and could lead to complications.
What else can Barbiturate Toxicity be?
If a patient shows signs of toxic reaction from barbiturates (a type of drugs), doctors also need to consider if these symptoms might actually be due to misuse of other substances, such as:
- Other sleeping medications or relaxants (like benzodiazepines)
- Alcohol
- Opioids
- Seizure medications
- Anticholinergic medications (used for various health problems, including breathing and stomach issues)
- Gamma-hydroxybutyric acid (often used illicitly)
Furthermore, doctors would also consider if certain metabolic disorders may be causing the symptoms, such as:
- Low blood sugar (hypoglycemia)
- A severe form of hypothyroidism (myxedema coma)
- High or low sodium levels in the blood (hypernatremia and hyponatremia)
- A serious condition due to kidney failure (uremic encephalopathy)
- Having too much carbon dioxide in the blood (hypercarbia)
Also, brain issues like meningitis (inflammation of brain coverings), encephalitis (brain inflammation), sepsis (body’s extreme response to an infection), brain tumors, cerebral edema (brain swelling), seizures, and bleeding within the brain may also be considered.
Last but not least, specific psychiatric conditions like functional coma (psychogenic coma) or catatonia (a state of unresponsiveness) are also important to keep in mind when diagnosing the cause of a patient’s symptoms.
What to expect with Barbiturate Toxicity
The in-hospital death rate for patients suffering from barbiturate toxicity (negative effects from barbiturate drugs), while receiving proper support care, is around 0.5 to 2%. Older individuals and those with heart or lung diseases are typically more at risk for experiencing complications from barbiturate toxicity compared to younger patients or patients without additional health conditions.
Possible Complications When Diagnosed with Barbiturate Toxicity
The administration of barbiturates, a type of drug, can sometimes lead to severe complications. These might include problems like aspiration pneumonia – a lung infection that occurs when we accidentally inhale food, drink, or saliva into our lungs; myocardial infarction – commonly known as a heart attack; cerebral edema – swelling in the brain; and pulmonary edema – fluid build-up in the lungs. In some severe cases, multiple organs could fail. These toxic effects can also lead to withdrawal symptoms when we try to discontinue or reduce the drug’s use, which can even become life-threatening.
It’s particularly important to be aware of this if you’ve been using barbiturates for an extended period or if you’re going through an enhanced detox from this drug as part of the management program for drug toxicity. After treatment, one might also experience rebound toxicity – your body could react negatively to no longer having the drug in its system. As the drug is gradually removed from the body, certain body functions like digestion and blood flow may speed up, potentially leading to a heightened response from the remaining drug in the body.
There could be several complications to remember:
- Aspiration pneumonia
- Myocardial infarction (heart attack)
- Cerebral edema (swelling in the brain)
- Pulmonary edema (fluid build-up in the lungs)
- Multiorgan failure
- Withdrawal symptoms with discontinuing or reduced use
- Rebound toxicity
- Increase in digestion and blood flow leading to heightened drug response
Preventing Barbiturate Toxicity
Efforts have been made to prevent the misuse and harmful effects of barbiturates. These efforts include government intervention, safety initiatives, and spreading awareness among the public and those who prescribe these drugs. The Drug Enforcement Administration began to oversee the production, distribution, and prescription of barbiturates under the Controlled Substances Act in 1970 to make the usage of these drugs safer.
Additionally, barbiturates have been made less accessible in many countries by withdrawing painkillers that contain them from the market. Programs are in place to monitor prescription drug usage, to prevent individuals from getting the same prescription from multiple sources.
Other measures include creating drug formulas that are less likely to be misused, safer packaging like blister packs and child-resistant caps, along with clear warning labels. Educational programs have also been set up to inform people who prescribe these drugs, as well as issuing public health advisories and creating clinical guidelines based on evidence. This has helped improve understanding about the risks associated with barbiturate drugs and safer alternatives that can be used for treatment.
