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GPs have been warned that barbiturate misuse – seen by many as an historical problem that was left behind in the past century – has been found in research which contains a surprising revelation. Barbiturate use for intentional self-harm has increased in the past 20 years.
Barbiturates were widely prescribed in the 1900s as anxiolytics, hypno-sedatives, and anticonvulsants. However, high levels of accidental poisoning and risks of dependence led to supply restrictions. As a result, they’re no longer routinely prescribed in Australia. Although prescribing rates continue to decline, barbiturates are still prescribed, for example, in cases of refractory epilepsy.
The study, published in the MJA, identified 1250 barbiturate-related hospitalisations, 993 drug treatment episodes and 511 deaths during 2000–2018. In this period, the annual rate of barbiturate-related hospitalisations declined, as did the annual rate of barbiturate-related drug treatment episodes.
However, the annual rate of barbiturate-related deaths increased from 0.07 per 100 000 population (13 deaths) in 2000–01 to 0.19 per 100 000 population (51 deaths) in 2016–17.
“In contrast to hospitalisations, treatment episodes, and prescribing, the population rate of barbiturate-related deaths increased significantly; in particular, the number of hospitalisations linked with deliberate self-harm declined, but the number of deaths increased,” the authors wrote in the study.
Professor Shane Darke, one of the study’s authors, said in an exclusive podcast that doctors need to consider whether the person they’re prescribing for is at risk.
“Are there other alternatives? And … getting across to people, these are highly toxic drugs. If you’re going to use a drug like this with alcohol, for example, that’s highly risky,” Professor Darke said.
He said doctors also need to consider where the drug might end up.
“With all of those drugs, the person you’re prescribing it to isn’t necessarily the person who’s going to end up using it,” he said.
When the authors characterised the 511 barbiturate-related deaths, they found two profiles: “Younger people with mental health problems and low levels of physical disease, and older people with higher levels of physical disease but low levels of mental health problems,” they wrote.
Many people who commit suicide have attempted it before. However, that wasn’t the case with many of the barbiturate related deaths.
“A lot of these cases are very deliberate, well planned, well sourced, well researched. Not all, but many of them. You’ve got people taking highly toxic drugs, and dying at first attempt,” Professor Darke explained.
The toxicity of barbiturates means there are no second chances. These people need to be reached before they make a suicide attempt.
Professor Darke said there are some red flags to look out for.
“One thing we did notice is that a large proportion of people turn up to a doctor to get antinausea drugs the week before or the days before their death, because they’re taking these drugs and they don’t want to vomit them up.
“And so, if a young person who you know to have mental health problems, turns up and suddenly needs antinausea drugs and has no medical reason, it’s a flag,” he said.
It might be appropriate to ask these patients some specific questions.
“Young people with serious mental health disorders need to be monitored by their GP and by specialists. Possibly asking, ‘have you been researching this? Have you been downloading euthanasia material?’,” he said.
One difficulty in managing this problem is working out where people are getting barbiturates from.
Professor Steve Allsop from the National Drug Research Institute said that when controls were originally brought in last century, there was substantial awareness about its dangers.
“Perhaps we need to consider whether we need to reinvigorate awareness-raising among medical practitioners and pharmacists?” he speculated.
There is evidence though, that many people aren’t getting their barbiturates from their doctor. The research found that in 8% of cases, the drugs came from veterinary practices. However, it’s assumed that most people are buying barbiturates online.
“The big increases seem to happen from about 2011, 2012 onwards. Probably because the net became so much more omnipresent,” Professor Darke explained.
People finding lethal drugs online is a difficult public health and border control problem and may require a more personalised approach.
Voluntary assisted dying is now legal in some Australian states. It remains to be seen whether this will have an impact on the use of barbiturates for some older people with higher level of physical disease.
These laws won’t affect younger people with high mental health problems, and that’s what has experts particularly worried.
Professor Allsop said what this information highlights is that suicide prevention is critically important for us as a society.
“While having a focus on a particular means or a particular substance is important, the larger strategy is all of us in the community (but also medical practitioners, our families, our coworkers, our workplaces, our governments) investing in preventing this dreadful consequence,” he said.
Professor Darke agreed these deaths are preventable and more needs to be done.
“It goes back to general suicide messages and promoting places like Beyond Blue and Lifeline. (Saying) it’s okay to reach out, depression is common. Suicidal ideation and ideas – they’re not uncommon in the population. You can reach out. There’s no shame involved at all,” he concluded.
If you or someone you know is having suicidal thoughts, there are people here to help. Please seek out help from one of the below contacts:
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The “First do no harm” rule does not apply when a patient has a terminal illness. The reason is simple – the patient is in pain and has lost all or most of their quality of life. If you are a caring professional it would be harmful to force that patient to suffer involuntarily from what will ultimately be a terminal illness where a painful death is the inevitable outcome of that illness.
This naturally does not apply to a young person who suffers only a mental illness – these illnesses can be treated successfully with various medicines in the majority of casee. A terminal illness usually cannot be treated past a certain point where the doctor has exhausted all possible interventions.
Once upon a time in the old days of my mid medical career, persons who are now eligible in some States for euthanasia would acquire and hoard a couple of pentobarbiturate scrips for themselves to quietly at their own choice of time personally end their lives by suicide without involving other members of the family or their doctors.
Now such patients have to ask us to deliberately prescribe via the VAD processes something similar under strict official control or ask one of us to personally kill them by probable injection.
We have deliberately made non violent, non serious illness reaction voluntary suicide very difficult for the average would be self euthanasia patient while at the same time “saving” all the younger overdoses from perishing so they wake up later in ICUs.
I suggest that our some of our professional health care policy and advocacy of that last century era has contributed to the demand for euthanasia and subsequent requests for us as medical practitioners with over 3000 years of “first do no harm” ethics to now deliberately kill selected patients.
Middle roads are not necessarily easy.
The main takeaway is to watch out for patients wanting nausea meds. They get barbiturates online of from their vet.
This topic is one link away from Right To Die issues. The initiative for VAD is wanted by much of the Community.
Like many of you, I surmised that bracket creep would be an issue – who’s allowed to be a ‘case’ and who is not? What about 100% psychological cases?
Check out this contemplation for allowing termination of psychiatric patients’ lives on request, on meeting criteria under development. (Belgium, where euthanasia contributes ~ 1.8% to annual all-cause mortality incidence.)
“When unbearable suffering inside psychiatric patients to request euthanasia: qualitative study.”
The British Journal of Psychiatry (2017). 211, 238-245. doi: 10.1192/bjp.bp117.199331