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Barbiturate Withdrawal

Barbiturate withdrawal is caused by a sudden discontinuation of short and intermediate-acting barbiturates after a prolonged period of heavy use. This leads to the classical signs and symptoms of withdrawal resembling alcohol withdrawal syndrome. Diagnosis of the condition is based on a detailed history and clinical findings. Laboratory tests to detect blood levels of barbiturates are usually unhelpful.


Presentation

Depending on their duration of action, barbiturates are classified as short, ultra short, intermediate and long-acting [1] [2]. Of these, the short and intermediate-acting barbiturates like pentobarbital and secobarbital [3] are often associated with withdrawal symptoms and signs. Barbiturate withdrawal can occur following the sudden cessation of the drug. This leads to a withdrawal syndrome identical to alcohol withdrawal with delirium tremens and can even be life-threatening in some patients.

Within a day after withdrawal of barbiturates, individuals develop restlessness, weakness, and tremulousness. Symptoms progressively increase on the second day with exaggerated deep tendon reflexes. Seizures can develop within 48 to 72 hours in patients who were on very high doses of barbiturates. This can even progress to status epilepticus and sometimes death [4]. Other clinical features like confusion, delirium, auditory and visual hallucinations, hyperpyrexia, circulatory collapse, and dehydration may occur between 48 to 120 hours after withdrawal [5].

Compared to alcohol withdrawal syndrome, barbiturate withdrawal is more variable and delayed [4] and patients can develop multiple seizures and delirium.

Fever
  • Barbiturate withdrawal symptoms: Irritability Sleeplessness Restlessness Seizures Tremors Hallucinations Fever Sweating Delirium Cardiovascular collapse Severe anxiety Hypotension Mood disorders Accidental overdose Intentional suicide Death Most barbiturate[recoveryconnection.com]
  • Barbiturates withdrawal effects can include the following: Hypotension Hallucinations Tremors Seizures Irritability Sleeplessness Restlessness Cardiovascular collapse Delirium Suicidal ideation Fever Excessive sweating Barbiturates treatment facilities[addictionhope.com]
  • Some Withdrawal Symptoms Include: Tremors Difficulty sleeping Agitation Hallucinations Fever Fatigue Seizures Barbiturates can build up in the human body and as a person ages, the body becomes less able to cleanse itself of barbiturates.[avalonmalibu.com]
  • Orally Drowsiness Headache Depression Excitement Joint or muscle pain Upset stomach Diarrhea Constipation Skin Rash Itching Sore throat Fever Easy bruising Bloody nose Unusual bleeding Confusion, hallucinations Weak or shallow breathing Slow heart rate[solutions-recovery.com]
  • Barbiturates Bleeding sores on lips Chest pain Fever Muscle or joint pain Red, thickened, or scaly skin Skin rash or hives Sores, ulcers, or white spots in mouth (painful) Sore throat and/or fever Swelling of eyelids, face, or lips Wheezing or tightness[blog.palmpartners.com]
Gangrene
  • Two of these cases were complicated by the presence of organic disease (Buerger's disease with gangrene, and acute yellow atrophy of the liver with blood dyscrasia), so that abstinence from barbiturates could be regarded only as FULL TEXT[annals.org]
Tachycardia
  • Symptoms are similar to those of alcohol withdrawal and include tachycardia, seizures, tremor, and hyperreflexia.[emedicine.medscape.com]
  • Cardiovascular: tachycardia . Musculoskeletal: leg pain, muscle fatigue. Genitourinary: diuresis . Miscellaneous: pruritus , fever, earache , nasal congestion , tinnitus , euphoria , allergic reactions.[rxlist.com]
  • PCP Mechanism NMDA receptor antagonist ketamine is a similar drug Intoxication pre sentation belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia[medbullets.com]
  • Signs and symptoms associated with amphetamine use include mydriasis (dilated pupils), sweating, increased temperature, tachycardia (rapid pulse), and hypertension.[medical.tpub.com]
  • The reaction to disulfiram is characterized by headache, diaphoresis, tachycardia, nausea and vomiting, cardiovascular collapse, delirium, seizures and, occasionally, death.[aafp.org]
Hypertension
  • Signs and symptoms associated with amphetamine use include mydriasis (dilated pupils), sweating, increased temperature, tachycardia (rapid pulse), and hypertension.[medical.tpub.com]
  • This drug is used for hypertension and to treat withdrawal from opiate narcotics.[encyclopedia.com]
  • […] biogenic amine (DA, NE, 5HT) reuptake Intoxication presentation mental status changes euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations sympathetic activation appetite, tachycardia, pupillary dilation, hypertension[medbullets.com]
  • […] insomnia, elevated blood pressure and pulse (mild) Intense desire for drugs, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise PCP/psychedelics Days to weeks Days to weeks Hyperactivity, increased pain threshold, nystagmus, hyperreflexia, hypertension[aafp.org]
Low Self-Esteem
  • Treatment programs also address the underlying causes of the addiction such as depression, anxiety or low self-esteem. Patients in barbiturate withdrawal treatment programs receive support from medical professionals, counselors and other patients.[livingsober.com]
Seizure
  • Spontaneous generalized or partial seizures occurred during withdrawal; the abnormal EEG patterns associated with seizures appeared to originate in various subcortical sites.[ncbi.nlm.nih.gov]
  • We propose that the occurrence of seizures, psychotic behavior, or a recent personality change should be considered clues to possible barbiturate abuse in patients with migraine.[ncbi.nlm.nih.gov]
  • It is essential to diagnose barbiturate withdrawal quickly, otherwise seizures, delirium, and death may follow.[symptoma.com]
  • , threshold , withdrawal , cns , barbiturate withdrawal , chlorpromazine , used extreme caution , antipsychotic , depressant withdrawal , olanzapine , seizure threshold , eg chlorpromazine 6: "Tne withdrawal syndrome following abrupt discontinuance of[www3.lymba.com]
  • SeizuresSeizures can occur at any point during the barbiturate withdrawal timeline. Often, a person will be tapered off of barbiturates instead of stopping abruptly to help prevent seizures and minimize other symptoms.[withdrawal.net]
Tremor
  • Symptoms include anxiety, restlessness, insomnia, rhythmic intention tremor, dizziness, seizures, and psychosis. If the syndrome is not recognized and correctly treated, hyperthermia, circulatory failure, and death may ensue.[ncbi.nlm.nih.gov]
  • During detox, other medical and psychiatric medications will be prescribed to control symptoms such as high heart rate and blood pressure, anxiety, depression, insomnia, muscle cramping, tremors, etc.[recoveryconnection.com]
  • Tremors or shaking. Rapid heart rate. Seizures.[withdrawal.net]
  • Tremors, hallucinations, and fatal seizures can occur during a non-medically monitored withdrawal process. There is a significantly high mortality rate associated with unmonitored barbiturate withdrawal.[wisegeek.com]
Confusion
  • Other clinical features like confusion, delirium, auditory and visual hallucinations, hyperpyrexia, circulatory collapse, and dehydration may occur between 48 to 120 hours after withdrawal.[symptoma.com]
  • In larger amounts, speech difficulties, confusion, poor decision making and staggering can result.[rehabthailand.com]
  • Physical effects can include: Disorientation Respiratory distress Drowsiness/Confusion Cardiac arrest Motor dysfunction Respiratory depression Headache Slowed, slurred speech Unconsciousness, coma In cases of overdose, death may result Psychological Effects[addictionhope.com]
  • An individual who is high on barbiturates will experience various symptoms such as fatigue, confusion, low blood pressure, respiratory depression, poor judgment and drowsiness.[broadwaytreatmentcenter.com]
  • The behavioral, emotional and physical signs of abuse and addiction may include: Drowsiness Slurred speech and confusion Breathing difficulties including shallow breathing Behavioral changes including excitement and irritability Improper judgment and[projectknow.com]
Agitation
  • […] and Statistical manual of mental disorders (DSM) - 5, the criteria for barbiturate withdrawal are the following: Reduction or cessation of use of sedative Two or more of the following symptoms: autonomic hyperactivity, insomnia, nausea, psychomotor agitation[symptoma.com]
  • Barbiturates withdrawal symptoms may include: Tremors and shakiness Insomnia Agitation Hallucinations Violent behavior Extremely high body temperature Seizures Respiratory depression Respiratory arrest Coma Death Treatment for Barbiturate Withdrawals[livingsober.com]
  • They are: Medication to stabilize the patient: The main aim here is to calm down a very agitated patient. For this purpose, they will give an intermediate-acting barbiturate. For example, Pentobarbital. You have to take it by mouth.[addictionresource.com]
  • Agitation. Insomnia. Weakness. Nausea. Vomiting. Anxiety. Tremors or shaking. Rapid heart rate. Seizures.[withdrawal.net]
  • Seizures can be dangerous, and the delirium some users experience can lead to agitation, hyperthermia, and cardiovascular failure. 1 Withdrawing from Barbiturates: Treatment Methods and Options for Help Medical assistance is recommended for barbiturate[withdrawal.net]
Hyperreflexia
  • Symptoms are similar to those of alcohol withdrawal and include tachycardia, seizures, tremor, and hyperreflexia.[emedicine.medscape.com]
  • Their general practice was to suspect benzodiazepine-induced delirium and trial flumazenil among patients with persistent confusion whose withdrawal seemed to have resolved (e.g. normal vital signs, no hyperreflexia).[emcrit.org]
  • […] lacrimation, diarrhea, insomnia, elevated blood pressure and pulse (mild) Intense desire for drugs, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise PCP/psychedelics Days to weeks Days to weeks Hyperactivity, increased pain threshold, nystagmus, hyperreflexia[aafp.org]

Workup

History is the most important part of the workup, with the diagnosis being based on clinical findings. It is essential to diagnose barbiturate withdrawal quickly, otherwise seizures, delirium, and death may follow [5]. According to the Diagnostic and Statistical manual of mental disorders (DSM) - 5 [6], the criteria for barbiturate withdrawal are the following:

  1. Reduction or cessation of use of sedative
  2. Two or more of the following symptoms: autonomic hyperactivity, insomnia, nausea, psychomotor agitation, anxiety, in addition to symptoms already mentioned, developing within hours to days after cessation
  3. Symptoms and signs mentioned in criterion 2 result in impairment of social, occupational or other functions
  4. The signs and symptoms cannot be due to any other medical condition, mental disorders, intoxication or withdrawal from other substances.

It is important for the physician to elicit a history of the exact barbiturate used/abused, duration of illicit usage or abuse, when it was last ingested, was the drug discontinued suddenly or accidentally, treatment received for withdrawal symptoms, and whether other substances like alcohol were also ingested.

Urine toxicology is performed in all cases and may help to detect other substances consumed along with the barbiturates. Most laboratories are unable to measure blood levels of barbiturates except phenobarbital. Routine laboratory tests like a complete blood cell count (CBC), serum electrolytes, blood urea nitrogen, serum creatinine, and blood glucose levels are obtained to exclude metabolic syndromes which cause symptoms identical to barbiturate withdrawal. Arterial blood gas (ABG) analysis is useful to diagnose metabolic acidosis and respiratory failure while serum lactic acid level helps to evaluate perfusion at the cellular level. A urine pregnancy test should be performed in all women in the childbearing age group.

Treatment

  • RESULTS: The patient was admitted to the hospital for the treatment of unexplained seizures that were followed by several days of an intense withdrawal syndrome.[ncbi.nlm.nih.gov]
  • Cats were made physically dependent on pentobarbital using a standard technique for chronic treatment developed in this laboratory.[ncbi.nlm.nih.gov]
  • Abstract Barbiturate withdrawal seizure susceptibility in rats increased with increasing duration of treatment during a 15-day treatment period in which the animals were given an i.p. dose of sodium barbital every 12 h.[ncbi.nlm.nih.gov]
  • If you or a loved one needs to find out more about barbiturate addiction treatment as well as treatment for addiction to other substances used along with barbiturates, please call our toll-free helpline for substance addiction treatment and recovery at[projectknow.com]
  • The clinical features, diagnosis and treatment of this condition are discussed.[ncbi.nlm.nih.gov]

Prognosis

  • A person's outcome, also called prognosis, after abusing barbiturates depends on a number of factors.[emedicinehealth.com]

Etiology

  • ETIOLOGY Not all patients who take benzodiazepines will experience a discontinuance syndrome when the drug is stopped. Several conditions must be present before the discontinuance syndrome is likely: Duration of treatment .[encyclopedia.com]

Epidemiology

  • Epidemiology of alcohol use and alcoholrelated consequences. In: Alcohol and health. Eighth special report to the U.S. Congress from the Secretary of Health and Human Services. September 1993:1–35. ... 2. Bennett JC, Plum F, eds.[aafp.org]
Sex distribution
Age distribution

Pathophysiology

  • Search through current and concise descriptions of pathophysiology of diseases and their impact on anesthesia! Gain expertise in understanding the impact of pathophysiology of coexisting diseases on anaesthesia![books.google.com]
  • This dual mechanism of action is well matched to the pathophysiology of alcohol withdrawal, making barbiturates theoretically superior to benzodiazepines. . Clinical experience: Barbiturates are more powerful than benzodiazepines .[emcrit.org]

Prevention

  • Medical assistance is often recommended for barbiturate withdrawal to reduce the severity of withdrawal symptoms and prevent life-threatening consequences.[withdrawal.net]
  • The dosage of pentobarbital is gradually reduced until the patient is no longer dependent on it to prevent withdrawal symptoms.[projectknow.com]
  • Appropriate medical supervision and treatment during withdrawal can help prevent many medical complications.[withdrawal.net]
  • Medical use for barbiturates includes sedation and seizure prevention. Patients who take more than 500 mg of barbiturates daily for more than five months are at risk for serious withdrawal symptoms once the drug is stopped.[wisegeek.com]
  • Abstract BARBITURATES are commonly used to prevent epileptic seizures 1 , but it has also been observed that susceptibility to ‘spontaneous’ seizure in both normal humans and animals is increased during abrupt withdrawal from chronically administered[nature.com]

References

Article

  1. Martin PR, Kapur BM, Whiteside EA et al. Intravenous phenobarbital therapy in barbiturate and other hypnosedative withdrawal reactions: a kinetic approach. Clin Pharmacol Ther 1979; 26: 356-364
  2. Fitch RH, Tatum AL. The duration of action of the barbituric acid hypnotics as a basis of classification. J Pharmacol Exp Ther 1932; 44: 325-335 25. Ewing JA, Bakewell WE: Diagnosis and management of depressant drug dependence. Am J Psychiatry 1967; 123: 909-917
  3. Ewing JA, Bakewell WE: Diagnosis and management of depressant drug dependence. Am J Psychiatry 1967; 123: 909-917
  4. Wolff MH (ed): The Barbiturate Withdrawal Syndrome, Munksgaard, Copenhagen, 1959
  5. Sarrecchia C1, Sordillo P, Conte G, Rocchi G.Barbiturate withdrawal syndrome: a case associated with the abuse of a headache medication. Ann Ital Med Int. 1998 Oct-Dec; 13(4):237-239
  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association. 2013; 550-560.

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Last updated: 2018-06-22 00:00