Notable among the pioneers in this field is John S Lundy of the Mayo Clinic Rochester, USA , who introduced sodium amobarbital and sodium pentobarbital in anesthesia. Ten years after its introduction, more than 10 million people had undergone operations with the help of this drug Adams This problem was solved through the next modification of the chemical structure of the basic nucleus of the barbiturates, the addition of a sulfur group to pentobarbital.
Thus born were the agents that would revolutionize intravenous anesthesia, the thiobarbiturates, thanks to the work of Volwiler and Tabern of Abbott Laboratories Tabern and Volwiler Its sodium salt was marketed as Pentothal Figure 5. This agent rapidly displaced the rest of the barbiturates as an anesthetic, partly due to the swiftness of its onset and its short action period, and it currently remains the preferred intravenous anesthetic in many types of surgical intervention.
Despite the anesthetic efficacy of both hexobarbital and thiopental, the barbiturates most commonly employed in surgery in the midth century, they were not without their clinical problems. Such problems were brought to the public eye in particularly unfortunate fashion after the involvement of these agents, apparently due to malpractice, in numerous cases of death in patients treated in states of shock after the Japanese attack on Pearl Harbor in December In clinical trials, methohexital showed itself to be more potent than thiopental and to lead to quicker recovery in patients; it was recommended for use as an anesthetic inducer in minor outpatient surgery Taylor and Stoelting The subsequent development of other anesthetic agents for intravenous administration hydroxydione, alphaxalone, etomidate, propofol, etc led to a reduction in the use of barbiturates in this context.
As mentioned earlier, chemists from different universities and pharmaceutical companies managed to synthesize over barbiturate derivates. The differential pharmacokinetic properties of these agents made it possible to draw up a practical clinical classification, based on the duration of their pharmacological action Hollister Thus, the barbiturates in the category of short or intermediate action secobarbital, amobarbital, pentobarbital were employed initially as hypnotics, whilst those of prolonged action phenobarbital were widely used as anxiolytics and anticonvulsants; ultrashort-acting agents, notably sodium thiopental, were especially useful as anesthetic inducers for minor operations Table 3.
From time to time, some barbiturates have been used in the treatment of other disorders. One such case is the use of primidone in the management of essential tremor Koller et al , while another is that of combinations of barbiturates and analgesics salicylates, codeine, etc in the treatment of headaches, migraines, and other types of pain Wolf et al , though such applications are considered counterproductive today. Classification and principal clinical applications of the barbiturates most commonly employed before World War II.
Adapted from Hollister In principle, the application of an infusion of barbiturates reverted temporarily the catatonic state of certain schizophrenic patients. These cures for catatonia allowed patients, for a few hours, to maintain conversations and interact with their environment, before returning to their state of lethargy. Despite the fact that the response was somewhat brief, these cures were quite customary in European asylums in the s and s. It was during the s and s that barbiturates attained their greatest popularity and were most widely used, putting them in a position that could be compared, according to Hollister , to that currently held by benzodiazepines.
The barbiturates most commonly used at that time were phenobarbital, sodium amobarbital, sodium secobarbital, sodium pentobarbital, and sodium thiopental. Despite their widespread use during the first half of the 20th century, no barbiturate succeeded in eliminating the main drawbacks of these drugs, which were the phenomena of dependence and death by overdose Johns Among the paradoxes of destiny is the possible death through overdose of the two scientists who introduced the first barbiturate, Fischer and von Mering, after some years of dependence upon these substances Escohotado To reduce these problems, from a legal perspective, a series of laws were passed aimed at regulating the distribution and sale of barbiturates.
The first of these came into force in California in The problem continued during the following decade, and it became necessary to arrange special conferences for all those involved, such as that held in Washington, under the auspices of the American Pharmaceutical Association, on 12th October Conference on the Regulation of Use and Distribution of Barbiturates. Barbiturate use in the pre-benzodiazepine period was such that, in the USA alone, production of these drugs reached, in , the quantity necessary for the treatment of 10 million people throughout an entire year.
Figure 6 shows the industrial production of barbiturates and their derivatives in the USA during the s and s. Evolution of annual barbiturates production in USA for the period — Adapted from Fort In order to palliate these effects, the Narcotics Expert Committee at the World Health Organization recommended at their sessions of 7th—12th January, , and 18th—24th October, that barbiturates should only be available on medical prescription.
In spite of this, and according to different estimates, in there were barbiturate addicts in England, whilst in the United States it was declared, by a special drug-dependence committee set up by President Kennedy in , that there may be as many as Americans addicted to barbiturates. Indeed, the USA currently produces 30 barbiturate pills per inhabitant per year Escohotado In relation to the frequent cases of death by overdose, given the small therapeutic margin of these substances, it should be pointed out that this was a common method in suicide attempts.
The lethal effect of these compounds was such that a mixture of barbiturates with other substances was even employed in some USA states for the execution of prisoners sentenced to death.
Figure 8 shows the evolution of number of deaths accidental or suicide by barbiturate overdose in England and Wales for the period — In this regard, and in the city of New York alone, in the period —, there were cases of barbiturate overdose, with deaths Sharpless , whilst in the United Kingdom, between and , there were 12 deaths attributed directly to barbiturates Barraclough These data should not surprise us, since in a period of just one year , In view of these data, the Advisory Council Campaign in Britain took measures restricting the prescription of these drugs.
Death certificate of the actress Marilyn Monroe, issued on 28th August Includes both accidental deaths and suicides. Adapted from Glatt The discovery of benzodiazepines was actually made possible, in part, by the 60 years of clinical and basic research provided by barbiturates, whose therapeutic life, from that time on, began to decline. Currently, the use of barbiturates is circumscribed to quite specific therapeutic applications Charney et al Thus, phenobarbital and butabarbital are still used as sedatives in cases of gastrointestinal and asthmatic functional disorders, as well as to antagonize the adverse central stimulant effects of some drugs, such as ephedrine, dextroamphetamine, or theophylline.
Phenobarbital is also used in cases of withdrawal syndromes of hypnosedative agents. In the field of neurology, barbiturates phenobarbital and primidone are still employed, not only in the treatment of certain types of epilepsy partial and tonic-clonic generalized seizures , but also in the emergency treatment of some types of convulsions, such as those associated with tetanus, eclampsia, cerebral hemorrhage, status epilepticus, or different forms of poisoning.
As intravenous anesthetic inducers, ultrashort-acting barbiturates are of use, mainly thiopental and methohexital, the latter also being administered rectally in children or as a sedative in some diagnostic imaging explorations. Table 4 shows the therapeutic applications of barbiturates that have survived to the present day. Adapted from Charney et al In addition to these approved indications, the barbiturates present other current uses.
Phenobarbital is capable of improving the hepatic transport of bilirubin in patients with hemolytic jaundice, so that it can be used in newborn babies to treat hyperbilirubinemia and kernicterus. At a diagnostic level, amobarbital, in low doses, can be injected directly into the carotid artery prior to neurosurgery to identify the dominant cerebral hemisphere. Finally, anesthetic doses of barbiturates can attenuate post-surgical cerebral edemas and have positive effects in cases of cardiac and cerebral ischemia, reducing the size of the infarcted region.
Moreover, barbiturates have been used since the s in the management of acute traumatic brain injury in their capacity to reduce intracranial pressure Marshall et al The mechanism through which high-dose barbiturates appear to exert their intracranial pressure-lowering effects is double: reduction of metabolism with the consequent lower oxygen demand by cerebral tissue and modifications in vascular tone Kassell et al Additionally some direct neuroprotective effects, such as membrane stabilization or inhibition of free radical-mediated lipid peroxidation, have been postulated Piatt and Schiff Despite results of the multicenter randomized clinical trial published by Eisenberg et al that demonstrated the efficacy of high-dose barbiturates in severely head-injured patients with intractable intracranial pressure elevations, recent collaborations, based in Cochrane methodology, concluded that there is no evidence of health improvement in this type of patient Roberts The barbiturates introduced clinically one century ago were the first pharmacological agents to have demonstrated — in an historical period that was therapeutically inhospitable — a real efficacy in different neuropsychiatric disorders.
They were the first-line treatment as hypnotics and anticonvulsants during the first half of the 20th century. The clinical results obtained in the last years in other indications such as the treatment acute or prophylactic of traumatic brain injury, although contradictory, seems to confirm that, from the pharmacological perspective, the barbiturates continue furnishing certain novelties and that in their history the last page has not yet been written.
National Center for Biotechnology Information , U. Journal List Neuropsychiatr Dis Treat v. Neuropsychiatr Dis Treat. Author information Copyright and License information Disclaimer.
All rights reserved. This article has been cited by other articles in PMC. Abstract The present work offers an analysis of the historical development of the discovery and use of barbiturates in the field of psychiatry and neurology, a century after their clinical introduction. Sedative and anticonvulsant drugs in the pre-barbiturate era Although, as mentioned, the therapeutic agents historically employed for their sedative, hypnotic, or anticonvulsant effects have been quite numerous, the most specific drugs in this regard have their origin in the 19th century.
The discovery and clinical introduction of barbiturates as sedative and hypnotic agents Between the s and the mids, practically the only drugs used as sedatives and hypnotics were barbiturates Lehmann and Ban Open in a separate window. Figure 1. Figure 2. From malonylurea to barbital The first of the barbiturates to come onto the market was diethyl-barbituric acid, also known as barbital, malonal, or gardenal.
Figure 3. The consolidation of barbiturate therapy: phenobarbital By means of small modifications to the chemical structure of the barbituric acid molecule, more than different agents were synthesized.
Clinical introduction of the new barbiturates The new barbiturates brought substantial advantages compared with their classical predecessors, such as a greater potency and duration of action, as well as a wider therapeutic range. Table 1 Mean and maximum dosage of the pharmacological agents used as hypnotics before the benzodiazepine era.
Dosage per administration Daily maximum dosage Drug Mean dosage Maximum dosage Ethchlorvynol mg mg mg Chloral hydrate mg mg mg Paraldehyde 3 mL 8 mL 8 mL Glutethimide mg mg mg Methyprylon mg mg mg Methaqualone mg mg mg Phenobarbital 50— mg mg mg Amobarbital 50— mg mg mg Secobarbital mg mg mg Pentobarbital mg mg mg Sodium tripental mg — mg —. Figure 4. Barbiturates as antiepileptic agents With phenobarbital, in addition to confirmation of the excellent hypnotic effect of barbiturates, it was demonstrated that these drugs had significant anticonvulsant properties.
Table 2 Anticonvulsant drugs used at the National Hospital Queen Square in London, before and after the clinical introduction of phenobarbital in the treatment of epilepsy. Figure 5. The peak and decline of barbiturate therapy As mentioned earlier, chemists from different universities and pharmaceutical companies managed to synthesize over barbiturate derivates.
Table 3 Classification and principal clinical applications of the barbiturates most commonly employed before World War II. Barbiturates Trade name Chemical name Clinical indications Long-acting Phenobarbital Luminal 5-ethylphenylbarbituric acid Sedative Intermediate-acting Amobarbital Amytal 5-ethylisopentylbarbituric acid Hypnotic Short-acting Pentobarbital Nembutal 5-ethyl 1-methylbutyl -barbituric acid Hypnotic and anticonvulsant Secobarbital Seconal 5-allyl 1-methylbutyl -barbituric acid Hypnotic Ultrashort-acting Thiopental Pentothal 5-ethyl 1-methylbutyl -thiobarbituric acid Anesthesia inducer.
Figure 6. Figure 7. Figure 8. Barbiturates today Currently, the use of barbiturates is circumscribed to quite specific therapeutic applications Charney et al Table 4 Barbiturates currently employed and therapeutic applications.
Abbreviations: IM, intramuscular; IV, intravenous. References Adams RC. Intravenous anesthesia. New York: Hoeber; Madrid: Ediciones Eurobook SL; The early history of modern psychopharmacology. Early medicinal uses of bromides. J Royal Coll Physic.
Pharmacotherapy of mental illness. A historical analysis. Prog Neuro-Psychopharmacol Biol Psychiatr. Are there safer hypnotics than barbiturates.
Narcosis as therapy in neuropsychiatric conditions. Production of sleep and rest in psychotic cases. Arch Neurol Psychiatry. The evaluation of mysoline — a new anticonvulsant drug. Br J Pharmacol. Thirtieth Annual Report. Report of the Medical Officer. Thirty-first Annual Report. Intavenose Narkosen mit Barbitur-saurederivaten. Though no longer relied upon as a first-line treatment, phenobarbital still remains an active component in the treatment of seizures, making it the oldest epilepsy medicine still in use.
Even pets suffering from seizures now benefit from phenobarbital. The barbiturate also found a calling treating jaundice in newborns. A high level of bilirubin, an insoluble breakdown product of hemoglobin, creates the yellow hue of jaundiced babies. Severe jaundice can create neurological problems. Phenobarbital lowers bilirubin levels by increasing liver metabolism. Phototherapy exposure to light replaced phenobarbital after it was accidentally discovered in the s to effectively and safely lower bilirubin levels; it remains the most common treatment option today.
Barbara's compound is not a complete "wonder drug," however, and has some serious side effects. Some of the drawbacks of phenobarbital include drowsiness and behavioral changes. And barbiturates in general are notorious for their tolerance issues. Over time, increasing doses are necessary to maintain the same level of effectiveness. The therapeutic dose limit for barbiturates, however, is dangerously close to its toxic level.
Accidental overdose or mixture with alcohol can prove fatal, as was probably the case with Marilyn Monroe's death in Phenobarbital played a role in an earlier scandal and indirectly influenced the development of current Good Manufacturing Practices. In December , Winthrop Chemical accidentally produced sulfathiazole tablets contaminated with phenobarbital. Each tablet contained about mg of phenobarbital, while the average adult sleep-inducing dose was only mg. Used to treat bacterial infections, sulfathiazole had relatively low toxicity and was often prescribed in large doses.
Hundreds of deaths and injuries resulted from the accidental intake of such large amounts of phenobarbital. Winthrop produced sulfathiazole and phenobarbital tablets in the same room on adjacent machines, which were often used interchangeably. Even though Winthrop knew of the contamination in December, cases of the contaminated pills were still surfacing three months later.
Winthrop's poor quality-control system, failure to report the contamination to FDA, and failure to quickly and effectively recall the tainted pills prompted FDA to require detailed controls of sulfathiazole production at Winthrop. Few pharmaceuticals share phenobarbital's claim to fame: A saint's namesake that is capable of taming seizures and is responsible for both the death of movie stars and the birth of Good Manufacturing Practices.
Contact the reporter. Submit a Letter to the Editor for publication. Engage with us on Twitter. The power is now in your nitrile gloved hands Sign up for a free account to increase your articles. Or go unlimited with ACS membership. Chemistry matters. Some individuals are reported to have consumed between 1. A residual central nervous system depression may occur the day following a hypnotic dose.
This may involve impairment of judgement and fine motor skills e. Accidental deaths and suicide attempts involving barbiturate use have been reported.
A study of fatal overdoses due to anxiolytics and sedatives in the UK between and reported a figure of The lethal dose varies from 2—3 g for amobarbital and pentobarbital to 6—10 g for phenobarbital. The concentrations that can cause death are lower if alcohol or other central nervous system depressants such as benzodiazepines are present. Symptoms of an overdose include incoordination, slurred speech, difficulty in thinking, coma, respiratory and cardiovascular depression with hypotension and shock leading to renal failure and death.
Regular use of even therapeutic doses of barbiturates is very likely to result in the development of tolerance and dependence. While tolerance to the sedative and intoxicating effects develops, the lethal dose is not similarly increased. As a result, acute barbiturate poisoning may occur at any time during chronic intoxication. Abrupt withdrawal from barbiturates can be life-threatening, unlike withdrawal from opiates.
Symptoms of withdrawal are similar to those of alcohol withdrawal. The individual becomes restless, anxious, apprehensive and weak, complaining of abdominal cramps, nausea and vomiting. The symptoms reach their peak during the second and third day, when convulsions may appear. The delirium resembles that sometimes seen during alcohol withdrawal delirium tremens and involves anxiety, disorientation and visual hallucinations. During the delirium, agitation and hyperthermia can lead to exhaustion, cardiovascular collapse and death.
But this is not inevitable and the symptoms can disappear with time typically after eight days or so.
The synthesis of barbiturates is mostly performed by the pharmaceutical and chemical industry, but descriptions of their synthesis from appropriate malonyl esters and urea appear on the Internet. Barbiturates are usually swallowed as tablets but can be injected for both medical and non-medical purposes. Numerous synonyms and proprietary names exist for the various barbiturates. User names include barbs, downers, Christmas trees, blue heavens, blues, goof balls, blockbusters, pinks, rainbows, reds, red devils, reds and blues, sekkies, sleepers, yellow jackets, etc.
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