[Barbiturate withdrawal syndrome: a case associated with the abuse of a headache medication]

[Article in Italian]

Sarrecchia C, Sordillo P, Conte G, Rocchi G.

Cattedra di Malattie Infettive, Universita degli Studi Tor Vergata di Roma.

Barbiturates can produce psychological and physical dependence and produce a withdrawal syndrome on the second to fourth day after the drug is suspended. 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. Although barbiturates are less frequently used nowadays, they are employed in combination with other drugs in many medications used for the treatment of headache. We report the case of a 54-year-old woman who developed a barbiturate abstinence syndrome when she suspended self-administration of a drug containing butalbital. The patient had been using barbiturates, 900 mg/die, for 2+ years for persistent headache. She was admitted to the hospital because of seizures, hallucinations and delirium not controlled by benzodiazepine and phenothiazine administration. Her symptoms resolved after parenteral phenobarbital administration.

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[Intractable vomiting, convulsions and megaloblastic anemia: anamnesis, key to diagnosis]

[Article in French]

Schlaeppi M, Humair L, de Torrente A.

Departement de Medecine Interne, Hopital Communal, La Chaux-de-Fonds.

In July 1996 a 43-year-old illiterate Hispanic woman presented with uncontrollable vomiting, palpitations and confusion. In 1994, despite several hospitalisations in other medical centres where a cerebral CT-scan, oesogastroduodenoscopy, colonoscopy and abdominal ultrasound were performed, no satisfactory diagnosis could be found. A psychiatric origin was finally considered. On admission, the laboratory findings showed severe metabolic alkalosis with associated hypokalaemia, confirmatory evidence of vomiting. The ECG showed tremendous P waves (5 mV) in the standard derivations, which can be explained by the hypokalaemia, with multiple supraventricular extrasystoles. Echocardiography and pulmonary scintigraphy ruled out pulmonary hypertension and a pulmonary embolus. After additional discussion with her daughter we discovered that the patient had been treating chronic headaches for years with 4-5 Cafergot-PB suppositories per day. This drug contains 2 mg ergotamine tartrate, 100 mg butalbital, 100 mg caffeine and 0.25 mg belladona alkaloids. As is known, vomiting is a classical symptom of ergotamine intoxication. After rehydration we discovered a megaloblastic anaemia with a folate deficiency compatible with chronic barbiturate intoxication. Folate and iron supplementation allowed a rapid normalisation of the haemoglobin values. Five months after having stopped the Cafergot-PB, the patient was well and did not vomit anymore. The headaches were treated with chlorpromazine with a good result. Despite sophisticated technical means, the diagnosis could only be established after a thorough history taking. This message should be heard in times when high tech medicine tends to obscure the place of a good history taking!

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Mechanistic studies on the use of 2H- and 13C-analogues as internal standards in selected ion monitoring GC-MS quantitative determination--butalbital example.

Chang WT, Liu RH.

Department of Forensic Sciences, Central Police University, Taoyuan, Taiwan.

As a part of our study on the use of isotopic analogues as the internal standard (IS) for the quantitation of drug analytes, this article reports on the performance characteristics of 2H5-butalbital and 13C4-butalbital with particular focus on (1) determining and comparing the effectiveness of the 2H- and 13C-analogues in serving as the ISs for quantitation; (2) understanding the "cross-contribution" phenomenon underlying the effectiveness of selected ion pairs used for quantitation purpose; and (3) examining whether the same characteristics, observed in our preliminary report for the secobarbital/2H5-secobarbital/13C4-secobarbital system, also exist in the butalbital/2H5-butalbital/13C4-butalbital system. Adapting similar procedures applied to our previous study on the secobarbital system, we observed that (1) both labeled analogues (13C4-butalbital and 2H5-butalbital) cause more significant cross-contributions to ions designated for butalbital than butalbital to the labeled analogues; (2) compared to 2H5-butalbital, 13C4-butalbital appears to cause less cross-contributions to ions designated for butalbital; (3) cross-contribution between the following ion pairs are minimal: m/z 200/196, 199/195, 185/181 (13C4-butalbital as the IS) and m/z 201/196 (2H5-butalbital as the IS). It is also concluded that the butalbital/2H5-butalbital system exhibits the same concentration dependency phenomenon observed in the secobarbital/ 2H5-secobarbital system, that is, ratios of ion pairs designated for these two isotopic analogues (resulting from routine gas chromatography-mass spectrometry protocol) increase as their concentrations are diluted. (In parallel with the secobarbital/13C4-secobarbital system, the butalbital/13C4-butalbital system does not exhibit this phenomenon.)

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A comparison of the potencies of a series of barbiturates at the neuromuscular junction and on the central nervous system.

Lee-Son S, Waud BE, Waud DR.

The ability of a series of barbiturates to depress the depolarizing action of carbachol at the end-plate of guinea-pig lumbrical muscle was studied. The compounds studied were: amorbarbital, aprobarbital, barbital, barbituric acid, butabarbital, butalbital, dimethylbutylethyl barbituric acid, hexobarbital, mephobarbitak, secobarbital, thiamylal, and thiopental. The depressant activity was sensitive to small changes in structure of the compounds strongly suggesting that a specific receptor site was involved in the interaction of the drug with the tissue. The observed relative potencies on the motor end-plate were compared with their anesthetic potencies assayed on tadpoles. The two potencies went hand-in-hand for all the compounds studied, including the convulsant member of the series.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate




Butalbital-containing agents: should they be banned? No.

Solomon S.

Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. sysol earthlink.net

Butalbital compounds are of proven efficacy in the treatment of tension headache. Decades of experience have established their value in the treatment of other mild-to-moderate headaches. Untold numbers of people rely on these medications as their drug of choice or use them when vasoconstrictors, opioids, or nonsteroidal anti-inflammatory agents are contraindicated. The medications are cost-effective with only occasional and minor immediate adverse effects. Their overuse may cause the evolution of episodic primary headaches to chronic daily headaches; however, removal of these agents from the market would reduce the chronic daily headache in the general population by a small fraction of 1%.

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