It is a curious fact that the more commonly a medical condition is found the less we know about it, and the less effort we make to find out. Ignorance of the common cold is a common jibe against doctors; on a more serious level, the effort and money devoted to the distressing but statistically insignificant thalidomide problem contrasts alarmingly with the minute funds allocated to research into schizophrenia — a malady that will affect one per cent of the population. So it is with barbiturates, the most commonly used addictive drug, with by far the most addicts. In many ways it is more pernicious than heroin, yet there is a minute literature on it, and an even smaller research effort; this is matched by only minimal public concern. For example a senior police officer at Scotland Yazd, who is directly responsible for drug control in the Metropolitan area, told me that barbiturates were in no sense addictive and that they presented nè problem. The Home Office considered putting barbiturates under the control of the Drugs (Prevention of Misuse) Act, 1964, when the Bill was being drafted, 'but in the absence of police or other evidence of social dangers arising from misuse, it was decided to take no action'.1
With this drug we have a social situation that is the reverse of those surrounding the other illicit drugs. Here abuse, addiction and suicide with the drug are taken as normal events of domestic life. Because barbiturates are prescribed by doctors to support the social system by making people tolerate ways of living that would otherwise be unbearable, society complacently accepts damage from them that would not even be contemplated from other drugs.
These dangers are nothing new.* A Dr Wilcox (later Sir William Wilcox) in 1913 was pointing out the perils of Veronal, which had been in clinical use only ten years. Sniping want on until the fifties, when the medical press slowly awoke to the menace. An editorial in the Lancet saw some 'evidence that the high noon of their popularity is passing' and that the barbiturates were true drugs of addiction' causing a risk that was the least ,appreciated and most sinister '.2 The British Medical Journal at about the same time published its own editorial warning that 'apart from the relatively slight tendency to increase the dosage compared with the behaviour of morphine addicts, barbiturates otherwise fulfil all the criteria for drugs of addiction '.3 Even this reservation can be disputed, for patients have been seen at Lexington whose tolerance has been built up to cope with a dose of 2 grn, in twenty-four hours* compared with a minimum daily dose needed to establish addiction of 0-4 gm.3
Barbiturate-type drugs swell the outer membranes of nerve cells, squeezing the channels through which sodium and potassium ions must pass. This slows the cell's energy-producing processes, and thus the ability of the nervous system to respond to stimuli.
Barbituric acid and its homologua, the hypnotics — of which Mandrax and Trinal are the most common, with another forty different preparations in general uses— have effects similar to alcohol, and in general opposite to the stimulants, caffeine, amphetamine and cocaine. In terms of Eysenck's personality continuum from introversion to extraversion, a dose of the hypnotics moves a given personality towards extraversion, a stimulant towards introversion. This may sound at odds with our ordinary ideas of drug effects — a teenager who is sleepless, garrulous, phrenetic on a large dose of amphetamines may seem to be extraverted rather than introverted; but in fact the stimulants direct the attention inwards towards the thoughts and feelings of the self, rather than outwards to the environment. Thus, this book was written with the help of about four gallons of black coffee. More important perhaps than movement on the intro-extraversion scale is the effect of barbiturates on Eysenck's basic idea of inhibition. In his scheme the distinction between the introvert and the extravert is found in the quantity of 'inhibition' their nervous systems generate. Inhibition is said to be the curtain that protects the self from the world; any stimulus, any activity, generates inhibition and so automatically starts to shut itself off. Freud observed that protection from stimuli was almost more important to the organism than their feception,7 and Aldous Huxley in The Doors of Perception describes the mind as a vast valve to shut off experience. In this sense, the extravert generates a lot of inhibition; he is easily bored, he needs new stimuli, and therefore appears more outgoing than the introvert who has low inhibition and is therefore satisfied longer with the same stimulus.8 In these terms the use of barbiturates accords well with the suspicion that its abuse is largely a middle-aged, domestic affair, g characteristic of overwrought people who need to increase their inhibition, to free themselves from the world: people who find that life is too much for them. This may be confirmed by the popularity of barbiturates for suicide. It is significant that regular barbiturate users tend to have twice as many car accidents as the rest of us.18 (Contrast the low accident rate of heroin users, p. 152)
Although equally serious, addiction to barbiturates differs from that to opiates in a few important respects. It seems far more destructive to personality; the barbiturate addict tends to dope himself until he is completely intoxicated — his object is oblivion. Patients whO have been seen at Lexington under the influence of both opiates and hypnotics, who are said to be sensible, restrained, skilled at their jobs and to show reduced sexuality on opiates, are obstinate, aggressive, apt to masturbate in public, and full of Irish excuses for their stumbling gait and confused speech when they are on barbiturates.
Another writer describes this type of addict.
Chronic barbiturate intoxication always causes marked social and emotional deterioration. Barbiturate addicts neglect their personal appearance and are unable to work or care for themselves adequately. They are rejected by their families, lose their jobs and friends .. . They may commit crimes and not remember them. The behaviour of persons chronically intoxicated with barbiturates resembles the behaviour of chronic alcoholics and appears to be influenced to some degree by their basic personality make-up and by the mood prevailing on any given day. A barbiturate addict may be hilariously amused one day and depressed and weeping the next. Loss of emotional control frequently occurs and addicts are likely to fight over minor matters. Some individuals become infantile, weep easily, and manage to have other persons attend to their bodily needs. Others may develop paranoid ideas and in this state are somewhat dangerous. Tendencies to depression are accentuated by chronic barbiturate intoxication.9
The difference between this and the quietism of the heroin user is striking.
Withdrawal from barbiturates is even more catastrophic than from heroin. It can be brought on by a sudden reduction of the dose by even fifty per cent. During the first sixteen hours the patient appears to improve, becomes more coherent and behaves better. Then he becomes apprehensive and progressively weaker so that soon he can hardly stand; his hands and face begin to shake, and if his forehead is tapped above the bridge of the nose, his eyelids flutter uncontrollably. Any reflex stimulus arouses disproportionate muscular response. His temperature can rise to 105°F, his pulse rate increases by ten to twenty beats a minute. If he stands up his heart is unable to adapt and the pulse rate can rise again by up to eighty beats a minute; blood pressure falls, and these effects become more pronounced the longer he stands, so he is soon likely to faint. After this phase grand mal convulsions can set in. In the worst cases he screams distressingly, falls rigid to the floor, thrashes about, froths at the mouth and fouls himseff. A few die at this point, but by the third day — having lost as much as twelve pounds in weight — major and minor convulsions should be over. Psychoses begin now:
Patients may see little people, giants, absent relatives, animals, insects, birds, snakes, fish and so on; and may believe that imghiy persons are trying to harm them. They may state that they have been blown up, cut with knives and forced to drink poison. The psychosis may also resemble schizophrenia. . showing mutism, bizarre affect with ideas of control and influence, building up a system of paranoid delusions and experiencing sexual hallucinations.'
Usually overt signs have gone within a fortnight, although some patients have also died of exhaustion during the psychotic phase. An otherwise sane person should be more or less normal by the end of two months. As with opiates, the early stages of withdrawal can be staved off by a restoring dose.
The pharmacological (Linger of barbiturate addiction is increased by the character of the people who use it. Unlike heroin there is little status attached to the use of this drug, and hardly a society of addicts. No one could use opiates regularly in Britain without realizing their characteristics and identifying himself as an addict. But barbiturates are prescribed wholesale by almost every G.P. The first Brain Committee Report estimated that enough of the drug was distributed each year to provide twenty tablets a head for the entire population. So trivially is it regarded that ten per cent of this enormous output probably lies about unused in bedside-table drawers. In the Poisons Centre at Guy's Hospital there was recently a gallon glass jar filled with pills — mostly hypnotics — that had been collected from ordinary homes in ten days by a Coroner's Officer investigating sudden deaths in the north of England. Thus the barbiturate addict is able to conceal his addiction from his family, friends and even himself.* He differs profoundly from the heroin addict who uses his addiction as a characteristic defining his position in society. So it is not unusual to admit rather mad people to hospital without finding out that their condition is due to massive doses of this drug. Glatt describes a middle-aged than who was admitted in an abusive and violent state, and who developed three grand mal seizures in quick succession three days later. It turned out that he had been taking twelve grains of sodium amytal daily for six months to 'steady his nerves '.15
It has been fairly common and is now, in 1970, almost commonplace to find chronic barbiturate use in heroin addicts. About a third of all addicts admitted to Lexington, most of whom use heroin, also use barbiturates. Some are 'pan-addicts' who are so dissatisfied with their mental state that they are willing to alter it in any direction; others have become used to barbiturates because of police control of heroin. In times of scarcity, stupefaction is better than withdrawal; and in any case, in the process of adulterating black-market heroin, substantial doses of barbiturates are used:
The horse [heroin] is cut with all manner of adulterous powders, until, at the average user's end, there remains 3% heroin. You can usually count on 3%. But there are times when codeine or even a barbiturate is substituted for the real thing. . . so long as they sum you, they reckon)*
Occasionally mystified patients at Lexington find that they are not really heroin addicts at all; their suppliers have them fooled — and hooked on an alien drug of low status.
One night! drove to meet a barbiturate addict at a crossroads in north London. I saw a gaunt man walking towards me straight across the junction of four roads. He got in the back of the car without a word, and we sat in the pale yellow sodium light. He looked terrible. People always look mauve under that light, but he looked mauver than most. His eyes went straight back in his head at the bottom of bony pits. He had a very smooth, round forehead, with a small worrying dent at the right temple. His hands galloped about in his lap, but his body sat still. He looked at main silence, then: 'Tell me how I can get off this terrible drug,' It was easy to ask him about his addiction and the effect on his family; less easy to get sensible answers. After some minutes he said: 'Tell me how I can get off this terrible drug.'
It took a lot of questioning to discover that he had been using barbiturates illegally for four years. His epileptic brother-in-law started him off with a dose of sodium amytal. Then he had been going to an old lady doctor, getting seconaL 'It's a shame to take advantage of her really. She's eighty and she shouldn't practise because she can't even write the data properly on the scripts. I can go in there, get eighty seconal, take a turn in the waiting room and go in and get eighty more.' He seems proud of this story and repeats it several times. He says that if he doesn't keep on taking barbiturates he gets terribly depressed first thing in the morning, and everything reels about so he can't stand up. 'I can't work, I haven't worked since February. These terrible drugs make me irresponsible.'
He has a wife and two children. A few months before a neighbour told the police that he was forging prescriptions and he was sent to hospital on probation. They didn't keep me long enough. Anyway, I could get out weekends and get more seconal. I even smuggled the pills back on Monday. They didn't look after us right at all.' He took me home to meet his wife, a youngish woman with a great mane of frizzy hair, and tired slitty eyes. At the moment she is calm and sensible, the room is clean, a fat four-year-old is climbing cheerfully over the furniture. The wife says: "The police searched the place when they arrested him last time. Well, there was nothing here that shouldn't have been, but in the bedroom the Sergeant picks up this little bottle of yellow pills. "What's this?" he says, and! said, "Put them back in your pocket. I've never seen them before." When we got down the station they wanted me to make a statement, so I put in about that. They said, "Never you mind; forget that." But I wouldn't. When the statement came through typed for me to sign, there was nothing in it about the bottle.'
She says het husband hasn't been taking the drug for a fortnight now; he's finished tapering off since he came out of hospital five weeks before. He wants to find a job and a fiat in another part of London where the police don't know him. He says the local ones wink at him menacingly. As I drive away I think that it is no coincidence his drug taking and his first child are both four years old. When he says, 'These terrible drugs make me irresponsible,' he perhaps means: 'I take these drugs sol can be irresponsible.'
Many cases of acute addiction — like this one — supplement their legitimate prescriptions by illegal means. But it is true to say that much barbiturate addiction is begun and encouraged by the general practitioner, of whose patients perhaps a third suffer from vague psychiatric and social troubles, inaccessible to his ordinary repertoire of remedies. Simply to stop the weeping and clear his waiting room he prescribes barbiturates. Nearly ten years ago an article in the British Journal o f Addiction commented that there was no doubt 'barbiturates are misused on a vast scale ',1I and another, that they were used 'almost as a placebo, often to assuage the doctor's own anxieties '.12 This is not as irresponsible as it might sound; many older practitioners were trained to regard barbiturates with complacency; and in the absence of a reliable placebo in the pharmacopoeia, they prescribe something that will have some psychic effect while doing less harm than many other drugs.
This can lead, however, to an unfortunate situation.
As long as the addict may be able to satisfy bis demands for the drug be may feel tolerably well in spite of his symptoms, though 'persistent symptoms, particularly those accompanied by a demand for drugs" might arouse suspicions. If this demand is not met the addict may suffer from symptoms such as anxiety, depression, insomnia; these temporary withdrawal symptoms may be thought to show an exacerbation of his original symptoms so that more barbiturates are prescribed, perhaps more frequently and in increasing doses. A vicious circle may set in in this manner so that an originally 'mild psychiatric disturbance is converted into a serious condition',13 which has on rare occasions been known to lead to a leucotomy, or to several such operations. 'Patients with chronic tension states' — as Sargant write04 — 'may continue to remain tense and anxious for years, because they are suffering more from a self-induced or doctor-induced chronic barbiturate tension state than from a persisting anxiety neurosis per se. I am now seeing patients who have had one, two or even three leucotomies performed for chronic persisting tension, and who have then turned out to be, probably, cases of chronic barbiturate addiction:15
These quotations are taken from articles nearly twenty years old. With the decline in the fashion for leucotomies, this unhappy fate - which, on occasion, has overtaken even chronic alcoholics, who display much the same constellation of symptoms16— is less likely. The younger doctor coming into general practice is probably more conscious of the dangers of barbiturate addiction, and also probably has marginally better psychiatric services to which he can refer his disturbed patients. But even so, there seems little evidence that the 'high noon' of barbiturates' popularity has passed. In 1969 barbiturates were nearly the most commonly prescribed medicine with 13.1 million scripts.17 0ne bizarre result of the success of the heroin control system, started in 1968 (see below, p. 176), is that large numbers of drug users turned in 1969-70 to the easily available barbiturates. Since no injectable barbiturate preparations are available, they developed the unpleasant habit of crushing the pills, or emptying the capsules, into water and injecting the mixture directly into a vein — as with heroin. The aim, as with barbiturates taken by mouth, is to achieve stupefaction. Naturally the effects of injecting the drug are more violent, and in addition, because barbiturate preparations are very alkaline, users soon develop enormous ulcers around the site of injection.19 It is estimated that there were, at the end of 1970, 6,000 to 8,000 people engaged in this habit.
But the place of barbiturates in public opinion is curious. Although there are 8,000 cases of barbiturate poisoning a year, although they are the second favourite means of suicide after coal gas — with ten per cent of deaths — and the favourite means of attempted suicide With nearly half of all essays, although the dangers of drinking on top of sleeping pills' are well known, and the dangers of addiction known anyway to doctors, barbiturates are regarded as a normal, friendly feature of life. No home is without them; and the man who crashes his car under their influence, or the woman who kills herself with a handful is reported in the papers as having `taken an overdose'. No more need be said; we all know of what.
*The material in this paragraph, and much of that elsewhere in this chapter, is taken from Dr M. M. Glatt's definitive article on barbiturates in U.N. Bulletin on Narcotics, April—June 1962
*See Evelyn Waugh, The Ordeal of Gilbert Phifold, 1457.