How does pentobarbital work. What are the main indications for pentobarbital use. What are the potential adverse effects of pentobarbital. How is pentobarbital administered. What are the contraindications for pentobarbital use. How does pentobarbital affect pregnant women. What role does pentobarbital play in veterinary medicine.

Understanding Pentobarbital: A Versatile Barbiturate

Pentobarbital is a powerful barbiturate that has found its place in various medical applications. This central nervous system depressant plays a crucial role in managing several conditions, from seizures to pre-anesthetic preparation. To fully grasp its significance in modern medicine, it’s essential to delve into its mechanism of action, uses, and potential risks.

The Mechanism of Action: How Pentobarbital Affects the Brain

At its core, pentobarbital works by interacting with specific receptors in the brain. But how exactly does this process unfold?

• Binds to GABA-A receptors
• Increases chloride channel opening duration
• Potentiates GABA effects
• Inhibits glutamate activity

Pentobarbital primarily targets gamma-aminobutyric acid (GABA) A subtype receptors in the central nervous system. By binding to these receptors, it induces a change in the chloride transport receptor. This alteration leads to an extended period during which chloride channels remain open, effectively amplifying the effects of GABA. As GABA is responsible for producing CNS depression, this prolonged channel opening intensifies the depressant effects on the central nervous system.

Additionally, pentobarbital inhibits glutamate, a neurotransmitter responsible for nerve depolarization in voltage-activated calcium currents. This dual action – enhancing GABA effects and suppressing glutamate activity – contributes to its potent CNS depressant properties.

Metabolism and Distribution

After administration, pentobarbital undergoes first-pass metabolism in the liver. This process affects its bioavailability and onset of action, which is an important consideration for medical professionals when determining dosage and administration routes.

Medical Indications: When Is Pentobarbital Prescribed?

Pentobarbital’s versatility in medical settings is evident through its various applications. What conditions warrant the use of this powerful barbiturate?

• Short-term treatment of insomnia
• Pre-anesthetic for surgery
• Emergency seizure control
• Medically induced comas
• Intracranial pressure control

At lower doses, pentobarbital serves as a short-term sedative for treating insomnia and as a pre-anesthetic agent for surgical procedures. Its rapid onset and short duration of action make it particularly suitable for these purposes.

When administered at higher doses, pentobarbital becomes an effective anticonvulsant for emergency seizure control. Its ability to quickly penetrate the brain and its relatively short half-life often make it the treatment of choice for refractory status epilepticus, outperforming other barbiturates like phenobarbital in this aspect.

Off-label uses of pentobarbital include the control of intracranial pressure in patients with severe brain injuries, cerebral ischemia, and those receiving treatment for Reye syndrome. These applications highlight the drug’s importance in managing critical neurological conditions.

Controversial Uses

It’s worth noting that pentobarbital has been used in capital punishment in some U.S. states. However, this remains a highly controversial topic, with many manufacturers refusing to sell the drug for this purpose.

Administration Routes: Delivering Pentobarbital Effectively

The method of administering pentobarbital can significantly impact its effectiveness and safety profile. What are the primary routes of administration for this drug?

1. Intramuscular injection
2. Intravenous administration
3. Oral ingestion

Intramuscular administration requires careful consideration. Healthcare providers should inject no more than 5 ml into a large muscle to avoid tissue irritation or necrosis. This method is often used when intravenous access is challenging or when a slower onset of action is desired.

Intravenous administration demands precision and caution. The drug should be administered through slow IV injection in its undiluted form, not exceeding 50 mg/minute. It’s crucial to avoid tissue extravasation during this process, as it can lead to tissue necrosis. Rapid IV injection can result in severe adverse effects such as respiratory depression, hypotension, and bronchospasm.

For pediatric patients, oral administration often proves to be the easiest and most comfortable route. To improve palatability, the drug can be mixed with flavored syrup. This method is particularly useful for outpatient treatments or when dealing with children who may be anxious about injections.

Adverse Effects: Recognizing the Risks of Pentobarbital Use

While pentobarbital can be highly effective in treating various conditions, it’s not without risks. What are the potential side effects that patients and healthcare providers should be aware of?

• Central nervous system effects
• Cardiovascular complications
• Respiratory issues
• Gastrointestinal disturbances
• Hematological effects
• Allergic reactions

The most common adverse reactions associated with pentobarbital use primarily affect the central nervous system. These can include altered mental status, agitation, confusion, drowsiness, and in severe cases, respiratory depression. Patients may experience hallucinations, headaches, or paradoxical insomnia.

Cardiovascular effects are another significant concern. Pentobarbital can cause bradycardia, hypotension, and in extreme cases, cardiovascular collapse. Syncope is also a potential risk, particularly in elderly patients or those with pre-existing cardiovascular conditions.

Respiratory complications such as laryngospasm, bronchospasm, and apnea can occur, especially with rapid intravenous administration. These effects underscore the importance of careful monitoring during and after drug administration.

Gastrointestinal side effects like nausea and vomiting are relatively common but usually manageable. More serious concerns include the potential for hepatotoxicity, which requires vigilant liver function monitoring in patients receiving long-term treatment.

Hematological effects, though rare, can be severe. Megaloblastic anemia has been reported in some cases, necessitating regular blood work for patients on extended pentobarbital therapy.

Allergic reactions, including angioedema, can occur in sensitive individuals. Healthcare providers should be prepared to manage these potential emergencies and should inquire about any history of drug allergies before administering pentobarbital.

Contraindications: When to Avoid Pentobarbital

Despite its therapeutic benefits, pentobarbital is not suitable for all patients. What conditions or factors contraindicate its use?

• Hypersensitivity to barbiturates
• Depressed respiratory function
• Porphyria
• Severe liver or kidney impairment
• History of substance abuse
• Pregnancy (Category D)

Any history of hypersensitivity reactions to barbiturates is an absolute contraindication for pentobarbital use. Patients with known allergies to this class of drugs should be offered alternative treatments.

Individuals with depressed respiratory function are at high risk of further respiratory compromise when given pentobarbital. The drug’s CNS depressant effects can exacerbate existing breathing difficulties, potentially leading to life-threatening situations.

Porphyria, a group of rare inherited blood disorders, is another absolute contraindication. Barbiturates can trigger acute attacks in these patients, causing severe abdominal pain, neurological symptoms, and even paralysis.

Caution is advised when considering pentobarbital for patients with severe liver or kidney impairment. The drug’s metabolism and excretion can be significantly affected in these conditions, potentially leading to toxicity or unpredictable effects.

A history of substance abuse warrants careful consideration before prescribing pentobarbital. The drug’s potential for dependence and abuse makes it risky for individuals with a past of addiction.

Pregnancy is a significant contraindication for pentobarbital use. Classified as a pregnancy category D drug, pentobarbital has been shown to cause fetal damage. It can cross the placental barrier and distribute throughout fetal tissue, with the highest concentrations found in the liver, brain, and placenta.

Special Populations

Extra caution is necessary when considering pentobarbital use in elderly patients. Age-related changes in drug metabolism and increased sensitivity to CNS depressants can amplify the drug’s effects and risks.

Pentobarbital in Veterinary Medicine: Beyond Human Applications

While pentobarbital’s use in human medicine is significant, it also plays a crucial role in veterinary practice. How is this drug utilized in animal care?

• Anesthesia for surgical procedures
• Euthanasia in terminally ill animals
• Emergency seizure control in pets

In veterinary settings, pentobarbital is commonly used as an anesthetic agent for various surgical procedures. Its rapid onset and controllable depth of anesthesia make it valuable for both routine and complex veterinary surgeries.

Perhaps the most well-known veterinary application of pentobarbital is in animal euthanasia. When administered in high doses, it provides a quick and painless end for terminally ill or severely injured animals. This use, while emotionally challenging, is considered a humane option in veterinary palliative care.

Similar to its use in humans, pentobarbital serves as an emergency anticonvulsant in veterinary medicine. It can be crucial in managing status epilepticus in dogs, cats, and other companion animals, potentially saving lives in critical situations.

Dosage Considerations in Veterinary Use

Veterinary dosages of pentobarbital vary widely depending on the species, size, and intended use. Precise calculations and careful administration are essential to ensure both efficacy and safety in animal patients.

Monitoring and Safety: Ensuring Proper Pentobarbital Use

Given the potent effects and potential risks associated with pentobarbital, proper monitoring is crucial. What measures should healthcare providers take to ensure patient safety?

• Regular vital sign checks
• Continuous respiratory monitoring
• Liver and kidney function tests
• Electrolyte balance assessment
• Drug level monitoring in long-term use

Vital sign monitoring is essential throughout pentobarbital administration and recovery. This includes regular checks of blood pressure, heart rate, and body temperature. Any significant deviations from baseline should prompt immediate medical intervention.

Continuous respiratory monitoring is critical, especially during and immediately after intravenous administration. Capnography and pulse oximetry can provide real-time data on a patient’s respiratory status, allowing for quick detection of any depression or obstruction.

For patients receiving pentobarbital over extended periods, regular liver and kidney function tests are necessary. These organs play crucial roles in the drug’s metabolism and excretion, and any impairment can lead to toxicity.

Electrolyte balance should be closely monitored, particularly in critically ill patients or those receiving high doses. Pentobarbital can affect sodium and potassium levels, potentially leading to further complications if left unchecked.

In cases of long-term use, such as for refractory seizures or medically induced comas, regular monitoring of drug levels in the blood is essential. This helps ensure that therapeutic levels are maintained while avoiding toxicity.

Withdrawal Considerations

For patients on long-term pentobarbital therapy, abrupt discontinuation can lead to severe withdrawal symptoms. A gradual tapering schedule should be implemented under close medical supervision to safely discontinue the drug.

Future Perspectives: The Evolving Role of Pentobarbital in Medicine

As medical science advances, how might the use of pentobarbital change in the coming years? What new applications or alternatives are on the horizon?

• Targeted drug delivery systems
• Combination therapies for enhanced efficacy
• Development of safer alternatives
• Personalized dosing based on genetic factors

Research into targeted drug delivery systems could revolutionize how pentobarbital is administered. By focusing the drug’s effects on specific brain regions, it may be possible to enhance its therapeutic benefits while minimizing systemic side effects.

Combination therapies that pair pentobarbital with other agents are being explored. These approaches aim to achieve better seizure control or more manageable sedation while using lower doses of each individual drug, potentially reducing overall side effects.

The search for safer alternatives to barbiturates continues. As our understanding of neuropharmacology grows, new compounds that mimic pentobarbital’s beneficial effects without its risks may emerge, gradually replacing its use in certain applications.

Advances in pharmacogenomics could lead to more personalized dosing strategies. By considering an individual’s genetic makeup, healthcare providers may be able to tailor pentobarbital therapy more precisely, maximizing efficacy while minimizing adverse effects.

Ethical Considerations

The use of pentobarbital in capital punishment remains a contentious issue. Ongoing ethical debates and legal challenges may reshape its availability and application in this context, potentially leading to significant policy changes in the future.

In conclusion, pentobarbital stands as a powerful tool in modern medicine, offering vital therapeutic options for various conditions. Its mechanism of action, centered on enhancing GABA effects and inhibiting glutamate, underlies its effectiveness in treating seizures, inducing sedation, and managing intracranial pressure. However, the drug’s potency also brings significant risks, necessitating careful consideration of its use, precise administration, and vigilant monitoring.

As medical science progresses, our understanding and utilization of pentobarbital continue to evolve. While it remains a crucial medication in certain scenarios, ongoing research into safer alternatives and more targeted approaches may gradually reshape its role in clinical practice. Healthcare providers must stay informed about these developments to ensure they’re providing the most effective and safest care possible to their patients.

The complex nature of pentobarbital – its benefits, risks, and ethical considerations – underscores the importance of a well-informed, interprofessional approach to its use. By maintaining open communication among healthcare team members, carefully weighing the drug’s indications against its potential adverse effects, and staying attuned to individual patient factors, medical professionals can harness the therapeutic power of pentobarbital while minimizing its risks.

Pentobarbital – StatPearls – NCBI Bookshelf

Continuing Education Activity

Pentobarbital is a medication used to manage and treat several medical conditions, including seizures, intracranial pressure control, insomnia, and as a pre-anesthetic in the operating room. This activity reviews the indications, mechanism of action, administration, adverse effects, and contraindications of pentobarbital therapy in the clinical setting. It is intended to relate the essential points needed by members of an interprofessional team managing the care of patients undergoing treatment with pentobarbital and its related conditions and sequelae.

Objectives:

• Identify the mechanism of action of pentobarbital.

• Describe the potential adverse effects of pentobarbital.

• Review the appropriate monitoring for the toxicity of pentobarbital.

• Explain interprofessional team strategies for improving care coordination and communication to advance the use of pentobarbital and improve outcomes.

Access free multiple choice questions on this topic.

Indications

Pentobarbital is a drug within the barbiturate class that works primarily on the central nervous system. At low doses, indications include short-term sedatives to treat insomnia and as a pre-anesthetic for surgery.[1] At higher doses, pentobarbital serves as an anticonvulsant for emergent seizure control and medically induced comas. Pentobarbital is often subject to comparison with phenobarbital, another barbiturate, in the use of refractory status epilepticus. Studies have found that pentobarbital is superior in that it has faster brain penetration and a shorter half-life, making it the treatment of choice.

Common off-label uses are for control of intracranial pressure in patients with severe brain injuries, cerebral ischemia, and those receiving treatment for Reye syndrome.[2] Some US states use it for capital punishment, but this remains a widely controversial topic, and some manufacturers do not allow its sale to prisons. More commonly, it is used by veterinarians for euthanasia and anesthesia.[3] 

Mechanism of Action

Pentobarbital works in the central nervous system by binding to gamma-aminobutyric acid (GABA) A subtype receptors. This action induces a change in the chloride transport receptor, leading to an increase in the duration that the chloride channels remain open, hence potentiating GABA effects. GABA is responsible for producing CNS depression and thus prolonging the time the channels remain open and intensifying the depressant effects on the CNS.[4] Pentobarbital also works by inhibiting glutamate, which is responsible for nerve depolarization in the voltage-activated calcium currents.[5] This activity is an additive effect on CNS depression. It undergoes first-pass metabolism in the liver.

Administration

Pentobarbital administration can be through three routes: intramuscular, intravenous, or oral. For intramuscular administration, it is advised to inject no more than 5 ml and only into a large muscle to avoid tissue irritation or necrosis. Intravenous administration is not to exceed 50 mg/minute and should only be given by slow IV injection in the undiluted form.[6] It is essential to avoid tissue extravasation in this process as it has been known to cause tissue necrosis. Clinicians should avoid rapid IV injection as it can result in respiratory depression, hypotension, and bronchospasm, among other adverse effects. In pediatric populations, oral administration is easier by mixing the drug with flavored syrup to improve the taste.[7]

Adverse Effects

The main adverse reactions surrounding pentobarbital use are central nervous system effects, including altered mental status, agitation, confusion, drowsiness, respiratory depression, bradycardia, hypotension, cardiovascular collapse, and syncope. Other significant side effects to be aware of include hallucinations, headache, insomnia, nausea, vomiting, hepatoxicity, megaloblastic anemia, angioedema, local injection site reactions, laryngospasm, bronchospasm, apnea, and hyperkinesia. [1]

Contraindications

Contraindications to pentobarbital use include any prior hypersensitivity reactions to previous drug use or barbiturate class use. Other contraindications include patients with depressed respiratory function and porphyria. Avoid abrupt drug withdrawal in those on long-term therapy. It is advised to exercise caution using this drug in the elderly, those with renal impairment, hepatic impairment, and those with drug use history.[8]   

Barbiturates have been shown to cause fetal damage if used in pregnant women and are pregnancy category D drugs. This class of drugs can cross the placental barrier and distribute throughout the fetal tissue with the highest concentrations in the liver, brain, and placenta. It is essential to monitor maternal blood levels for fetal safety in any pregnant female taking these drugs. There is documentation of withdrawal in infants born to mothers who took barbiturates during pregnancy. Newborns should be closely monitored for seizures and hyperirritability as this may indicate a need for withdrawal treatment. Symptoms can be delayed for up to two weeks and require prompt treatment if indicated.[9]

Monitoring

Toxic doses of pentobarbital occur at approximately 1 gram in most adults, with death occurring at 2 to 10 grams. The therapeutic values for pentobarbital depend on the intended therapeutic effect. For sedation, it is 1 to 5 mcg/mL. For intracranial pressure therapy, it is 30 to 40 mcg/mL, and for therapeutic coma, it is 20 to 50 mcg/mL. Toxic values for sedation are greater than 10 mcg/mL. The time to steady-state in adults is 3 to 6 days. Monitoring parameters include EEG and serum drug levels. Other things to consider when assessing for toxicity are a complete blood count (CBC),  liver function tests (LFTs), and a blood urea nitrogen (BUN) to creatinine ratio if on continuous treatment. Clinicians need to be aware that pentobarbital is often confused with phenobarbital, a different drug with varying dosage differences.

Pentobarbital is a high-risk habit-forming drug categorized by the Federal Controlled Substances Act under DEA schedule II. Tolerance, physical dependence, and psychological effects can occur in patients with long-term use. Estimates are that beyond 400 mg daily for greater than 90 days is the threshold for developing a dependence. Doses of 600 to 800 mg daily for greater than 35 days correlate with withdrawal seizures. Symptoms of acute intoxication include gait and speech alterations and neurological manifestations. Chronic intoxication demonstrates confusion, agitation, insomnia, and generalized myalgias. Minor withdrawal is seen within 8 to 12 hours and major withdrawal within 16 hours, lasting for up to one week following cessation of the drug. Treatment of dependence includes close monitoring and gradual withdrawal of the drug by small dosage decreases over many weeks—infants with physical dependence commonly present with hyperactivity, sleep disturbances, and hyperreflexia. Treatment of withdrawal in this population usually spans over two weeks.[10]

Toxicity

Treatment of pentobarbital toxicity involves supportive care, as there is no antidote. Overdose can lead to airway compromise, cardiovascular collapse, coma, and death. Treatment often requires intubation, hemodynamic support with vasopressors, and maintaining body temperature with warmers, commonly in an ICU setting. In mild or early cases of toxicity, activated charcoal and alkaline diuresis have been added but show minimal benefits. Always contact poison control if poisoning or overdose is suspected.

Special care is necessary for those with renal and hepatic impairment. The manufacturer does not provide dosage adjustment recommendations for renal impairment, but it is essential to monitor kidney function if using high doses or before undergoing prolonged treatment. Similar effects occur in those with hepatic impairment, and recommendations are for close patient monitoring.

Pentobarbital interacts with several major classes of drugs and requires close monitoring to ensure therapeutic drug levels are maintained. As a class, barbiturates induce hepatic microsomal enzymes, which increase the rate of metabolism of other drugs metabolized by these hepatic enzymes. In particular, anticoagulants can be affected, and patients taking these drugs, predominantly Warfarin, may require dosage adjustments. Other drug interactions to be aware of include levothyroxine, corticosteroids, doxycycline, phenytoin, valproic acid, alcohol, monoamine oxidase inhibitors (MAOI’s), and some hormones such as estradiol, estrone, and progesterone, to name a few.[11]

Enhancing Healthcare Team Outcomes

Pentobarbital is not used widely in clinical medicine because of its poor safety, habituation, and lack of an antidote. All clinicians who prescribe should be aware of its toxicity and side effect profile.

Withdrawal from pentobarbital can be life-threatening. Managing pentobarbital withdrawal requires a well-trained interprofessional team of healthcare professionals, including nurses, pharmacists, and several physicians from different specialties. Without proper management, the morbidity and mortality from unrecognized pentobarbital withdrawal are high. Properly treating pentobarbital withdrawal begins the moment a health care provider recognizes the patient is either susceptible to or suffering from withdrawal. The moment that withdrawal is suspected, the interprofessional team must coordinate the care for the patient, including:

• Obtaining a thorough history and physical

• Ordering drug levels in the blood and or urine, appropriate labs, imaging in the emergency department

• Monitor the patient for signs and symptoms of respiratory depression, cardiovascular collapse, central nervous system dysfunction, renal or hepatic toxicity 

• Preparing to provide airway protection and vasopressor support if indicated

• Consult with the pharmacist about possible drug interactions if the patient is taking other medications

• Consult with a toxicologist

• Consult with the intensivist about ICU care and monitoring while in the hospital

• Consider long-term management with social work to provide outpatient follow-up.

To avoid the high potential for morbidity and mortality associated with pentobarbital, the pharmacist should recommend prescribing clinicians safer alternative agents. Nursing should monitor the patient at subsequent visits, verifying medication compliance and treatment effectiveness. With an interprofessional team approach, the morbidity of pentobarbital is reducible and clinical success optimized. [Level 5]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

References

1.

Abou Khaled KJ, Hirsch LJ. Updates in the management of seizures and status epilepticus in critically ill patients. Neurol Clin. 2008 May;26(2):385-408, viii. [PubMed: 18514819]

2.

Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, Kochanek PM, Miller HC, Partington MD, Selden NR, Warden CR, Wright DW., American Association for Surgery of Trauma. Child Neurology Society. International Society for Pediatric Neurosurgery. International Trauma Anesthesia and Critical Care Society. Society of Critical Care Medicine. World Federation of Pediatric Intensive and Critical Care Societies. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 13. The use of barbiturates in the control of intracranial hypertension in severe pediatric traumatic brain injury. Pediatr Crit Care Med. 2003 Jul;4(3 Suppl):S49-52. [PubMed: 12847349]

3.

Holtkamp M, Masuhr F, Harms L, Einhäupl KM, Meierkord H, Buchheim K. The management of refractory generalised convulsive and complex partial status epilepticus in three European countries: a survey among epileptologists and critical care neurologists. J Neurol Neurosurg Psychiatry. 2003 Aug;74(8):1095-9. [PMC free article: PMC1738579] [PubMed: 12876241]

4.

Walker SE, Iazzetta J. Compatibility and stability of pentobarbital ininfusions. Anesthesiology. 1981 Oct;55(4):487-9. [PubMed: 7294399]

5.

Wermeling DP, Blouin RA, Porter WH, Rapp RP, Tibbs PA. Pentobarbital pharmacokinetics in patients with severe head injury. Drug Intell Clin Pharm. 1987 May;21(5):459-63. [PubMed: 3582175]

6.

Knodell RG, Spector MH, Brooks DA, Keller FX, Kyner WT. Alterations in pentobarbital pharmacokinetics in response to parenteral and enteral alimentation in the rat. Gastroenterology. 1980 Dec;79(6):1211-6. [PubMed: 6777235]

7.

Ehrnebo M. Pharmacokinetics and distribution properties of pentobarbital in humans following oral and intravenous administration. J Pharm Sci. 1974 Jul;63(7):1114-8. [PubMed: 4853598]

8.

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. [PubMed: 30693946]

9.

Ashtarinezhad A, Panahyab A, Shaterzadeh-Oskouei S, Khoshniat H, Mohamadzadehasl B, Shirazi FH. Teratogenic study of phenobarbital and levamisole on mouse fetus liver tissue using biospectroscopy. J Pharm Biomed Anal. 2016 Sep 05;128:174-183. [PubMed: 27262993]

10.

Preuss CV, Kalava A, King KC. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 21, 2022. Prescription of Controlled Substances: Benefits and Risks. [PubMed: 30726003]

11.

Singh V. Survival after fatal pentobarbital ingestion. Indian J Anaesth. 2014 Jan;58(1):85-6. [PMC free article: PMC3968666] [PubMed: 24700912]

Disclosure: Anna Johnson declares no relevant financial relationships with ineligible companies.

Disclosure: Nazia Sadiq declares no relevant financial relationships with ineligible companies.

DOJ to Use Pentobarbital in Executions. Here’s Why That’s Controversial

U. S. Attorney General William Barr’s surprise announcement that the federal government would resume executions after more than 15 years included one detail in particular that is troubling many anti-death penalty advocates.

Barr announced last Thursday that the Justice Department will start executing federal death-row inmates for the first time since 2003, bringing back the practice that has been highly criticized and removed from certain states. Seven states have abandoned the death penalty since 2003.

“Congress has expressly authorized the death penalty through legislation adopted by the people’s representatives in both houses of Congress and signed by the President,” Attorney General Barr said in a statement. “The Justice Department upholds the rule of law—and we owe it to the victims and their families to carry forward the sentence imposed by our justice system.”

As opposed to prior executions, which used multiple drugs for lethal injection, federal executions will only use one drug: pentobarbital. Some states have already used the chemical for executions including Texas, Missouri and Georgia.

States started using it for executions in 2011, due to a shortage of sodium thiopental, which was previously used in executions––along with pancuronium bromide and potassium chloride.

Barr’s announcement comes five years after the botched execution of Clayton Lockett in Oklahoma. In 2014, Lockett was injected with a combination of midazolam, vecuronium bromide and potassium chloride. It was an untested blend of chemicals. Appearing to be unconscious, Lockett woke up and thrashed around before dying of a heart attack 43 minutes later. The case brought national attention to the drugs used in lethal injections.

Then-President Barack Obama responded to the public outrage on the incident by calling on Attorney General Eric Holder to review how the death penalty is applied.

Concerns over the effectiveness of multi-drug lethal injections also encouraged states to turn to pentobarbital, according to experts.

“Since 2010, 14 states have used pentobarbital in over 200 executions and federal courts, including the Supreme Court, have repeatedly upheld the use of pentobarbital in executions as consistent with the Eighth Amendment,” the Department of Justice said in a statement announcing the resumption of federal executions.

The first execution dates for the new procedure are set for December for five convicted murderers. There are currently 65 federal prisoners on death row.

Here’s what to know about pentobarbital and why it’s controversial.

What is pentobarbital?

Pentobarbital is a sedative that slows the activity of the brain and nervous system. The drug is commonly used to euthanize pets.

There have been 143 executions that were carried out only with pentobarbital, but it’s unclear where the federal government will get it from and how they will administer it.

“Nobody knows if the pentobarbital that the government has obtained will address the serious risks that individuals across the country are facing of being tortured to death through lethal injection,” Sam Spital, the Director of Litigation for the NAACP Legal Defense and Educational Fund tells TIME.

Capital punishment opponents say this is problematic because a bad batch of the drug, or improper use could lead to botched executions that cause pain before death.

Ruth Friedman, the director of the Federal Capital Habeas Project, says the Justice Department was deliberate in not giving details on where they’re getting the drug from or how it will be administered.

“We have no idea if it’s imported, we have no idea if it’s compounded or manufactured. There’s no way to know,” Freidman tells TIME. “That was a calculated decision.”

Freidman believes it is meant to avoid getting pushback from anti-death penalty groups.

In 2014, Oklahoma used a combination of pentobarbital, potassium chloride and vecuronium bromide to execute convicted murderer Michael Lee Wilson. As the drugs were administered Wilson said, “I feel my whole body burning” before he died.

The new federal guidelines state that only pentobarbital will be used and, according to the DOJ statement, the Supreme Court has upheld the use of this drug in executions.

In April, the Texas Supreme Court allowed the state to protect the identity of their pentobarbital supplier. The Supreme Court in Missouri upheld the use of pentobarbital for death row inmate Russell Bucklew. He is scheduled to be executed on Oct. 1.

Many pharmaceutical companies have stopped supplying drugs to the government for executions, but death penalty opponents say there are ways for the government to find workarounds.

Compounding pharmacies, which are companies that produce mixtures of drugs, are not as heavily regulated as drug manufacturers, and anti-death penalty advocates say that state governments are already using them to get access to drugs for lethal injections.

The DOJ would not comment on where the pentobarbital it plans to use in executions will come from, or how it will be administered.

In Texas, the Woodlands Compounding Pharmacy made the state return pentobarbital that had been purchased for executions after the company’s identity was publicly leaked. Missouri also paid cash for pentobarbital from a compounding pharmacy so there would be no paper trail.

Did the Justice Department go through the correct legal process?

Death penalty opponents are also concerned that Barr’s decision to use pentobarbital in executions did not go through the Administrative Procedures Act (APA), which governs the process of rule making for federal agencies.

“Congress and the public have a right to know what this is about,” Freidman says.

Megan McCracken, a lawyer at the University of California-Berkley School of Law’s Death Penalty Clinic, tells TIME that skipping the APA process makes this new death penalty procedure invalid and therefore open to legal challenges.

“That is an act that brings transparency and accountability to the rule making process for an agency and here they skipped that process all together,” McCracken says.

Normally, when a federal agency develops or makes changes to regulations, it must go through the APA which allows the public to comment on proposed changes before they are put into place.

There is also a lawsuit pending against the federal government on behalf of some death row inmates that argues the use of lethal injection exposes the inmates to a considerable risk of pain.

While the lawsuit is still under review in the federal D.C. District Court, the five men set to be executed in December were not a part of that lawsuit, so the Justice Department was able to avoid addressing the suit with its announcement.

How will this decision affect the state level?

Right now, there are 21 states that don’t have the death penalty and another four that have moratoriums on executions. Federal death row inmates make up a small proportion of the 2,673 inmates on death row in the states that don’t ban executions. According to experts, it’s unclear how the new federal decision will impact those states.

“I continue to believe that the country as a whole is moving away from the death penalty and I don’t believe this one decision will change that,” Spital says. “On the other hand, the federal government does lead by example and to have the federal government so sharply going this way is deeply troubling.”

Support for the death penalty was at a record low in 2016, but has increased slightly since then according to the Pew Research Center. A 2018 survey by Pew found that only 39% of Americans were against the death penalty while 54% were in support of it.

Nationwide, executions slowed down as states struggled to find the drugs for lethal injections. However, they have begun picking up again in some states. Texas has executed three people this year. Last year the state executed 13. Tennessee had three executions in 2018. Florida and Georgia both had two executions in 2018.

“There are many states that have been carrying out executions while the feds have been doing nothing so there’s no direct reason why this should affect any given state for any reason.” McCraken says.

However she also acknowledges that because it’s the federal government, that they could have an “atmospheric affect” on what the states decide to do.

“In so many states the death penalty is a broken system and it is just as broken in the federal government. So you have problems of race and innocence and the most vulnerable people ending up on death row,” McCraken says. “It shouldn’t be a situation where the feds are held up as leaders.”

Write to Josiah Bates at [email protected].

Sodium Pentobarbital – Overdose Risk – Center for Healthy Youth

Sodium pentobarbital (trade name Nembutal) is a common fast-acting barbiturate drug. According to the instructions for use, its main action is sleeping pills. The effect occurs after 20-30 minutes after ingestion. The main danger of this drug is overdose, which can lead to death. In case of an overdose, respiratory arrest occurs and almost instantaneous death of a person. In addition, pentobarbital, if used inappropriately, can cause dependence.

Interesting Facts

In America, this drug was used as a death sentence, but the pharmaceutical company that produced this drug refused to supply it to prisons, which led to its replacement with analogues. Today, pentobarbital is used in countries where euthanasia (voluntary death) is allowed, as well as for the “euthanasia” of animals in veterinary medicine.

It was Nembutal who used the love of his life and Mayakovsky’s muse, Lilya Brik, for a successful suicide attempt at the age of 87.

In our country, sodium pentobarbital is included in List II of narcotic drugs, psychotropic substances and their precursors, and its circulation is strictly monitored by the responsible authorities. This substance is used by drug addicts for recreational purposes (for drug intoxication), as well as by people who attempt suicide.

Do not confuse pentobarbital with phenobarbital, which is an antiepileptic but also a barbiturate.

Composition and action

Dosage form of the substance – tablets, injection solution, capsules. The powder is highly soluble in water.

Sodium pentobarbital depresses the central nervous system. The drug acts on the nerve endings and blocks the ability to receive and transmit signals. In addition, the active substance acts on the enhancement of GABA receptors (inhibitory neurotransmitter). The medicine can cause drowsiness, lethargy, lethargy, as it negatively affects the cerebral cortex.

Medical effect of pentobarbital

If Etaminal-sodium is taken in therapeutic doses, not exceeding the daily dosage recommended by the doctor (usually 0.1 g), no side effects will occur.

How does dependence on barbiturates develop?

Addiction and drug addiction develop quite quickly. In just a few weeks of systematic use, there is not only a physical, but also a mental craving for the drug. However, addiction to the standard dose soon sets in. A person without another pill becomes nervous and irritable, emotionally unstable, aggressive, he is tormented by insomnia, which at times increases intoxication and the risk of serious health complications, including death.

If the next dose is missing, the addict begins to withdraw. The withdrawal syndrome is very difficult for the addict both mentally and physically. He cannot fully sleep, he is tormented by nightmares, depression, suicidal thoughts. The treatment of sodium pentobarbital addiction takes quite a long time, often recovery lasts 6-12 months.

It is not uncommon for people to come to the Center for Healthy Youth with poisoning from this drug and similar barbiturates. Mortality from overdose is about 3%.

Danger of the drug

Among the risk factors for overdose are:

• combination of tablets with alcohol intake;
• non-prescription and uncontrolled use of the drug.

People with alcohol addiction, mental disorders, deep personal experiences and unstable psycho-emotional background are at risk of developing addiction and overdose. With regular intake, tolerance to the usual dose occurs, which leads to its increase, and with this an increase in the risk of poisoning.

Symptoms of an overdose of pentobarbital sodium

The danger of taking this substance is that often an overdose can be overlooked. The addict simply falls asleep, and then stops responding to external stimuli, neither pain nor a loud sound can wake him up. To determine that there is intoxication and a health hazard, it is necessary to monitor the reaction of the pupil to light. A healthy person has a narrow pupil in the light, and a wide one in the dark.

If you touch the cornea, the eyelids normally close instantly. If the addict does not have these reflexes, it is worth calling a narcologist to the house. Emergency drug treatment services in Moscow and throughout Russia are provided by the Center for Healthy Youth.

In case of a critical overdose of pentobarbital, the addict’s respiratory center is depressed, he begins to breathe less frequently, his pulse slows down and his blood pressure drops.

There are 4 phases of intoxication:

1. Falling asleep. The victim does not respond to stimuli, is drowsy and indifferent to everything.
2. Superficial coma. The person is unconscious, swallowing is difficult, tongue retraction is possible, airway is blocked.
3. Deep coma. Complete absence of reflexes. Violation of the work of internal organs, breathing.
4. Post coma. Consciousness returns to the person, he can behave irritably, nervously, excitedly, have problems with sleep, feel overwhelmed, lethargic.

If the poisoning is mild, two intermediate phases are missing. If an addict has a deep coma, he may not get out of it without the provision of drug treatment. Death is not uncommon in drug abuse.

Consequences of use

Regular use of this sleeping pill can lead to significant health complications. Among them: neurological disorders, depression, mental disorders, disruption of the internal organs, kidneys, heart, coma. In 30% of addicts, after providing emergency care and resuscitation and detoxification, problems with the respiratory system, as well as trophic ulcers, dermatitis, bedsores, develop.

The causes of death of drug addicts are: cardiac arrest, respiratory arrest, liver dysfunction.

Emergency care

Even a minor overdose is a serious reason to call an ambulance doctor at home. It is important to make a call in time, as the condition of the victim may worsen. The primary task of doctors in case of intoxication is to remove toxins from the human body as soon as possible. If the victim is conscious, the stomach is cleansed, it is necessary to give him as much water as possible, adsorbents and induce vomiting so that toxic substances are no longer absorbed into the blood through the gastrointestinal tract. If there is paralysis of the respiratory system, it is worth giving the addict artificial respiration before the doctor arrives.

It is worth entrusting all other rehabilitation and medication measures to doctors. Specialists examine the patient and, based on express diagnostics, will be able to select symptomatic drugs, in particular, diuretics.

Inpatient treatment

Pharmacy drug poisoning is a condition that only experienced drug specialists can help. At home, it is very difficult to identify the entire clinical picture. It is possible to fully examine, examine, take tests from a patient only in the conditions of a hospital of a narcological center. Specialists measure vital signs, then study the state of internal organs, the consequences of poisoning, existing diseases, and draw up a complete drug treatment plan, including detoxification procedures.

Measures taken to cleanse and restore the patient’s body in the hospital:

• gastric probing;
• mechanical ventilation;
• infusion-drip therapy.

Droppers are installed to quickly remove toxins from the blood and cleanse the body, as well as normalize the water-salt, electrolyte and acid-base balance. In addition to infusions, hemodialysis and hemosorption are used, these are hardware methods of blood purification. The result of the provision of drug treatment largely depends on the state in which the person was initially. It is very important to start providing assistance in time, the sooner you seek professional help, the less negative consequences a dangerous pharmacy drug will leave behind. An additional plus will be the passage of a drug rehabilitation program after the main course of therapy.

Voluntary death. Explaining how the euthanasia procedure works around the world

Elizabeth
Console

news editor

The voluntary end of life procedure, called euthanasia, is not accepted in all countries. There are individual rules for euthanasia, as well as types and indications. We tell you what euthanasia is like, how the procedure goes and what drugs exist for this.

Read Hi-Tech in

What is euthanasia?

Euthanasia is a procedure for the voluntary termination of a person’s life at his own request. Usually, there are indications for the procedure in the form of an incurable disease or unbearable suffering.

A similar term is used for a veterinary procedure, but it is more common than euthanasia.

“Euthanasia” comes from the Greek words “death” and “good”. For the first time these concepts in a medical context were used by the scientist Francis Bacon at the end of the 16th century. He stated that the doctor should not only heal the patient, but also relieve the torment caused by ailments for which there is no cure.

What is euthanasia like?

• Active euthanasia

In this case, lethal injection is performed directly at the person’s request. With active euthanasia, the doctor must obtain permission from relatives or the patient himself.

There is a deliberate action to end life, and this is always interpreted in two ways. There is mortification out of compassion – a doctor interrupts the life of a patient who is undergoing terrible suffering and has no hope of healing.

• Passive euthanasia

In passive euthanasia, life-sustaining treatment is not started or the patient refuses the previously planned course of treatment.

In this case, passive euthanasia is when a terminally ill person stops receiving medical care, which leads to an early natural death. This type of euthanasia is called the delayed syringe method. This also includes involuntary euthanasia – carried out without the consent of the patient (if he is unconscious), the decision is made by his relatives on the basis of considerations to alleviate a serious condition.

Where is euthanasia legal?

• The Netherlands

In 2002, the Dutch parliament approved a list of conditions in which a doctor can act as an assistant to the patient’s voluntary death by lethal injection or pill. However, in order to carry out the procedure, you need to wait for the approval of the decision from a special “ethics committee”.

• Switzerland

In the country, this procedure is popular among foreigners. Since it is allowed to conduct it not only to representatives of the local population, but also to citizens of other countries. Assistance in the artificial killing of patients is carried out in specialized clinics.

• Belgium

The law was adopted in 2002, following the Netherlands. Available only to Belgians permanently residing in the state. There are a number of restrictions – the patient must be in a state of physical suffering that cannot be corrected, only the doctor who has been treating the patient for a long time acts as an assistant. It is the attending physician who can buy the euthanasia kit, which is sold in a number of pharmacies. Most of those who died voluntarily in Belgium are known to have done so at home.

• USA

Euthanasia is legal in the USA in several states. The first was the state of Oregon. They adopted a law “On a dignified death”, which states that a doctor prescribes a lethal dose to a seriously ill person, and the patient administers the medicine (injections). In 2008, the law was passed in Washington, a year later – in Montana. Vermont and California later joined. In general, euthanasia is currently legal in ten states: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, Oregon, Vermont, and Washington.

• Canada

In Canada, terminally ill people over the age of 18 can voluntarily die. By law, only citizens of the country received the right to die in Canada. For foreigners, this procedure is not available. Most Canadians support the law, under which their seriously ill relatives can easily lose their lives. The death must be “reasonably foreseeable”.

• Mexico

At the beginning of 2017, Mexico decided to legalize “death at will”. At that time, Mexico City adopted the first city constitution in history, including the “Death with Dignity Law”.

It also became known today that New Zealanders voted in a referendum to allow euthanasia. It was approved by more than 65% of the population. The law on its legalization will come into force in 2021.

How is the procedure?

First you need to write a statement, it is often required to do this at certain intervals in order to confirm the desire of the person. A special committee, which includes psychologists, lawyers and doctors, considers indications for euthanasia based on the medical history.

Next, it is necessary to confirm the awareness of the person’s decision and assess his psychological state. The doctor must be convinced that the disease is incurable and the patient’s physical suffering is unbearable. It is important to make sure that there is no other way to save a person from torment.

Once the request for euthanasia is approved and the person confirms their intent to end their life, the legal process and drug preparation will begin.

The procedure is carried out exclusively by a doctor and only with the use of medical devices. How people are euthanized depends on the legislation of those countries where the procedure is legalized, and on the medical organization.

Before people are euthanized, they are given pain medication. Preparations for human euthanasia are made on the basis of a barbiturate. The lethal pills can cause nausea and vomiting. Therefore, the injection form is more effective.

Euthanasia preparations

Such preparations are of course not freely available. They are available only in specialized medical institutions.

Some doctors give injections based on barbituric acid. It provokes spasms of the respiratory tract, which leads to death.