THE USE AND MISUSE OF SEDATIVES AND HYPNOTIC
DRUGS I
BY
] R.
1
E. HEMPHILL, M.A., M.D., D.P.M.
1
Consultant Lecturer in
Psychiatric Physician,
United Bristol Hospitals and
Bristol Mental Hospitals. Charge, Department of Psychiatry, University of Bristol.
i
Sedatives have come to occupy a unique place in medical practice. Their an consumption in this country now probably exceeds that of all other drugs put toge': In the U.S.A. in 1948 the production of barbiturates alone amounted to 336 or the equivalent of 24 therapeutic doses per inhabitant (W. H. O. Report, and it is certainly greater today. However, sedative therapy is comparatively I and until the nineteenth century was confined to the alleviation of pain. In the therapeutics of the ancients, hypnotics and sedatives rarely figure; inmore attention was paid to somnolence than to insomnia or restlessness, and diet, purges, exercise and bleeding we re the usual treatments for mental and ne^: disorders. Opium and mandrake?ancient remedies?were recommended i?[ casional use in the relief of pain. They were probably not used for what would n0'; called nervous conditions although something similar to anxiety was known anci been described under the title of "watchfulness". Paulus Aegineta, in his celebj; synopsis in the seventh century, distinguishes between watchfulness proceeding pain and fever and the watchfulness of those in health, and of the latter he (1844); "If their watchfulness proceeds from sorrow, care or any mental emotion, we endeavour, if possible, to remove the offending cause and then to divert the att^ ^ by agreeable sounds. For this purpose, some seek after the gentle noise of by which they are soothed and lulled to rest. After proper digestion they sf^ use baths, especially in the evening, and a moistening diet. They may also n
green leaves of the black poppy with condiments and eat fish of easy
digei_
They should also use plenty of wine which is light and not old. I have koW*1," succeeding suddenly to fatigue produce the effect. Moderate coition will somet" do the same."
To seek for
a cause
of the mental distress first would be
general practice today. Sedation by day is a modern
good
advice in
psychiatf); 1
introduction. It is
not
mentioned by the older describes in Villette the
classical novelists. Charlotte Bronte writing in 1853 ll'; sedatives at that date: "The sedative had been administered; in fact they had I But by the end ?t me a strong opiate?I was to be held quiet for one night." century bromides and valerian as daily sedatives were recommended in sta^ textbooks of medicine. The term "sedation" is loosely used today and expre5'(: such as "adequately sedated" are without any real meaning. However, the sl "hypnotic" is precise and of ancient origin being "a medicine that causes Interest in hypnotics, other than opium, alcohol and cannabis indica, dates fr0'1; discovery of anaesthesia, and the search for anaesthetic substances produced a of new hypnotic and narcotic drugs such as bromides, chloral hydrate, paraldehyde. After a considerable vogue in the last century, they have notf practically superseded by the barbiturates and newer hypnotics. The hist0'
fl1^;
sulphofl^
?
*
A paper
given
to
the Bristol
Medico-Chirurgical Society,
on
12th December, 1955-
1
DRUGS USE AND MISUSE OF SEDATIVES AND HYPNOTIC
drugs of the is the history of the it. jMdernaMshsedation pharmaceutical publicity that has accompanied barbiturate
use
j
and of the successful
PROPERTIES barbiturates: their history AND
first introduced into medicine
by
Fischer
the oldest barbiturate, followed It lncjar in 1903; sold "veronal", it is still occasionally used. still y^ering prescribed "luminal", trade under the synthesized lnt-912 bY phenobarbitone 2,000 barbiturates few years, the During and Gitman, 1955). ind f0l\. market the an^ ak?ut 5? (Goodman put and shorter duration Th 1C^' barbiturates have the advantage of lighter action was
^
0n
was
as
n
as an
name
sant-
C
were
mo
over
next
U
were
on
n
of producing sleep All the barbiturates are capable With adequate else. USGembl?Sa^e' T WVo? ^ro\vs'e^ree hasT^88 ^xcitabTtC' mind^V ?k hnCe .
1SS
fjernon af'
Piturates^w' for8 sjn?i
addirt;^n^
Barbitn; act^^8 J**-6 is10n
udano-f^^rv
hS 1,11StrUments V*d fo?t, Te'r fusion is?r yellow'U^irf'nemorv^f SV>' ?
^
There^h?^netar^ recently
tendency
DR. R. E. HEMPHILL
14
assumption some
other
a combination of a light barbiturate with a heavy one, or both v, substance, packed in special capsules with different rates of absorpt'i slow, steady absorption of the sedative over a long period of time \
that
produces a thereby tranquillizes the patient. It has yet to be shown that these mixtures have J advantage over the single and probably cheaper preparations. Barbiturates alone have no analgesic properties and may even excite or into#' patients suffering physical pain. It is claimed that the addition of barbiturate aspirin enhances the analgesic effect and mixtures of this sort may be superb codeine in the relief of mild pain such as toothache or slight injuries. Some of the more commonly used barbiturates with their trade names and doseS", Seconal Quinalbarbitone (light) 3 gr. (0-2 g.) Sodium amytal 3 gr. (0-2 g.) Amylobarbitone (medium) Butobarbitone (medium) 3 gr. (0-2 g.) Soneryl Pentobarbitone (light) Nembutal 3 gr. (0-2 g.) Phenobarbitone (heavy) Luminal \-2. gr. (32 mg-120 mg.) Barbitone sodium (heavy) Medinal 5~io gr. (0-3 g.-o-6 g.) ;
NON-BARBITURATE HYPNOTICS
A number of hypnotics have been introduced as an alternative to barbitufS Methylpentynol or "Oblivon" is probably the best known. Its hypnotic potency15" high and it is claimed to be non-addiction-forming, produce no hangover afl^ little toxic. In spite of the claims, some deaths attributed to over-dosage have recorded and Glatt (1955) has described certain alcoholics who had become ad^M
Oblivon, either in addition to or as an alternative to alcohol. It is of portance for it can be obtained, as Schedule I, without medical prescription, an"1 some reputation because of its honorary title of "the confidence drug". Methylpen^ s seems undoubtedly to reduce apprehension and give an illusion of contentment or 3;c a interview even after successful to elation. calm, Candidates, amounting cessful viva, have attributed the result to the drug; and a series of volunteers exair1 by a police surgeon Sinton (1954) with the "drunk in charge" tests did better normal. Hare (1955a) found with patients in Dundry Villas Neurosis Centre f self-controlled trial that methylpentynol was inferior to Carbromal, which in tuff*; inferior to butobarbitone for securing sleep. It undoubtedly is of value and pro^'e has a special advantage in the treatment of insomnia in old people who are "fc susceptible to barbiturate and bromide intoxication. Carbromal ureide, sim" 1 Adalin and Dormiprin, has about the same hypnotic strength as dose 12 gr. Generally regarded as harmless, it may cause dermatitis and as it cp obtained without medical prescription cases of addiction or at least drug depend 1 occur. Persomnia resembles carbromal; and carbrital, which is in fact carbrom^ a pentobarbitone, has some vogue.
specif:*
to
methylpen^r
sleep
inability sleep normally or to sleep at all?is feared by all people. Throughout the ages, writers and poets have extolled the gift of deep n^.( sleep that refreshes the body and shuts out care. These imaginative writers dre3j,t dreams that spring from the active unconscious, in contrast to those of children a of pleasant phantasies and wish-fulfilments. Keats speaks of "sleep, the soft embalmer of the still midnight"; and he clinical indication for a hypnotic drug for anxiety and insomnia when he write5' ( Insomnia?the
to
,
"Save me from curious conscience that still lords 5 Its strength o'er darkness, burrowing like a mole. Turn the key softly in the veiled wards And seal the hushed casket of my soul." A good hypnotic should be certain in action and produce sleep from whiA-c patient awakes refreshed, without hangover. Although hypnotics cannot
5
DRUGS USE AND MISUSE OF SEDATIVES AND HYPNOTIC
ttack the
cause of
sleeplessness merely by securing
a
good night
rest,
s
ien interrupting succession of sleepless nights make the pa vith the mental or physical circumstances that have been mitia y
?Y
a
?,
p
,
^ rQr
amo The aim in the treatment of insomnia should be to secure a reasonable usual the sleep g been have Jeep for the patient. It is important to inquire what t e he how slept, labits?the hour he normally went to bed, long u~urs than is whether a light sleeper or not. Since most people sleep for many ? night's sleep a long s g Necessary to repair their fatigue, it is not to be expected thatanxie ^ ^ or y ;an be obtained if the patient is troubled by real worries unconscious, without heavy doses of a hypnotic.
usu^
TREATMENT TYPES OF INSOMNIA AND THEIR
The
can be grouped as: and anticipation. Over-excitement (a) (b) Anxiety and psychoneurosis. or depression. (c) Psychotic conditions, such as mania in senility. (d) Disturbed sleep pattern i (e) The loss of the sleep habit. s (/) Pain and physical illness. or an e (a) In over-excitement and anticipation (for example, before a \\edding a ang the subject may get no sleep at all without a hypnotic. m g ^voided, he should not be given the drug late probably not a er ^ > econa
DRUGS I
BY
] R.
1
E. HEMPHILL, M.A., M.D., D.P.M.
1
Consultant Lecturer in
Psychiatric Physician,
United Bristol Hospitals and
Bristol Mental Hospitals. Charge, Department of Psychiatry, University of Bristol.
i
Sedatives have come to occupy a unique place in medical practice. Their an consumption in this country now probably exceeds that of all other drugs put toge': In the U.S.A. in 1948 the production of barbiturates alone amounted to 336 or the equivalent of 24 therapeutic doses per inhabitant (W. H. O. Report, and it is certainly greater today. However, sedative therapy is comparatively I and until the nineteenth century was confined to the alleviation of pain. In the therapeutics of the ancients, hypnotics and sedatives rarely figure; inmore attention was paid to somnolence than to insomnia or restlessness, and diet, purges, exercise and bleeding we re the usual treatments for mental and ne^: disorders. Opium and mandrake?ancient remedies?were recommended i?[ casional use in the relief of pain. They were probably not used for what would n0'; called nervous conditions although something similar to anxiety was known anci been described under the title of "watchfulness". Paulus Aegineta, in his celebj; synopsis in the seventh century, distinguishes between watchfulness proceeding pain and fever and the watchfulness of those in health, and of the latter he (1844); "If their watchfulness proceeds from sorrow, care or any mental emotion, we endeavour, if possible, to remove the offending cause and then to divert the att^ ^ by agreeable sounds. For this purpose, some seek after the gentle noise of by which they are soothed and lulled to rest. After proper digestion they sf^ use baths, especially in the evening, and a moistening diet. They may also n
green leaves of the black poppy with condiments and eat fish of easy
digei_
They should also use plenty of wine which is light and not old. I have koW*1," succeeding suddenly to fatigue produce the effect. Moderate coition will somet" do the same."
To seek for
a cause
of the mental distress first would be
general practice today. Sedation by day is a modern
good
advice in
psychiatf); 1
introduction. It is
not
mentioned by the older describes in Villette the
classical novelists. Charlotte Bronte writing in 1853 ll'; sedatives at that date: "The sedative had been administered; in fact they had I But by the end ?t me a strong opiate?I was to be held quiet for one night." century bromides and valerian as daily sedatives were recommended in sta^ textbooks of medicine. The term "sedation" is loosely used today and expre5'(: such as "adequately sedated" are without any real meaning. However, the sl "hypnotic" is precise and of ancient origin being "a medicine that causes Interest in hypnotics, other than opium, alcohol and cannabis indica, dates fr0'1; discovery of anaesthesia, and the search for anaesthetic substances produced a of new hypnotic and narcotic drugs such as bromides, chloral hydrate, paraldehyde. After a considerable vogue in the last century, they have notf practically superseded by the barbiturates and newer hypnotics. The hist0'
fl1^;
sulphofl^
?
*
A paper
given
to
the Bristol
Medico-Chirurgical Society,
on
12th December, 1955-
1
DRUGS USE AND MISUSE OF SEDATIVES AND HYPNOTIC
drugs of the is the history of the it. jMdernaMshsedation pharmaceutical publicity that has accompanied barbiturate
use
j
and of the successful
PROPERTIES barbiturates: their history AND
first introduced into medicine
by
Fischer
the oldest barbiturate, followed It lncjar in 1903; sold "veronal", it is still occasionally used. still y^ering prescribed "luminal", trade under the synthesized lnt-912 bY phenobarbitone 2,000 barbiturates few years, the During and Gitman, 1955). ind f0l\. market the an^ ak?ut 5? (Goodman put and shorter duration Th 1C^' barbiturates have the advantage of lighter action was
^
0n
was
as
n
as an
name
sant-
C
were
mo
over
next
U
were
on
n
of producing sleep All the barbiturates are capable With adequate else. USGembl?Sa^e' T WVo? ^ro\vs'e^ree hasT^88 ^xcitabTtC' mind^V ?k hnCe .
1SS
fjernon af'
Piturates^w' for8 sjn?i
addirt;^n^
Barbitn; act^^8 J**-6 is10n
udano-f^^rv
hS 1,11StrUments V*d fo?t, Te'r fusion is?r yellow'U^irf'nemorv^f SV>' ?
^
There^h?^netar^ recently
tendency
DR. R. E. HEMPHILL
14
assumption some
other
a combination of a light barbiturate with a heavy one, or both v, substance, packed in special capsules with different rates of absorpt'i slow, steady absorption of the sedative over a long period of time \
that
produces a thereby tranquillizes the patient. It has yet to be shown that these mixtures have J advantage over the single and probably cheaper preparations. Barbiturates alone have no analgesic properties and may even excite or into#' patients suffering physical pain. It is claimed that the addition of barbiturate aspirin enhances the analgesic effect and mixtures of this sort may be superb codeine in the relief of mild pain such as toothache or slight injuries. Some of the more commonly used barbiturates with their trade names and doseS", Seconal Quinalbarbitone (light) 3 gr. (0-2 g.) Sodium amytal 3 gr. (0-2 g.) Amylobarbitone (medium) Butobarbitone (medium) 3 gr. (0-2 g.) Soneryl Pentobarbitone (light) Nembutal 3 gr. (0-2 g.) Phenobarbitone (heavy) Luminal \-2. gr. (32 mg-120 mg.) Barbitone sodium (heavy) Medinal 5~io gr. (0-3 g.-o-6 g.) ;
NON-BARBITURATE HYPNOTICS
A number of hypnotics have been introduced as an alternative to barbitufS Methylpentynol or "Oblivon" is probably the best known. Its hypnotic potency15" high and it is claimed to be non-addiction-forming, produce no hangover afl^ little toxic. In spite of the claims, some deaths attributed to over-dosage have recorded and Glatt (1955) has described certain alcoholics who had become ad^M
Oblivon, either in addition to or as an alternative to alcohol. It is of portance for it can be obtained, as Schedule I, without medical prescription, an"1 some reputation because of its honorary title of "the confidence drug". Methylpen^ s seems undoubtedly to reduce apprehension and give an illusion of contentment or 3;c a interview even after successful to elation. calm, Candidates, amounting cessful viva, have attributed the result to the drug; and a series of volunteers exair1 by a police surgeon Sinton (1954) with the "drunk in charge" tests did better normal. Hare (1955a) found with patients in Dundry Villas Neurosis Centre f self-controlled trial that methylpentynol was inferior to Carbromal, which in tuff*; inferior to butobarbitone for securing sleep. It undoubtedly is of value and pro^'e has a special advantage in the treatment of insomnia in old people who are "fc susceptible to barbiturate and bromide intoxication. Carbromal ureide, sim" 1 Adalin and Dormiprin, has about the same hypnotic strength as dose 12 gr. Generally regarded as harmless, it may cause dermatitis and as it cp obtained without medical prescription cases of addiction or at least drug depend 1 occur. Persomnia resembles carbromal; and carbrital, which is in fact carbrom^ a pentobarbitone, has some vogue.
specif:*
to
methylpen^r
sleep
inability sleep normally or to sleep at all?is feared by all people. Throughout the ages, writers and poets have extolled the gift of deep n^.( sleep that refreshes the body and shuts out care. These imaginative writers dre3j,t dreams that spring from the active unconscious, in contrast to those of children a of pleasant phantasies and wish-fulfilments. Keats speaks of "sleep, the soft embalmer of the still midnight"; and he clinical indication for a hypnotic drug for anxiety and insomnia when he write5' ( Insomnia?the
to
,
"Save me from curious conscience that still lords 5 Its strength o'er darkness, burrowing like a mole. Turn the key softly in the veiled wards And seal the hushed casket of my soul." A good hypnotic should be certain in action and produce sleep from whiA-c patient awakes refreshed, without hangover. Although hypnotics cannot
5
DRUGS USE AND MISUSE OF SEDATIVES AND HYPNOTIC
ttack the
cause of
sleeplessness merely by securing
a
good night
rest,
s
ien interrupting succession of sleepless nights make the pa vith the mental or physical circumstances that have been mitia y
?Y
a
?,
p
,
^ rQr
amo The aim in the treatment of insomnia should be to secure a reasonable usual the sleep g been have Jeep for the patient. It is important to inquire what t e he how slept, labits?the hour he normally went to bed, long u~urs than is whether a light sleeper or not. Since most people sleep for many ? night's sleep a long s g Necessary to repair their fatigue, it is not to be expected thatanxie ^ ^ or y ;an be obtained if the patient is troubled by real worries unconscious, without heavy doses of a hypnotic.
usu^
TREATMENT TYPES OF INSOMNIA AND THEIR
The
can be grouped as: and anticipation. Over-excitement (a) (b) Anxiety and psychoneurosis. or depression. (c) Psychotic conditions, such as mania in senility. (d) Disturbed sleep pattern i (e) The loss of the sleep habit. s (/) Pain and physical illness. or an e (a) In over-excitement and anticipation (for example, before a \\edding a ang the subject may get no sleep at all without a hypnotic. m g ^voided, he should not be given the drug late probably not a er ^ > econa
