Potential Adverse Reactions (continued):
- "The reinforcing properties of barbiturates account for their ability to induce dependence."1 We can develop a physical dependence to drugs such as Fiorinal and Fioricet because we can "maintain a high rate of self-administration." Butalbital is a drug of short to intermediate duration of action (half-lives of 10 to 50 hours). Minor withdrawal symptoms occur eight to 36 hours after the last dose, reach their peak at 40 hours, then decrease gradually over a period of two to 15 days. "Symptoms can be severe and include anxiety, involuntary muscle twitching, coarse tremor, weakness and dizziness, distortion of visual perception, nausea and vomiting, insomnia, weight loss, and postural hypotension. Patients may not have all minor signs and symptoms."5
- "Seizures and/or delirium characterize the syndrome. Seizures occur between 24 and 115 hours after cessation of the drug, and are often multiple. Over half of patients with seizures develop delirium tremens, which lasts from 1 to several days; this is characterized by disorientation to time and place (but not person) and by predominantly visual hallucinations."6
- "Deaths have been associated with barbiturate withdrawal."7
- The severity of withdrawal symptoms experienced is directly related to the amounts of medication taken and the duration over which it was taken.
- In some cases of barbiturate withdrawal, medical treatment with other medications may be indicated and helpful.
Headache and Migraine
Treatment with Butalbital/Analgesic Drugs:
It's probably not news to any of us that one of the main concerns
with these medications is rebound or "analgesic overuse" headaches. What
constitutes "overuse" is still somewhat controversial and often debated.
Silberstein and McCrory say:
"...'excessive' use typically is characterized by as few as three daily doses of a given acute agent taken more than 2 or 3 days a week. Medication overuse by patients prone to headache is believed to incite or, at least, reinforce chronic daily headache, with growing dependence on, and habituation to, symptomatic medication and refractoriness to preventative medications ... If the offending acute medication is stopped, this eventually may result in headache improvement (after a period of increased headache during the analgesic washout period)."1
Summary:
As noted earlier, Silberstein and McCrory comment that these
drugs can be effective backup medications for times when other medications don't
work or can't be used. They recommend that they be used on a limited basis and
carefully monitored. Their recommendation for an individual headache or Migraine
attack is that the patient take one or two tablets or capsules initially, and no
more than six per attack. They also advise limiting use to no more than two or
three days a week. They also note that these medications should not be
prescribed for patients who have overused or abused medications in the past.
If you are taking any of the medications
discussed here or other medications from which you may be experiencing rebound,
talk to your doctor for assistance in breaking the rebound cycle. Your doctor
can work with you, not only to break the cycle, but to manage your headaches or
Migraine attacks with different classes of drugs to avoid future rebound.
____________________
Resources:
1
Silberstein, Stephen D. & McCrory, Douglas C. (2001) "Butalbital in the Treatment of Headache: History, Pharmacology, and Efficacy."
Headache: The Journal of Head and Face Pain 41 (10), 953-967.
Available from: http://dx.doi.org/10.1046/j.1526-4610.2001.01189.x
2 Sellers EM, Hoornweg K, Busto UE,
Romach MK. Risk of drug dependence and abuse posed by barbiturate-containing
analgesics. Can J Clin Pharmacol. 1999;6:18-25.
3 McLean W, Boucher EA, Brennan M, et al. Is there an indication for
the use of barbiturate-containing analgesic agents in the treatment of pain?
Guidelines for their safe use and withdrawal management. Can J Clin Pharmacol.
2000;7:191-197.
4 Ciraulo DA & Greenblatt DJ. Sedative-, hypnotic-, or anxiolytic-related disorders. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 6th ed. Baltimore: Williams & Wilkins; 1995:872-887.
5 Sullivan JT & Sellers EM. Treatment of the barbiturate abstinence syndrome. Med J Aust. 1986;145:456-458.
6
Fraser HF, Wikier A, Essig CF, Isbell H. Degree of physical dependence induced
by secobarbital or pentobarbital. JAMA. 1958;166:126-129.
7 Sullivan JT & Sellers EM. Treatment of the barbiturate abstinence
syndrome. Med J Aust. 1986;145:456-458.
