Responding to the rising number of suicides using barbiturates

Suicide prevention requires ensuring that social media are responsible and accountable, and that poisoning surveillance systems are adequately supported

Barbiturates have a narrow therapeutic index, and accidental or deliberate poisoning can cause coma and cardiorespiratory arrest. Barbiturate‐related death rates were high in the mid‐20th century, when barbiturates were still commonly prescribed, but safer alternatives mean that clinical indications for prescribing them are now extremely limited.1 Over the past twenty years, however, interest in barbiturates has increased, particularly in their use at the end of life.2

In this issue of the MJA, Darke and his colleagues1 report that barbiturate‐related deaths in Australia, although uncommon, are increasing in number despite declines in barbiturate prescribing and hospital presentations with barbiturate‐related harm, and low levels of treatment for barbiturate misuse. Their findings suggest that most barbiturate‐related deaths are not related to misadventure among therapeutic or recreational users, but rather to their use for suicide.1 These premature deaths prompt reflection on and discussion of contributory health, social, and legislative factors, and consideration of what can and should be done to optimise outcomes for all involved.

Barbiturate‐related suicide deaths can be divided into two groups.3 The first includes older people with more complex physical health problems. Use of barbiturates for euthanasia — intentionally ending life to relieve suffering — is increasing around the world.2 Growing community acceptance of voluntary assisted dying — in which health care practitioners assist a person to end their life — has prompted the enactment of supporting legislation. Such laws are already operative in Victoria and Western Australia, and will become effective in South Australia, Queensland, and Tasmania over the next two years.4 The Queensland University of Technology website4 provides an excellent overview of the complex terminology and legislation related to voluntary assisted dying, euthanasia, and suicide.

One aspiration of voluntary assisted dying legislation may be that the number of barbiturate‐related suicides would decline as people accessed treatment through conventional services. However, the number of suicides using barbiturates (but not that of other drug overdose suicides) increased in the Netherlands between 2013 and 2017, despite voluntary assisted dying legislation being enacted in 2001.5 A book describing methods for assisted suicide is thought to have contributed to the increase.5

Ethical and legal challenges arise for families and health care practitioners when someone attempts suicide outside the voluntary assisted dying legal framework. For example, a family member who accompanies the person and does not seek medical assistance may face legal consequences.4 Conversely, if a person known to want to die because of intolerable suffering attempts suicide, family members may seek health care support without necessarily wanting active treatment for them. For a health care practitioner, considerations include patient autonomy, assessment of mood, decisional capacity and reversible health conditions, and the implications of unwanted resuscitation and failure to allow a peaceful death. But these considerations must be balanced against local legislation (eg, mental health laws) and the premise that people who attempt suicide should generally receive life‐saving treatment.6 Advancing the discussion and legal framework of voluntary assisted dying, and ensuring adequate palliative care and social support, may reduce the challenges in such cases, consistent with the principle that voluntary assisted dying is voluntary for both the patient and the prescriber.7

The second group of barbiturate‐related suicide deaths are those of younger people with mental health and substance use problems, and they present different challenges.3 Both the community and professional groups feel great discomfort about assisted dying for such people. Assessing decisional capacity in someone with psychiatric illness or the increased impulsivity associated with alcohol or drug intoxication is complex.8 Nonetheless, although uncommon, people experiencing intractable suffering caused by psychiatric illness are eligible for consideration of voluntary assisted dying in some countries, such as the Netherlands and Belgium.9

A recurring theme in both groups is the impact of social media and advocacy groups in disseminating information about the use of barbiturates for suicide and facilitating their purchase.1,5 Sources outside legal voluntary assisted dying include the internet and veterinary supplies.3 Media coverage of suicide, particularly explicit descriptions of methods, can cause imitative behaviour. A code of conduct for the media has been developed to reduce this risk,10 and mainstream media have been responsive. Responsible reporting and presentation of information in social media, however, is more difficult.

Darke and his colleagues have identified a problem with barbiturates, but it is a sentinel observation of a broader problem that needs urgent attention: the influence of the internet and social media on suicidal behaviour. For example, Australian toxicology networks have recently reported similar observations regarding intentional self‐poisoning with sodium nitrite.11 Such problems are often not fully recognised because of limitations in the routine coding of poisonings in Australia. Effective solutions for protecting people at risk of suicide must include ensuring that social media are responsible and accountable, and adequate resourcing of poisoning surveillance systems (toxico‐vigilance), thereby enabling more agile responses to emerging problems.