29.  Alcohol and barbiturates: Two ways of getting drunk

While the enormous usefulness of the barbiturates cannot be questioned, evidence increasingly accumulated during the 1930s and 1940s to indicate that, when misused, they are not so great an improvement over alcohol as had at first been supposed. Indeed, they resemble alcohol in almost all respects. You can get drunk on barbiturates (especially the short-acting kinds) as on alcohol. You can become addicted to barbiturates (especially the short-acting kinds) as to alcohol. A barbiturate addict suffers much the same delirium tremens when withdrawn from barbiturates as an alcoholic withdrawn from alcohol. And abrupt withdrawal may in both cases prove fatal. The parallel between the short-acting barbiturates and alcohol is particularly close, for alcohol is also a short-acting drug. (A long acting alcohol might be a safer drug.)

Among the several studies establishing the parallel between the barbiturates and alcohol, one small-scale experiment conducted at the United States Public Health Service Hospital in Lexington, Kentucky, is of special interest because of the many details it provides. Dr. Harris Isbell and his associates at Lexington isolated in a hospital research ward five prisoner volunteers serving sentences for narcotic law violations. The five were closely observed for a preliminary period, and subjected to a battery of neurological and psychological tests. Then each patient was given a large dose of a barbiturate.

The result was "a marked degree of intoxication," which resembled alcohol intoxication in almost all respects. In a word, the five men became dead drunk. "All patients had difficulty in thinking and deterioration in their ability in performing the psychologic tests." They also showed neurological signs of alcohol intoxication, such as tremors and incoordination.

As in the case with alcohol drunks, the reactions of the five patients drunk on barbiturates were far from uniform. Three of them passed out cold; the other two did not. Before passing out, two patients "became garrulous, boisterous, and silly"–– the familiar behavior of many alcohol drunks. Two others became quiet and depressed, as also happens on alcohol. Just as an alcohol drunk often tries to pretend he is sober, moreover, these two "made desperate efforts to suppress signs of intoxication." The fifth patient, though he received as large a dose as the others, appeared to be little affected. In all cases, "signs of intoxication began to diminish within two hours after the drug was administered, and after four to five hours all clinical evidence of intoxication had disappeared." The patients slept poorly that night, however, and "on the subsequent day they were nervous and tremulous and complained of anorexia [loss of appetite] and headache. They compared these [withdrawal] symptoms to a 'hangover' after an alcoholic debauch."

Having thus demonstrated that a barbiturate drunk is precisely like an alcohol drunk, including the subsequent hangover, Dr. Isbell and his associates next went on to reproduce by means of barbiturates all of the phases of  chronic alcoholism. Each morning for more than three months, the five men were given a small "eye-opener" dose of a barbiturate before breakfast. Larger doses were then administered through the day–– at 9 A.M. and at 2, 7, and 11 P.M.–– much as some chronic alcoholics drink through the day. "Generally, the signs of intoxication were minimal early in the morning and increased throughout the day," the Isbell report noted, "reaching maximum intensity after the 11 P.M. dose" –– a finding equally common among some alcoholics.

"They neglected their appearance, became unkempt and dirty, did not shave, bathed infrequently, and allowed their living quarters to become filthy. They were content to wear clothes soiled with food which they had spilled. All patients were confused and had difficulty in performing simple tasks or in playing cards or dominoes."

During the preliminary drug-free period of the experiment, the five men had become good friends and had developed a spirit of camaraderie among themselves. While drunk on barbiturates, in contrast, they became "irritable and quarrelsome. They cursed one another, and at times even fought–– all traits of the alcohol drunk.

At any cocktail party, one drunk may behave affectionately and garrulously while another becomes morose and a third becomes combative. Among these barbiturate drunks, too, "the effects on mood varied from day to day and from patient to patient. S-1, though occasionally euphoric, garrulous, and pleasant, was usually depressed, complained of various aches and pains, and continually sought increases in medication, although he was so intoxicated that he frequently could not walk." Bartenders, of course, are familiar with the similar behavior of the drunk who, though barely able to stagger to the bar, pleads for just one more drink. Also like an alcoholic, patient S-1 "would weep over his wasted life and the state of his family."

Alcoholics often "swear off "–– until it's time for the next drink; S-1 was like that, too. He "frequently asked to be released from the experiment, but would always change his mind within thirty minutes after missing a dose." In a word, he was addicted.

Patient P-3 was "frequently elated, hyperactive, and garrulous. At other times he was depressed, quiet and withdrawn and talked of the joys of death, but when pressed denied suicidal intentions. He continually attempted to obtain increases in medication. Although he always got along well with other patients when not intoxicated, he became involved in three fights and in a considerable number of cursing matches while taking pentobarbital."

Patient A-5, in contrast, "became even quieter and more withdrawn than he was before.... He sometimes spent days alone in his room and came out only for meals.... He had vague paranoid ideas"–– like many alcoholics–– "and stated the belief that the other patients did not like him and that the attendants were showing favor to them. He could not play dominoes without becoming involved in altercations. Some evidence suggestive of homosexual trends appeared.... He frequently made confused attempts to obtain increases in medication and seemed, as did S-1 and P-3, to be motivated by a desire to become completely unconscious."

The remaining two patients "showed less pronounced changes in behavior. They continued to maintain good relationships with the other patients and with the attendants, and their personal appearance deteriorated less... The general picture in both these men was that of a person who was drunk and enjoyed it." Psychological and neurological test results closely paralleled the results of tests on chronic alcoholics; the neurological signs increased throughout the day, so that by 11 P.M. "all the patients would be staggering and unable to walk except by sliding along the walls. In spite of close supervision, they occasionally fell and were injured." Similar falls and injuries are frequent among alcoholics. "The patients also tended to be more boisterous and quarrelsome at night, and most fights occurred at that time.... Great care had to be exercised to prevent patients from smoking in bed and setting fires"–– a major hazard also among alcoholics.

As in the case of alcoholics, the amount of barbiturate needed to keep these barbiturate addicts drunk "varied widely from subject to subject."

It was following withdrawal of barbiturate, however, that the parallel between that drug and alcohol was most impressively demonstrated. When an alcoholic who has been continuously drunk for days or weeks is abruptly deprived of his alcohol, he goes through a series of well–– defined stages. At first he seems to be sobering up normally. Then anxiety and weakness set in, along with a gross tremor–– "the shakes." The patient eats little but vomits often. A more dangerous stage follows, characterized by "rum fits"–– convulsions like those seen in epilepsy. Then comes delirium tremens–– a life-threatening condition characterized by delusions, hallucinations, and other signs of psychosis as well as physical signs (such as profuse sweating and, in some cases, high fever). These five barbiturate addicts went through precisely this sequence of changes when their drug was withdrawn.

Dr. Isbell and his associates, of course, had had long experience with morphine and heroin addicts at the Public Health Service Hospital in Lexington. They were therefore in a position to compare these barbiturate phenomena with the comparable opiate phenomena.

The manifestations of chronic barbiturate intoxication are, in most ways, much more serious than those of addiction to morphine [they noted]. Morphine causes much less impairment of mental ability and emotional control and produces no motor incoordination. Furthermore, such impairment as does occur becomes less as tolerance to morphine develops, and withdrawal of morphine is much less dangerous than is withdrawal of barbiturates.

The Isbell group also compared the barbiturates and alcohol. "It is obvious," they concluded, "that chronic barbiturate intoxication is a dangerous and undesirable condition, which is very similar to chronic alcoholism"; and they added, "The similarity of the barbiturate withdrawal syndrome to alcoholic delirium tremens is striking." Readers were left to draw the two corollaries for themselves–– that alcoholism is in most respects much more serious than morphine addiction; and that withdrawal of alcohol is even more dangerous than morphine withdrawal.

Current scientific opinion confirms the findings of earlier decades. Thus Dr. Jerome H. Jaffe notes in Goodman and Gilman's textbook (1970):

. . . The subjective effects of barbiturates and sedatives . . . are similar to those of alcohol. [As with alcohol], the effects vary considerably with the dose, the situation, and the personality of the user.... The patterns of abuse are as varied as those for alcohol and range from infrequent sprees of gross intoxication, lasting a few days, to the prolonged, compulsive, dai1v use of huge quantities and a preoccupation with securing and maintaining adequate supplies.

In addition to this evidence demonstrating the parallel between barbiturates and alcohol, there is even more startling evidence to indicate that these two substances are in fact producing many of the same effects –– that the barbiturates might be labeled a "solid alcohol" and alcohol classed as a "liquid barbiturate." A man who drinks increasing quantities of alcohol, for example, becomes tolerant to alcohol effects–– but he simultaneously develops cross-tolerance for barbiturate effects as well, and can tolerate an enormous dose of a barbiturate the very first time he tries the drug. The same is true in reverse; as the barbiturate addict increases his dose, be simultaneously achieves cross-tolerance for alcohol as well as barbiturates, and can take enormous doses. Some alcoholics under pressure to give up alcohol do give it up completely, without any of the usual suffering, "shakes," "rum fits," and delirium tremens–– by substituting barbiturates for alcohol. (Some who make the changeover report that they prefer the barbiturates.) Many addicts use alcohol and barbiturates interchangeably, depending on which is cheaper or more conveniently available at the moment. Many use the two drugs at the same time. Simultaneous use is dangerous, however; for with either drug, there is only a narrow margin between the maximum dose that an addict can manage and the lethal dose–– and it is harder to gauge the dose when both drugs are taken together.

Finally, the barbiturate effect of alcohol and the alcohol effect of the barbiturates is demonstrated during delirium tremens; either drug can  relieve delirium tremens, whether caused by the same drug or by its twin. Indeed, one of the standard treatments for alcohol delirium tremens is to place the patient on intoxicating doses of a barbiturate, and then slowly to taper off the dosage. Drugs of another closely related group, the minor tranquilizers, are also now used for this purpose.

There are also significant practical differences between alcohol and the barbiturates. The latter are less likely to lead to serious malnutrition and accompanying neurological damage (see below), and are less damaging to the gastrointestinal system. Alcohol in the form of light wines and beer is less concentrated, so that the imbibing of a moderate series of doses can be spread over a period of time. An overdose of alcohol is toxic and sometimes lethal; but it is much easier to pop a whole handful of pills than to down a quart of whiskey. Hence, death from barbiturate overdose (or from a combination of alcohol and barbiturate), either accidental or with suicidal intent, is more common. Despite these and other differences, some in favor of alcohol and some the barbiturates, the close parallel between these drugs might be expected to lead to similar moral attitudes toward them–– and to similar laws and national policies.

In fact, however, society takes a very different stance with respect to these twin drugs. Alcohol is treated as a nondrug; it is on sale in multidose bottles at some 40,000 liquor stores and in countless other outlets as well; it is freely sold to those "of age," in saloons, taverns, cocktail lounges, nightclubs, roadhouses, and even ordinary family restaurants; and more than $250,000,000 a year is spent on advertising alcohol. The barbiturates, in contrast, are legally salable only on prescription in pharmacies; other sales are severely punishable criminal offenses. It is a curious fact, indeed, that Americans today are bombarded with advertising urging them to buy a liquid that, if secured without a prescription in tablet or capsule form, could lead to imprisonment for both seller and buyer.

Footnotes
Chapter 29

5. Ibid., p. 11.

6. Ibid.

7. Ibid.

8. Ibid., p. 14.

9. Ibid., p. 15.

10. Ibid., p. 27.

11. Ibid., p. 23.

12. Jerome H. Jaffe in  Goodman and Gilman, 4th ed. (1970), p. 289.