Increased barbiturate deaths: an unintended consequence of increased publicity for methods of do‐it‐yourself euthanasia?

Barbiturate-related deaths have increased in Australia in two major demographic groups: older people with physical health problems and younger people with mental health problems. The former are the intended beneficiaries of laws that allow euthanasia. The latter have been described as collateral damage from increased access to barbiturates, a class of drug often used for euthanasia, regardless of its legality or illegality. Between 2001 and 2017 barbiturate-related deaths increased in Australia in two demographic groups: older people with physical health problems, and younger adults with mental health problems [1]. The former reflected extra-legal forms of euthanasia using illicitly obtained barbiturates because euthanasia was not legal in any Australian state in this period. The deaths among younger adults have been described by one euthanasia advocate as ‘collateral damage’ [2] from increased social media coverage of options for terminally ill individuals to end their suffering. Given the increased public discussion about how to use barbiturates for euthanasia, such ‘collateral damage’ could represent a potentially serious public health concern that our field needs to recognise. During the first half of the 20th century, barbiturates were one of the most widely used sedative-hypnotics and central nervous system depressants [3]. From the 1960s, they were largely replaced by benzodiazepines because of their dependence potential and high risk of fatal overdose [4]. The shift from prescribing barbiturates to benzodiazepines reduced population-level suicide rates [3]. Today, in human medicine barbiturates are used, relatively rarely, for induction-anaesthesia and to treat epilepsy. In veterinary medicine, barbiturates are used to euthanize animals. In Australia, the post-mortem detection of barbiturates has increased over the past two decades, despite an ~50% reduction in the quantity prescribed [1]. Before 2000, barbiturate overdose deaths primarily comprised of suicides among veterinary professionals who used barbiturates intended for animal euthanasia. Since 2000, barbiturate-related suicides have increased in Australia during a period when euthanasia was not a legal option (although it has since become one in two Australian states). These deaths seem to have occurred among people who acquired knowledge of this use of barbiturates from resources provided by euthanasia support groups and/or the web [1]. Barbiturates are very effective in euthanasia because of their high lethality in overdose. Pentobarbitone (Nembutal) has been most often used because it can be acquired via overseas websites, based predominantly in Mexico and China. There are instances of people travelling to these places to purchase the barbiturates that they use to kill themselves when they return home. The prevalence of these deaths is likely to be underestimated because only a minority of deaths in terminally ill adults may be referred to the coroner. Society faces a political and ethical dilemma. As adults live longer, and more suffer from significant physical illnesses, public support has grown for laws to legalise euthanasia to relieve suffering in persons with terminal illnesses. These laws have passed in Belgium, Canada, the Netherlands, some states of the United States and in the Australian states of Victoria and Western Australia [5]. There are, however, differences in how restrictive these laws are. Jurisdictions within the United States and Australia require the diagnosis of terminal illness with limited life expectancy. Other countries, such as Belgium and the Netherlands, only require evidence of ‘unbearable suffering’ and no requirement for a terminal diagnosis [6]. Belgium allows depression and other mental disorders to qualify as unbearable suffering [6]. A recent review identified that there had been slight increases in psychiatric patients requesting euthanasia or assisted suicide in Switzerland, the Netherlands and Belgium [5], although most requests were refused or withdrawn. Additionally, although euthanasia in Switzerland is prohibited, assistance in suicide is legal if no selfish interests are involved, and there has been no documented increase in the number of young people using methods supported by right-to-die groups [7]. There are a number of important issues that we need to consider in jurisdictions where assisted dying remains illegal or the laws that allow it are very restrictive. One unintended effect of civil society campaigns to facilitate assisted dying has been the dissemination of information about the lethality and availability of barbiturates to people with mental health problems who are at increased risk for suicide, (see Fig. 1). In Australia, we previously documented that people accessing pentobarbitone from illicit sources, (i.e. overseas websites, overseas travel to purchase and the dark web) [1]. As with any illicit market, there have been scams with websites falsely claiming to sell and failing to deliver Nembutal, costing desperate individuals considerable amounts of money. Testing kits are now being sold by euthanasia advocacy groups for a nominal cost. Because of the difficulties in accessing pentobarbitone, other methods have begun to receive attention such as the use of sodium nitrite and nitrogen gas that are much cheaper, easier to obtain and harder to detect in toxicology testing. These early indications of increased barbiturate deaths warrant further research and watchful alertness on the part of policy makers. We need better estimates of the scale of the problem in societies that collect toxicological data on suspected drug overdoses, suicides or otherwise suspicious deaths. Drug early warning monitoring systems and wastewater monitoring programs should look for indications of increased use of barbiturates. Any evidence of illicit barbiturate production and distribution would be of especial concern because it would enable these drugs to be sold to people who inject drugs, increasing their risks of fatal overdoses. If there is evidence of increased use of barbiturates (or other methods) for suicide by persons with mental health problems, then we will need to explore strategies to minimise this unwelcome by-product of increased publicity about methods for assisted dying. An important question is whether policy makers can find ways to implement laws that permit the legal use of these drugs for euthanasia to ensure that they are primarily used for their intended purpose by informed, terminally ill adults rather than as the highly effective method of suicide by vulnerable younger adults. None. G.C. is supported by National Health and Medical Research Council Early Career Research Fellowship (1119992). Gabrielle Campbell: Conceptualization; data curation; formal analysis. Shane Darke: Conceptualization; data curation; supervision. Wayne Hall: Conceptualization; supervision. Julia Lappin: Conceptualization.

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