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Paraldehyde Addiction

Posted on August 21, 2013 in Prescription Drug Addiction

Paraldehyde AddictionParaldehyde is an addictive sedative once prescribed to ease childbirth pain and discomfort from alcohol withdrawal. Today newer and safer barbiturates, sleeping pills and benzodiazepines have mostly replaced the 19th-century drug. Nevertheless, the United States Drug Enforcement Agency still lists paraldehyde as a “drug of concern,” which means drug dealers and addicts are still diverting it from medical facilities for recreational and illegal uses.

Alcoholics often “like” paraldehyde better than alcohol, and once they become addicted to it, they use it in dangerous amounts that cause long-term damage to their vital organs. Withdrawal from a paraldehyde addiction is very similar to withdrawing from alcohol, producing the same dangerous symptoms such as hallucinations, tremors, and delirium tremors. If you are addicted to paraldehyde, you should not try to go through withdrawal alone. This is a difficult drug to kick, and you will need professional help.

What is Paraldehyde?

Paraldehyde is a drug first synthesized in 1829 and first used for medical reasons in Great Britain by Dr. Vincenzo Cerzello in 1882. It is classified as a sedative/sleeping pill and, like most of these drugs, paraldehyde is a sedative at low doses and a sleeping pill at higher ones. Its chemical name is 2, 4, 6-trimethyl-1, 3, 5-trioxane.

In chemical terms, paraldehyde is a cyclic trimer of acetaldehyde, soluble in water.  It forms crystals at low temperatures and becomes liquid if warmed. Paraldehyde liquid is transparent, colorless or pale yellow, with a strong odor and disagreeable taste.[i]

In legal terms, the United States government classifies paraldehyde as a Schedule IV Controlled Substance, which means it has some medical uses and can be legally prescribed by a doctor, although it has potential for addiction. State and federal governments regulate this drug, and you can be subject to fines and prison terms for possessing or selling it without a doctor’s prescription.

For many decades, paraldehyde was one of the most useful medications for psychiatric patients, and for those with coughs, seizure disorders or insomnia. However, after barbiturates came out in the early 1900s and benzodiazepines were introduced in the 1950s and 1960s, both of these kinds of newer, safer drugs mostly replaced paraldehyde as a sedative. In the 1970s, newer sleeping pills such as zolpidem (brand name: Ambien) and zaleplon (brand name: Sonata) gradually replaced paraldehyde as an aid for insomnia.[ii]

How Does Paraldehyde Work?

Paraldehyde works in nerve cells in the brain and other parts of the central nervous system. These cells communicate with one another through electrical signals. If their signals are too fast or repetitive, the brain can become over-stimulated, and the person will have a seizure. A neurotransmitter called gamma-aminobutyric acid or GABA calms nerve activity. Paraldehyde increases the effects of GABA and decreases levels of glutamate, a chemical that excites nerve activity. It prevents certain chemicals from passing through openings in nerve cells.[iii]

Paraldehyde accumulates in spinal fluid, and crosses the placenta in pregnant patients. It is metabolized in the liver to acetaldehyde, which becomes aldehyde dehydrogenase, which further breaks down to acetic acid.[iv] Some of it is excreted through the lungs, which is why it causes bad breath.

Paraldehyde has some industrial uses in the manufacture of leather and resin, and as a solvent.[v] It is a volatile flavor component of bacon.[vi]

What are the Medical Uses of Paraldehyde?

Psychiatrists sometimes prescribe paraldehyde to calm or relax agitated patients or to put them to sleep. Until around the 1960s, it was regularly used for this purpose but has gradually been replaced by newer drugs. Its most common use was to prevent and ease delirium tremors and seizures among alcoholics going through withdrawal.[vii] Doctors also use paraldehyde with patients who have a life-threatening condition called status epilepticus, which keeps their brains into permanent state of seizures. How paraldehyde stops these seizures is unclear.[viii]

In the mid-1930s, doctors thought they had found “one of the most noteworthy steps to do away with suffering during childbirth,” as Professor Howard Kane of George Washington Medical School said at the time. Paraldehyde along with benzyl alcohol was tested in hundreds of cases, and produced sleep in laboring mothers within 30 to 60 minutes. These women would sleep through the labor process for six to eight hours, only stirring slightly during their contractions.

“The patient awakens from her long sleep actually refreshed after giving birth,” Dr. Kane said.[ix]

After several decades of experimentation, researchers determined that the use of paraldehyde during childbirth carries the risk of respiratory depression in newborn babies, and so it was discontinued.[x]

Today paraldehyde is available in solution, liquid or injection form. Although it causes little cardio-respiratory risk in adults, it is mostly administered rectally if no facility for resuscitation is available — for example, with homebound patients. The usual rectal dosage is 5mg to 10mg, repeated every 15 to 30 minutes as necessary.[xi]

Only doctors or trained nurses can administer paraldehyde injections. The usual dosage is no more than 5ML into muscles in the buttocks.[xii]

In general, the dose for insomnia is 10 mL; for use as a sedative, it is 5mL; for use as a seizure or remedy or for status epilepticus, it is 5mL to 10mL. For alcohol withdrawal, it is 5mL every four to six hours during the first 24 hours, and then every six hours up to 30mL. After that, the dose is 20mL per day as needed.

The United States Food Drug Administration advises that oral, rectal and injected doses of paraldehyde should be determined by a doctor.[xiii]

Does Paraldehyde Show up on Urine Tests?

Paraldehyde usually does not show up on routine urine tests at work or school because its metabolites decompose rapidly. The half-life of paraldehyde is 3.5 to 9.5 hours, with an average of 7.5 hours, which means it could theoretically show up for several days after taking it.[xiv]

What Drugs Interact with Paraldehyde?

Paraldehyde plus alcohol can cause death.[xv]

Do not take paraldehyde with other central nervous system depressants such as barbiturates, muscle relaxants, anesthetics, tranquilizers, sedatives, prescription pain killers, medications for colds and allergies, seizure medications, and almost any drug that causes drowsiness.[xvi] Paraldehyde will reduce the effects of tricyclic antidepressants such as imipramine.[xvii] If you are taking disulfiram (Antabuse) for alcoholism, paraldehyde will cause nausea, flushing, dizziness, vomiting, and headaches similar to the symptoms that you develop when you drink alcohol.[xviii]

Do not take paraldehyde with fospropofol, ketorolac, ginkgo, or naproxen.[xix]

What are the Side Effects of Paraldehyde?

The most common side effects caused by paraldehyde are rashes and coughs. Less common are redness and pain at the site of the injection, abscesses, nerve damage, tissue necrosis, itching, fever and dark urine. If taken long-term, some people develop yellow eyes and skin. Many people cannot take paraldehyde by mouth because it tastes so bad and causes nausea.[xx]

What are the Risks of Taking Paraldehyde?

Paraldehyde is an addictive drug controlled by state and federal governments. Once you become physically and psychologically dependent on it, you will experience drug cravings when it is unavailable, you will develop a tolerance for its effect, and you will go through withdrawal syndrome once you stop using it.[xxi]

Since paraldehyde is metabolized in the lungs and liver, these organs can become overloaded and develop problems for certain patients using this drug. Paraldehyde also can stress the gastrointestinal tract so that a patient can develop ulcers.[xxii]

Paraldehyde must be handled and stored with special precautions. It has a short shelf life.  If exposed to air and light, it can decompose into acetaldehyde and then oxidize into acetic acid.  It should never be used unless the solution is clear –decomposed paraldehyde turns brown. It should never be used unless the solution is clear. Decomposed paraldehyde can cause thrombosis, microsembolism and cardiovascular collapse.[xxiii] Paraldehyde reacts with rubber and plastic, and therefore you must use the correct equipment or you can cause tissue damage.

If improperly injected near nerves in the trunk of the body, paraldehyde can cause permanent nerve damage. If paraldehyde is not injected properly, the result can be severe abscesses and nerve damage. Thrombophlebitis, circulatory collapse and pulmonary edema can be complications of intravenous injections of paraldehyde.[xxiv]

Paraldehyde can be toxic if inhaled or absorbed through the skin. It produces irritating gases when burned.[xxv]

 

A few people are allergic to paraldehyde and enter a life-threatening syndrome that includes rashes, hives, wheezing, difficulty breathing, swollen face and lips, and other symptoms. If a patient experiences such a reaction, he or she should seek medical help immediately.[xxvi]

What People Should Not Take Paraldehyde?

People with stomach disorders, hepatic impairment, liver diseases, stomach ulcers, histories of substance abuse or alcoholism, or lung disorders such as asthma, bronchitis or emphysema, should not take paraldehyde. Do not take paraldehyde when you have the flu. Do not administer paraldehyde rectally to a patient with colitis.[xxvii] Paraldehyde is not prescribed to pregnant or lactating women because it can damage their babies.

What is a Paraldehyde Overdose?

Most people who die of paraldehyde overdoses have combined the drug with alcohol. Only one to two ounces of alcohol plus paraldehyde is necessary to cause death within 30 minutes to four hours. The usual progression of symptoms in a fatal overdose are coma, severe hypotension, stoppage of breathing, pulmonary edema, and stoppage of the heart. Most die of respiratory failure, heart failure or acidosis.[xxviii] Other conditions that can develop from an overdose are azotemia, oliguria, albuminuria, leukolytosis, nephrosis, toxic hepatitis, fatty changes in the liver and kidneys, and lung hemorrhages.[xxix]

Some people have survived dosages of 125 mL, but others have died after a rectal dose of only 25 mL.[xxx]

Symptoms of a paraldehyde overdose are confusion, decreased or cloudy urine, fast deep breathing, muscle tremors, nausea, vomiting, nervousness, irritability, shortness of breath, slowing of the heartbeat, severe stomach cramps, severe weakness, drowsiness, clumsiness, dizziness, and confusion.[xxxi] Paraldehyde overdose can also cause changes to the eyes, but does not injure the nerve or retina.[xxxii]

The usual treatment for overdose is to open that person’s airway and to administer oxygen and sodium bicarbonate or sodium lactate intravenously to counter acidosis.

What is Paraldehyde Withdrawal?

Paraldehyde withdrawal is a series of severe symptoms that occur when a person addicted or physically dependent on the drug stops taking it. The syndrome is very similar to what alcoholics endure once they stop drinking.

Symptoms can be convulsions, hallucinations, increased sweating, muscle cramps, stomach cramps, trembling, nausea, and depression.[xxxiii] The person can develop delirium tremors. No one should try to withdraw from paraldehyde alone because some of these symptoms are dangerous to manage.[xxxiv] Withdrawal can last for weeks, depending on the level of addiction. A doctor can make a person more comfortable by gradually lowering the amount of paraldehyde the person takes over a long period.[xxxv]

What is Paraldehyde Addiction?

Recovering alcoholics are sometimes given paraldehyde to ease them through their delirium tremens, hallucinations, seizures and other withdrawal symptoms when they give up drinking. These are the people who are most likely to become addicted to paraldehyde. Many of them prefer it to alcohol, in spite of its foul odor and bad taste. They cannot stop using the drug and develop tolerance for its effects, cravings, as well as a withdrawal syndrome similar to that of alcoholism.

Paraldehyde addicts are known to take 120 mL a day or more. Long-term use of paraldehyde, especially in large amounts, can cause impairments to memory, speech and intellect, unsteady gait, tremors, anorexia, weight loss, and mental delusions. These problems can look like alcoholism.[xxxvi] Other long-term health problems of paraldehyde addiction include toxic hepatitis, nephritis (a kidney disorder), and metabolic acidosis.

What Treatments are Available for Paraldehyde Addiction?

Treatment for paraldehyde addiction is most likely to succeed if you enter a residential treatment center and remain there for a month or longer. The first day you will undergo a complete physical and psychological examination to determine the level of your addiction and whether or not you have any comorbidities or psychiatric problems that may be contributing but not necessarily causing your addiction. Once you complete the evaluation process, the next step is detoxification.

Chemical detoxification or withdrawal from paraldehyde is completed under the direction of medical professionals at the residential treatment center, who can wean you from the drug gradually, prescribe certain medications and use techniques to help you avoid severe unpleasantness and discomfort.

Once detoxification is complete, you move out of the detox unit to the residential center to work with others with similar challenges with substance abuse. You may start your day with a refreshing run before breakfast, and then attend a class on drug addiction, learning about why it became a compulsive behavior, how cravings develop and how to handle them, and much more. You will also learn how to deal with people and situations that trigger relapses into paraldehyde addiction.

In the afternoons you may attend sessions in drama, art or music designed to help you get in touch with your emotions, and you most certainly will have one-on-one therapy with the personal counselor assigned to your case. This professional will understand you as an individual and help you make the transition into a drug-free life. Sometimes that means a career change or letting go of certain unhealthy relationships. You may have some free time to do journaling, participate in outdoor or indoor sports activities, go sightseeing, or even have a party with your new friends at the center. Sometimes you may attend 12-step support meetings in the evening. Other components of a good program might be family and couples counseling, group therapy, and career counseling.

Most people with addictions have psychiatric comorbidities such as depression, posttraumatic stress syndrome, attention deficit disorder, bipolar disorder, and many more. Usually these are undiagnosed problems that must be treated in a medical protocol separate from the one for addiction.

Once you return home and back to normal life, you usually continue in one-on-one counseling and attend support meetings in your community.

How Can I Tell if I Am Addicted to Paraldehyde?

If you can answer yes to any of the following questions, you should consult your family physician or an addiction specialist about your problem with paraldehyde.

  • Are you using paraldehyde without a doctor’s prescription?
  • Are you using paraldehyde with alcohol?
  • Are you obtaining paraldehyde from illegal sources?
  • Have you developed physical symptoms, such as irritability and confusion, because your problem with paraldehyde?
  • Have you tried to quit using paraldehyde on your own but failed?
  • Do you develop withdrawal symptoms when you try to stop using paraldehyde?
  • Are you using paraldehyde in amounts not medically recommended?
  • Do your friends and family members criticize you for your drug use?
  • Do your drug problems interfere with your relationships and your functioning at work or school?
  • Do you ever feel guilty or ashamed about your drug use?
  • Have you ever driven under the influence of paraldehyde or otherwise endangered yourself physically because of your drug use?

[i] “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[ii] Lukas, Scott E., and Nicholas Demartinis. “Sedative-Hypnotic.” Encyclopedia of Drugs, Alcohol & Addictive Behavior. Ed. Rosalyn Carson-DeWitt. 2nd ed. Vol. 3. New York: Macmillan Reference USA, 2001. 1018-1019. Gale Virtual Reference Library. Web. 14 July 2013.

[iii] “Paraldehyde,” Medical Authority of the United Kingdom, Netdoctor, see http://www.netdoctor.co.uk/brain-and-nervous-system/medicines/paraldehyde.html

[iv] Gilman, AG et al. The Pharmacological Basis of Therapeutics (Eighth edition). New York: Pergamon Books, 1990, pg. 368.

[v] “Paraldehyde,” The Toxicity Data Network, The National Institutes of Health, seehttp://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3375

[vi] Ho, CT et al. The Journal of Agricultural and Food Chemistry 31, pages 336-42.

[vii] “Paraldehyde (Oral route, Injection route, Rectal route),” Official Information from the United States Food and Drug Administration, see http://www.drugs.com/cons/paraldehyde-oral-injection-rectal.html

[viii] “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[ix] “Childbirth during Sound Sleep Reported with Refreshing Drug,” The New York Times, February 16, 1936.

[x] “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[xi] Ibid.

[xii] Ibid.

[xiii] “Paraldehyde (Oral route, Injection route, Rectal route),” Official Information from the United States Food and Drug Administration, see http://www.drugs.com/cons/paraldehyde-oral-injection-rectal.html

[xiv] “Paraldehyde and Its Metabolites,” NMS Laboratories, see http://www.nmslabs.com/tests/Paraldehyde-and-Metabolite–Urine/3310U

[xv][xv] “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[xvi] “Paraldehyde (Oral route, Injection route, Rectal route),” Official Information from the United States Food and Drug Administration, see http://www.drugs.com/cons/paraldehyde-oral-injection-rectal.html

[xvii] “Paraldehyde,” The Toxicity Data Network, The National Institutes of Health, seehttp://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3375

[xviii] Fuller, Richard K., Raye Z. Litten, and Rebecca J. Frey. “Disulfiram.” Encyclopedia of Drugs, Alcohol & Addictive Behavior. Ed. Rosalyn Carson-DeWitt. 2nd ed. Vol. 1. New York: Macmillan Reference USA, 2001. 410-412. Gale Virtual Reference Library. Web. 14 July 2013.

[xix] “Paraldehyde (Oral route, Injection route, Rectal route),” Official Information from the United States Food and Drug Administration, see http://www.drugs.com/cons/paraldehyde-oral-injection-rectal.html

[xx] Ibid, see also “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[xxi] “Paraldehyde: Drugs of Concern,” The United States Drug Enforcement Agency, see http://www.justice.gov/dea/druginfo/concern_meth.shtml

[xxii] “Paraldehyde,” Medical Authority of the United Kingdom, Netdoctor, see http://www.netdoctor.co.uk/brain-and-nervous-system/medicines/paraldehyde.html

[xxiii] “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[xxiv] American Medical Association, Department of Drugs. Drug Evaluations. Chicago: The American Medical Association, 1986, pg. 193.

[xxv] “Paraldehyde,” The Toxicity Data Network, The National Institutes of Health, seehttp://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3375

[xxvi] “Paraldehyde,” The Staff of the University of Michigan Medical School, see https://wiki.umms.med.umich.edu/display/NEURO/Paraldehyde

[xxvii] Paraldehyde (Oral route, Injection route, Rectal route),” Official Information from the United States Food and Drug Administration, see http://www.drugs.com/cons/paraldehyde-oral-injection-rectal.html

[xxviii] Ibid.

[xxix] “Paraldehyde,” The Toxicity Data Network, The National Institutes of Health, seehttp://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3375

[xxx] Ellenhorn, MJ et al.  Medical Toxicology. New York: Elseview Science Publishing Co., 1988, page 242.

[xxxi] “Paraldehyde (Oral route, Injection route, Rectal route),” The Staff of the Mayo Clinic, see http://www.mayoclinic.com/health/drug-information/DR601071

[xxxii] Grant, William. Toxicology of the Eye. Third Edition. Springfield, Illinois: Charles Thompson, 1986, page 696.

[xxxiii] Paraldehyde (Oral route, Injection route, Rectal route),” Official Information from the United States Food and Drug Administration, see http://www.drugs.com/cons/paraldehyde-oral-injection-rectal.html

[xxxiv] Gilman, AG et al. The Pharmaceutical Basis of Therapeutics. New York: Pergaman Press, 1990, pg. 368.

[xxxv] McEvoy, GK. American Hospital Formulary Service, the American Society of Hospital Pharmacists, 1994, page 1532.

[xxxvi] “Paraldehyde,” The Toxicity Data Network, The National Institutes of Health, seehttp://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3375

 

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