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Jun 17, 2022
As of 2019, pentobarbital is the most standard drug for human euthanasia. The official euthanasia guidelines of the Dutch Medical Association and Pharmacists Association suggest that pentobarbital and secobarbital are two oral drugs (KNMG/KNMP, 2012), and states where euthanasia is legal in Oregon, Washington, and Colorado, USA Until there was a shortage of barbital supply, they almost always used pentobarbital and secobarbital. Among the private euthanasia organizations in Switzerland, Exit Deutsche Schweiz, which operates mainly for Koreans, and Dignitas, which operates mainly for foreigners, have continued to use it for a long time. I use pentobarbital.

However, in North America, a new drug to replace pentobarbital has recently been developed due to a shortage of barbital supply. The US has been importing pentobarbital for execution and euthanasia mainly from Europe. Around 2011, when the European Commission banned the export of pentobarbital to the US on the grounds that the death penalty was unacceptable for human rights, pentobarbital from the US The price of Vital started to soar and reached 30 million won per person around 2016*, and the price of secobarbital, an alternative product, also naturally increased due to economic logic, reaching 7 million won per person. It is less than 50,000 won per person and illegal pentobarbital circulated on the black market is also around 500,000 won per person, so I don't know why the price jumped like this only in North America. Anyway), it is regulated by the Death with Dignity Act in the United States As more and more patients were unable to purchase euthanasia drugs because they did not have enough money despite all legal procedures, some doctors in Washington state started administering 20 g of phenobarbital, 20 g of phosuchloral, and 3 g of morphine sulfate around 2016. A novel euthanasia drug combination was developed by mixing it with 30 mL of ethanol. However, this combination has the disadvantage that the high content of phosuchloral severely irritates the throat mucosa and causes pain. Soon, a new drug combination called DDMP was developed by anesthesiologists, veterinarians, pharmacists, and toxicologists across the United States. * DDMP1 is a combination of diazepam 500mg, digoxin 25mg, propranolol 2g, and morphine sulfate 10g Harty et al., 2018). The legal purchase price is about 500,000 won per person. DDMP, like pentobarbital, has a success rate of just over 99%, but the time to death is much longer. DDMP2 had a median of 120 min and a median of 230 min, pentobarbital had a median of 20 min, median 97 min, and secobarbital had a median of 139 min at 25 min (Oregon Health Authority, 2019).

What we commonly call pentobarbital is precisely sodium pentobarbital, a salt combined with sodium. When labeling the dose, pentobarbital sodium is the standard. For example, the standard amount of pentobarbital used for euthanasia recommended by the Dutch Medical Association and Pharmacists Association is 15g, which does not mean that it is 15g based on the weight of the remainder after removing sodium from sodium pentobarbital, but the total weight of pentobarbital sodium. It means 15g as a standard.

Sodium pentobarbital is an ingredient name, and Nembutal is a trade name. It is the same as sometimes calling a drug containing acetaminophen under the trade name Tylenol. Because there are many drugs with pentobarbital ingredients other than nembutal, it is better to just call them pentobarbital if possible.

In English-speaking suicide communities, pentobarbital is sometimes called N after the first letter of nembutal. In the German-speaking world, the expression NaP, which is an abbreviation of Natrium-Pentobarbital, seems to be commonly used.

Substances with similar names include sodium phenobarbital and sodium pentotal (= sodium thiopental). Both are different substances from pentobarbital.

success rate
When a terminally ill patient whose original lifespan was less than 6 months was given an unlimited time for several days until death after taking 9 to 10 g of seccobarbital or pentobarbital, the success rate was calculated based on data from DWDA, Oregon, USA. Barbital is 99.3% and pentobarbital is 100%. It can be higher if the intake is increased, and lower if given a time limit, such as a suicide attempt in a motel. There seems to be little chance of success if you call 911 yourself after ingestion or if your family calls 911 by saying goodbye. Please refer to a separate post for more details.

collection of failures
A 45-year-old man drank 20 g of pentobarbital in water, purchased two years ago, and notified her mother by texting 10 minutes later. The mother immediately called 911, and rescue teams arrived 20 minutes after taking the medicine. After the rescue team performed CPR, the heart started beating again 10 minutes later. He received hospital treatment and recovered without sequelae (Druda et al., 2019).

A 24-year-old pregnant woman was found to have stopped breathing and her heart rate after hours of insanity after consuming Dolethal® injection in an amount equivalent to 9 grams of pentobarbital. She received hospital treatment and both mother and baby recovered without noticeable sequelae until delivery (André et al., 2019).

A 43-year-old woman with borderline personality disorder ate an unsatisfactory amount of pentobarbital purchased online and a few minutes later she called 911 herself. At the time of discovery, her patient was in a coma with GCS 3/15. On day 6 she recovered GCS 15/15 and on day 10 she was transferred to a psychiatric ward (Lamarié et al., 2016).

A 48-year-old woman with a history of depression overdosed on clonazepam pills, with an injection of Euthasol®, an animal comfort injection consisting of 390 mg/mL pentobarbital and 50 mg/mL phenytoin, into the inside of her left elbow. It was discovered by her husband, who was a veterinarian after hours of She regained consciousness on day 2, and on day 3 she was diagnosed with psychosis, including prolapse, mood disorder, unspecified, and she was discharged without sequelae on day 13 (Crellin & Katz, 2016).

A 61-year-old man was found to be in cardiac arrest after taking 5 grams of pentobarbital, but her heart rate returned with the use of a defibrillator, CPR, and epinephrine. She was taken to hospital where she recovered without sequelae (Arens & Smollin, 2015).

A young man working in the horse transport business was found to have stopped breathing after consuming 13 g of pentobarbital, and was intubated and taken to the hospital. At the time of his arrival at the hospital, his body temperature was 32 °C and his level of consciousness was GCS 3/15. Blood pressure was measured at 50/20 mmHg. He received hospital treatment and recovered without sequelae (Singh, 2014).

A 20-year-old woman was found after hours of burns after drinking Sedalphorte® injection in an amount equivalent to 12.6 g of pentobarbital along with metoclopramide. She was hospitalized and she recovered without sequelae. She said the woman followed the instructions in The Peaceful Pill Handbook and she went to Mexico where she bought pentobarbital (Cantrell et al., 2010).

Around 2013, a person with the nickname David455 measured 16 g of pentobarbital powder, drank it with water, and immediately sent a text message to the people around the statue saying goodbye. The recipient of the text message reported it immediately, and the suicide attempter was found 15 minutes after taking the medicine and was taken to the hospital and recovered without any sequelae.*

According to a series of posts¹²³ posted in early 2017 by the person using the nickname BML, this is a 45-year-old man weighing 108 kg who never drank or took drugs, and was reported to by Johnson, a Chinese pentobarbital seller, in September 2016. I bought 20g of pentobarbital powder and kept it, and on a Saturday night or Sunday night in December 2016, I drank about 15g of the powder mixed with water. Then he was found in a coma for 36 or 60 hours before being found by the police at lunchtime on Tuesday, and was taken to the hospital where he recovered without any sequelae. When people working in the Peaceful Pill Forums sent their purchased pentobarbital to the Energy Control Lab in Spain for purity analysis, it was found that the purity of pentobarbital sold by Johnson varies from 30% to 70%. can If so, the 15g of powder eaten by BML-Jeogo would have contained 4.5g to 10.5g of pentobarbital depending on the purity.

time taken
The most extensive data on lead times comes from Oregon's Dignity and Judicial Law Annual Reports. In the United States, it is only legal for a patient to take the euthanasia drug himself, and so-called 'active euthanasia', in which a doctor physically promotes the patient's death, is illegal (Emanuel et al., 2016), so patients do not die quickly after taking pentobarbital. Since it is impossible to cause death by administering additional drugs intravenously for some reason, it is possible to reliably determine the longest time required and the probability of failure when the drug is taken purely by mouth.
Let's break this table down a little bit by year. Until 2014, 9 to 10 g of secobarbital or pentobarbital was used in more than 99% of cases before 2014, but since 2015, other drugs have also started to be used in a significant proportion, so we will only look at data up to 2014 below. .

Year* Number of patients† Scope of time of death Number of failures‡
2014 20 people (85 Buddha statues) 11 minutes to 1 hour
2013 11 people (60 Buddha statues) 5 minutes to 5.6 hours
2012 11 people (66 Buddha statues) 10 minutes to 3.5 hours 1 person
2011 8 people (63 Buddha statues) 15 minutes to 1.5 hours 2 people
2010 32 people (33 Buddha statues) 5 minutes - 53 hours 2 people
2009 57 people (2 Buddha statues) 2 minutes to 104 hours
2008 54 people (6 Buddha statues) 2 minutes to 25 hours
2007 44 people (5 Buddha statues) 6 minutes to 83 hours¹
2006 43 people (3 Buddha statues) 1 minute to 16.5 hours
2005 36 people (2 Buddha statues) 5 minutes to 9.5 hours 1 person
2004 34 people (3 Buddha statues) 5 minutes to 31 hours²
2003 41 people (1 Buddha) 5 minutes to 48 hours³
2002 37 people (1 Buddha) 5 minutes to 14 hours⁴
2001 20 people (1 Buddha) 5 minutes to 37 hours⁵
2000 19 people (8 Buddha statues) 5 to 75 minutes
1999 27 people (Buddha? people) 4 minutes to 26 hours⁶
1998 15 (Buddha?) 10 minutes to 11.5 hours
* After 2015, drugs other than pentobarbital and secobarbital were also excluded because they were used in a significant proportion.
† Along with the number of patients with known time of death, the number of patients with unknown time of death (unknown) is indicated in parentheses next to it. All of the patients whose death time was unreasonable eventually succeeded.
‡ One loser in 2012 regained low-level consciousness two days after taking the drug and died six days after taking the drug. In 2011, one out of two failures took the medicine but did not consume the entire amount, but lost consciousness 14 hours later, regained consciousness, and died 38 hours later from chronic disease. After eating and losing consciousness, he briefly regained consciousness and died of chronic disease 30 hours later. In 2010, 1 out of 2 failures took medicine, vomited, and lost consciousness, regained consciousness within 24 hours, and died 5 days later from chronic disease. Three months later, he died of chronic disease. In 2005, one failed person lost consciousness 25 minutes after taking the medicine, but recovered consciousness 65 hours later and died 14 days later from chronic disease. Of these six losers, five took secobarbital and the other took guitar, but it is not known in the report who ate seco and who ate guitar.
¹ In 2007, one person who took 83 hours vomited.
² In 2004, one person who took 31 hours took only one-third of the drug and also vomited. One person died 19.5 hours after taking the entire drug.
³ In 2003, one person who took 48 hours took only 1/2 the drug and vomited 1/3 of the amount eaten. The amount of barbital eaten whole was only 3g.
⁴ In 2002, 3 patients had over 6 hours, of which 1 with indigestion took 14 hours, 1 with intestinal obstruction took 9 hours, and the other patient took 12 hours for some reason, although it is not stated for some reason.
⁵ In 2001, one patient vomited and it took 25 hours, and one patient took 37 hours, for unknown reasons (no mention of vomiting).
⁶ In 1999, 24 of the patients died within 4 hours, 2 of the remaining 3 patients died 11 hours after eating the whole amount, and the remaining 1 patient died 26 hours after eating 2/3 of them.
In 1998, 11 of the patients died within 3 hours. One person, which took 11.5 hours, ate the entire 9g of barbital.

Washington State is one of the states that has a Dignity Justice Act. Data for Washington State are as follows: I've heard that Washington State hasn't had a loser yet.

The dosage is 10, 12, or 15 g in the photo below, but the text says 10 to 12 g, so it is unclear whether some people ate 15 g or not.
Data from the Swiss euthanasia organization Exit Deutsche Schweiz on 261 people who committed suicide by taking pentobarbital are as follows. The dosage is 10, 12, or 15 g in the photo below, but the text says 10 to 12 g, so it is unclear whether some people ate 15 g or not. The median was 23 minutes, and the one with >12h in the table took exactly 17 hours and 55 minutes.
Data on people who committed suicide by taking pentobarbital or secobarbital in the Netherlands include: In the Netherlands, where active euthanasia is legal, unlike in the United States or Switzerland, if a patient who took euthanasia does not die after a long period of time, the doctor administers a separate drug such as rocuronium intravenously to save time. euthanize by injecting The standard cut-off time according to the guidelines of the Dutch Medical Association/Pharmacist Association is 2 hours (KNMG/KNMP, 2012), but depending on the patient's preference, the cut-off time is less than 1 hour (Harty et al., 2018). The proportion of those who received a cut-off was 20% of all 245 patients in 1998-2011, and 9% of 170 patients in 2013-2015 (Horikx, 2016). As the Dutch turnaround data, quoted in the photo below, are grouped together without distinguishing between those who have been cut-off and those who have not, underestimated the proportion of patients who spent more than 2 hours and overstated the proportion of patients who spent less than 2 hours. it is evaluated In Switzerland, 8% of patients spent more than two hours, which is why only 2-3% of Dutch data.
For reference, in the Netherlands, the official guidelines were to eat 9 grams of Saeco or Pento between 1998 and 2011 and 15 grams of Saeco or Pento between 2013 and 2015.
Since the time required data for each country above is for a group of terminally ill patients who have been receiving treatment in a hospital for a long time, there is a possibility that the case of suicide of the general public may be slightly different. They may die later because they are healthier, or they may die sooner because they are not taking drugs that cause pentobarbital resistance.
When you watch a video of British businessman Peter Smedley drinking pentobarbital with the help of Dignitas and dying after drinking pentobarbital, you don't feel very much right after drinking pentobarbital. Or you feel thirsty, and soon you seem to fall asleep while snoring. When Smedley is looking for water, the Dignitas staff calmly hugs him instead of bringing it to him in embarrassment. In the literature, it was found that thirst symptoms are commonly reported in patients addicted to pentobarbital (Suddock & Cain, 2018).

If you watch a video of Michèle Causse euthanizing in Dignitas, the patient can be seen talking faster and complaining of her dizziness before she loses consciousness. Euthanasia Guidelines (2013) published by the American Veterinary Medical Association AVMA states that when animals are euthanized with pentobarbital, an excitatory phase may occur that makes the observer uncomfortable. It is assumed that the dizziness felt at this time is similar to that of being drunk (see Groenewoud et al., 2000: "feeling of drunkenness" section).

According to a survey on barbiturate euthanasia conducted in the Netherlands in the 1990s, extreme gasping occurred in 3 out of 114 patients (Groenewoud et al., 2000). Whether these symptoms appeared before or after loss of consciousness was not reported in the paper.

Animal Euthanasia Manual (2013) published by HSUS, the American Society for the Protection of Animals, states that animals receiving pentobarbital may become increasingly sensitive to noise, skin contact, or other stimuli in the process of lowering their level of consciousness. It is said that it is recommended to wear a soft restraint device in a quiet place.

Among the 165 people who were euthanized by taking secobarbital or pentobarbital in the Netherlands between 2013 and 2015, one person each complained of pain in the neck and stomach, and one person complained of a heat sensation (Horikx, 2016). .

Illegal Nembutal Distribution
There is a perception that pentobarbital can only be obtained by doctors and veterinarians and cannot be obtained by the general public, but in fact, this is not necessarily the case. In developed countries such as the United States, Canada, Portugal, and Switzerland, it is common for the general public to commit suicide by illegally purchasing pentobarbital (e.g., Cantrell & McIntyre, 2018; Covach et al., 2018; Melo et al., 2017; Romain et al. al., 2003; Solbeck et al., 2018). In Korea, looking at the statistical microdata of the cause of death, approximately 7 people were identified from January 1, 2007 to December 31, 2017, who committed suicide due to overdose of barbiturates and were given codes T423 and X61. (Statistics on the cause of death in 2018 are not yet available as they will be released in the second half of 2019.) Among them, only one person had a "professional" occupation code, including doctors and veterinarians, and the rest were ordinary people. Since there are no illegal pentobarbital sellers in Korea, they probably committed suicide by importing pentobarbital from abroad.

Most of these people probably referred to The Peaceful Pill Handbook (PPH), a suicide note written by an Australian doctor. PPH is an e-book that contains information on local pentobarbital sellers in Mexico, South America, and Southeast Asia, as well as remote sellers who receive payment in cryptocurrency and deliver by international mail. Although this book is not officially sold to people under the age of 50, pirated versions are being distributed in suicide communities such as 8ch.net/suicide and sanctionedsuicide.com, so it seems that people under 50 can actually get the information.

However, it is questionable how easy it will be to obtain accurate information. First of all, there has been a case in which a scammer distributed a pirated version of the book by swipingly swapping the seller's information with his or her own information. In the case of the PPH October 2018 version posted on the above site, one letter that was originally a in the seller's email address has been altered to an e. There have even been cases where the contact details of the scammers were posted on the original PPH. Patrick and Domingo, who went up briefly at the end of 2018 and then down again in 2019, were the scammers. Sometimes honest (?) sellers on PPH turn into scammers. For example, Samulle Pindolon (cochetartaruga) originally supplied genuine illegal pentobarbital, but since late 2016, the trust that has been built up has been lost by exiting scams. It is said that he used the last time to cheat. Johnson in China claimed to be selling high-purity pentobarbital powder, but the recipients later sent it to Energy Control Labs in Spain to test it, revealing that it was only as low as 30-70% pure.

The exact reason is unknown, but foreign governments do not appear to be interested in arresting the few pentobarbital sellers around the world. In the case of Alejandro Vasquez of Mexico (commonly referred to as 'A'), who is currently the most famous seller in the first world, in the past, he contacted the buyer using his Google Gmail account. The information was passed on to Interpol, and Interpol passed the information back to the police of the country where each buyer resides, and the police of the country visited the homes of buyers who had already purchased and stored pentobarbital from A. There are examples of recovery. Actually, the word is hacking, but looking at the information obtained from the hacking being transferred to Interpol, it is highly likely that this is not a hack, but an investigation agency such as the FBI of the United States received a warrant and formally handed over the data from Google.

At this time, if the FBI or Mexican police had made up their minds, A could have been arrested easily. This seller used Google Gmail, and has been using Western Union and Moneygram as a payment method for a long time, and the cryptocurrency accepts only easy-to-track currencies such as BTC, BCH, Ripple, and Litecoin, not anonymized currencies such as Monero. This is because they are doing activities that are far from OPSEC. However, the police did not do that, and A changed to ProtonMail because he thought he could not use Google Gmail, and continues to operate as of 2019. ProtonMail seems to block the user if the word Nembutal is included in the e-mail content, so it seems that suicides are calling N or the product in e-mail communication with the seller.

Under the current circumstances, it does not seem easy for customs to detect illegal pentobarbital entering Korea. In the case of goods coming in international mail, customs inspects narcotics using methods such as X-rays, detection dogs, and ion scanners.

However, it seems that it may be possible to detect if certain conditions are met. According to a post he himself posted on Ilbe in 2015, a man named Kang Mo, who quit working as a production worker at a small and medium-sized company, conspired with three co-buyers to see the Peaceful Pill Handbook, and contacted Johnson, a Chinese seller who came out of it, to buy pentobarbital. I have tried to buy. Mr. Kang contacted the accomplices via text message and the English-speaking person who asked for PPH translation via KakaoTalk. I used the overseas remittance method. The seller did not send all the goods at once, but sent 26g the first time and 50g the second time 1-2 weeks later, but both times the recipient was Mr. Kang. The first shipment went through customs without any problems, but the second shipment was caught by customs. In this case, it is possible that the same person received a series of 50g white powder delivered to the same address seemed suspicious. If they didn't purchase together, but bought each individually, no one might have been caught.

(In this case, the three female accomplices were investigated without detention, but the prosecution suspended the indictment on condition that they received treatment at the hospital. He was released after being sentenced to one year in prison and two years of probation. In fact, considering the final probation, this was not a serious crime that required arrest, but it seems that Kang was arrested because of the possibility of suicide. Although it is not explicitly stipulated in the Criminal Procedure Act, it is the practice of the prosecution and the court to detain a suspect with a possible suicide and keep them alive until a judgment is made.)

Even if the customs officer knows the seller's name, shipping address, the shape of the box, stealth techniques, etc., they will be able to catch it with a relatively high probability. In the narcotics trade, stealth is an English-speaking slang term for a technique to avoid customs eyes by disguising narcotics as other ordinary objects. Johnson, a Chinese seller who has now stopped working, wrote fumaric acid or potassium formate on the pentobarbital packaging bag (Solbeck et al., 2018), which is a kind of stealth. These characteristics may be known by the customs accidentally discovering the item or by ordering the item under the guise of the customs itself as a buyer. In reality, since suicides do not have an incentive to protect the identity of the seller even after their death, packaging boxes, etc. are usually found by police officers and forensic officers who go to the autopsy at the scene of the suicide, and they give information to customs.
Even if the customs officer knows the seller's name, shipping address, the shape of the box, stealth techniques, etc., they will be able to catch it with a relatively high probability. In the narcotics trade, stealth is an English-speaking slang term for a technique to avoid customs eyes by disguising narcotics as other ordinary objects. Johnson, a Chinese seller who has now stopped working, wrote fumaric acid or potassium formate on the pentobarbital packaging bag (Solbeck et al., 2018), which is a kind of stealth. These characteristics may be known by the customs accidentally discovering the item or by ordering the item under the guise of the customs itself as a buyer. In reality, since suicides do not have an incentive to protect the identity of the seller even after their death, usually packaging boxes are found by police officers, forensic officers, etc. e.g., Solbeck et al., 2018) seem to be known in many cases. Also, since buyers of suicide drugs have no reason to continue dealing with sellers and only buy one item, buyers who think they are safe because they have already purchased may leak stealth techniques to the Internet community. If there are more buyers of Nembutal in Korea, it is expected that there will be cases where Koreans refer to the seller's name and country as the initial consonant, as they do when referring to a specific brand name in the community.

It is not known if there are any real cases, but in theory, it may be possible for intelligent suicides to escape the custody or escape arrest even if pentobarbital is caught at customs. As mentioned in the previous article, it is impossible to directly punish the recipient for importing narcotics just because it is written as the recipient on the parcel box of narcotics passing through customs. This is because it cannot be excluded that a third party completely unrelated to the recipient may have used the recipient's house as a drop-off location.

In this case, it is thought that there are two main methods for the prosecution to prove the fact of the recipient's order. ① Have the customs officer call the consignee and give him a sneak peek that he needs help with the customs process (if the consignee says he knows something about the parcel, that could be evidence of guilt), or During the arrest, they seized and searched computers and mobile phones to obtain direct evidence of the order act itself, such as obtaining a pentobarbital order email. Or, ② suggests that the recipient may have had suicidal thoughts, such as frequently talking about death to people around him, searching for the word suicide as a result of analysis of mobile phone or internet logs, or having been recently treated for depression in a hospital collect evidence that Since pentobarbital is a drug used exclusively for suicide, and the number of people having suicidal thoughts is very small, if the recipient of pentobarbital had suicidal thoughts, this is strong circumstantial evidence that the recipient ordered pentobarbital. becomes Of course, it may be difficult to get a conviction on this alone without other evidence, but if there is this, there is room to see that the probability of a crime as a requirement for a detention investigation is secured, and once detained, it is not a person with a criminal history. Only then will you confess.

If so, the buyer may conversely think of escaping the investigation by destroying these evidences in advance. For example, even if a difficult situation arises and a buyer is depressed and has a hard time, he can continue his school life and work life faithfully in a bright atmosphere while treating it with various folk remedies that do not leave a record. When collecting suicide drug-related information on the Internet, anonymizing means such as Tales are used, but by not leaving traces of the use of such information, it will be possible to avoid anything suspicious in the eyes of investigative agencies later. Cash is not withdrawn a lot at once, but little by little over a long period of time so that there is no suspiciousness in the transaction history. By making a purchase, you will be able to make an anonymous payment by not leaving a record of your Bitcoin purchase, converting it to Monero* and sending it to the seller in Bitcoin using XMR.TO. It is possible to receive delivery in your own name, but sometimes, if you live in the same house with your family, you can order it in the name of the family. Or, it would be possible to pay for a gosiwon room anonymously and have it go to the gosiwon room. Considering the time the CCTV will be deleted, ask the seller to let it arrive after more than a month, and after payment is complete, throw the Tales USB into the trash or reset the mobile phone or computer, and there will be no evidence left. If there is a location tracking and tamper detection beacon in the box, or in case investigators come in at a time lag and search, wear plastic gloves to prevent fingerprints and DNA from being left behind, pick up the box, and then go to the boiler room in the building. It may be possible to use a strategy to hide for a few days in a public space without CCTV, such as a corner of a laundry room or a place where things are cluttered in the corner of the hallway, and then open it later on the spot to check that there are no beacons and bring things.

Vomiting and antiemetics
Drugs that act on GABAA receptors, such as midazolam (Ahn et al., 2016; Grant et al., 2016), triazolam (see Pyeon et al., 2017), and propofol (Apfel et al., 2004), are dopamine and serotonin It has the effect of preventing vomiting by reducing the secretion of Pentobarbital is also a drug that acts on GABAA receptors, and in patients suffering from nausea and vomiting caused by chemotherapy, pentobarbital is additionally administered intravenously compared to when procloperazine and dexamethasone alone are administered as antiemetics. It has been reported that vomiting decreased when administered (Wheelock, 1989). However, since a significant proportion of people vomit when they eat bitter substances (Peyrot des Gachons et al., 2011), and pentobarbital is a substance with a strong bitter taste, it is possible that it induces vomiting (Harty et al. , 2018).

Statistically, the rate of vomiting during pentobarbital suicide is low. Of the 1,459 people who were euthanized by DWDA in Oregon, out of the remaining 691 people, with the exception of 768 for whom the problem was unknown, 28 had difficulty swallowing or part of the drug they took (Oregon Health Authority, 2019). In the Netherlands, 9 out of 165 people euthanized with pentobarbital or secobarbital between 2013 and 2015 experienced nausea or vomiting (Horikx, 2016), and between 1998 and 2000 39 out of 60 people took metoclopramide. 2 out of 21 people who did not take it (1 of them taking ondansetron, 1 taking none) vomited (Horikx & Admiraal, 2000), and between 1990 and 1996, 4 out of 114 experienced nausea or vomiting ( Groenewoud et al., 2000).

If vomiting occurs during pentobarbital suicide, the pentobarbital dose is reduced and the probability of failure increases. Therefore, all euthanasia guidelines recommend taking antiemetics to minimize the chance of vomiting.

There are various types of antiemetics. Dopamine D2 receptor antagonists include metoclopramide, domperidone, and haloperidol, 5-HT₃ receptor antagonists include ondansetron, and NK1 receptor antagonists include aprepitant. Diphenhydramine (dimenhydrinate), a motion sickness drug, suppresses vomiting through its antihistamine and anticholinergic action. Dexamethasone, a kind of steroid, is also frequently used for antiemetics, but the specific mechanism of action is not yet known (Kovac, 2013). Gabapentin and midazolam have also been proven to have antiemetic effects. Ingestion of ginger powder (Marx & Isenring, 2015) or smelling ginger essential oil (Lee & Shin, 2016) are also known to produce antiemetic effects through antagonism of 5-HT₃ receptors (Walstab et al. , 2013). Acupressure of internal blood vessels by non-pharmacological methods such as wearing a morning sickness band for pregnant women also has an antiemetic effect (Lee et al., 2015). Other methods such as sniffing a disposable alcohol swab containing isopropyl alcohol (Beadle et al., 2016) and soaking a cotton ball in ethanol for disinfection and sniffing it (Soyoung Oh et al., 2009) are also effective, although it is still too early to draw a definite conclusion. It is reported that there is

There is still no high-level evidence as to which type of antiemetic, and how much, is optimal for pentobarbital euthanasia. However, in each country where euthanasia is legal, a committee composed of doctors and pharmacists is making guidelines, and this has the level of evidence as an expert opinion.
Looking at the expert opinions, the guidelines of the Dutch Medical Association and Pharmacists Association (2012) recommend that you take metoclopramide 10 mg each for a total of 30 mg 12 hours, 6 hours, and 1 hour before execution. The Canadian Euthanasia Council guidelines (Harty et al., 2018) recommend taking ondansetron 4-8 mg or dexamethasone 8 mg along with metoclopramide 20 mg 1 hour before execution. Washington State guidelines recommend taking metoclopramide 20 mg and haloperidol 2 mg 1 hour before practice (recited from Harty et al., 2018).

Admiraal et al., an anesthesiologist and chair of the expert committee that created guidelines for euthanasia in the Netherlands, wrote a guide to suicide for the general public in 2006 called Guide to a Humane Self-Chosen Death*. According to this, metoclopramide can be replaced with the same amount of domperidone. Domperidone has been shown to have anti-emetic and gastrointestinal motility-promoting effects equivalent to those of metoclopramide in RCT, and is less likely to cause side effects such as extrapyramidal syndrome than metoclopramide, there seems to be no The peak point in blood concentration of domperidone is 0.6 hours after drinking liquid and 1.2 hours after taking domperidone maleate tablets (Huang et al., 1986).

Vomiting due to pentobarbital is thought to be associated with bitter taste, and vomiting due to bitter taste is associated with motion sickness and morning sickness (Sharma et al., 2008; Sipiora et al., 2000). Intravascular acupressure through morning sickness bands may also be effective in preventing vomiting caused by pentobarbital. Diphenhydramine motion sickness medicine is usually labeled as dimenhydrinate on the ingredient list, but it is a mixture of 8-chlorotheophylline, a caffeine-like ingredient, with diphenhydramine to alleviate the drowsy side effect of diphenhydramine. It comes from hydramine. Drugs containing only diphenhydramine are marketed as sleep inducers.

Ginger may replace ondansetron because it antagonizes the 5-HT₃ receptor. In addition, pentobarbital is degraded by enzymes called CYP2B6 and CYP2D6 in the liver (Tsuji et al., 1996), because ginger has the effect of inhibiting the action of these enzymes (Kim et al., 2017; Li et al. ., 2013), it is possible that eating ginger slightly improves the lethality of pentobarbital.

Other guidelines
In addition, the guidelines in the guidelines are summarized.

Tolerance: Admiraal et al. manual on page 44 states that benzodiazepines can induce barbiturate resistance, so those taking benzodiazepines should reduce the dose for 2 weeks over 5 weeks prior to practice, and then stop completely for 3 weeks thereafter.

Fasting: Admiraal et al.'s manual recommends fasting 12 hours prior to practice to accelerate pentobarbital absorption. You can drink water or soft drinks. It is also advised to eat a biscuit or cracker with "stuff" in it 30 minutes before eating pentobarbital to activate the stomach. Canadian guidelines (Part 2: 2018) suggest a six-hour fast, and you can drink non-carbonated liquids during fasting. In the case of pentobarbital, there are no data yet on exactly how fasting affects lethality, but in the case of sodium nitrite euthanasia, it is known that the lethal dose in the fed state is four times higher than the lethal dose in the fasting state.

Posture: Dutch Medical Association/Pharmacist Association guidelines recommend that you sit upright on your bed. Canadian guidelines recommend that you take your medication in Fowler's position with your back tilted to 60° and hold that position for 20 minutes after eating (even after losing consciousness) to prevent nausea and speed up drug absorption.
Opening the Glass Bottle: A video from the Peaceful Pill Handbook explains that the rubber stopper underneath can be opened by cutting the aluminum ring with sharp-pointed hairdressing scissors.

Drinking: Dutch Medical Association/Pharmacist Association guidelines tell patients not to allow drinking through a straw. If you use a straw, there is a risk that the medicine will take effect before you drink the full amount. Canadian guidelines say that patients should take the medicine as soon as possible to consume the entire amount before falling asleep or losing consciousness. If you look at Peter Smedley's dynamics above, the patient seems to be fine without any signs of sleepiness for a while after taking the medicine, and then suddenly lose consciousness as the medicine takes effect. I think there may be.

Alcohol: According to Canadian guidelines, drink 1/4 cup of alcohol with high alcohol content, such as vodka or whiskey, or 1/2 cup of non-carbonated, room-temperature soda to relieve the bitter taste and enhance the effect of the drug after taking euthanasia. They say you can eat a cup. Avoid alcohol and beverages containing cream or milk.

sequelae of failure
Bedsores can develop if you lie still unconsciously for several days. Other than that, no other sequelae were found.

shelf life
When I bought pentobarbital and secobarbital tablets in their original packaging that were 28 to 40 years old and had an expiration date at a local pharmacy and tested the content, the packaging said that the pentobarbital was 90mg, but the actual content was 105.1. It was ± 7.4 mg, and the packaging of secobarbital was written as 100 mg, but the actual content was 90.5 ± 7.1 mg (Cantrell et al., 2012).

Pentobarbital injection, manufactured as a pharmaceutical, consists of water + 50% sodium pentobarbital, 40% propylene glycol, 10% alcohol, and a little hydrochloric acid or sodium hydroxide to adjust the pH to about 9.5.* Researchers found that water + pentobarbital Dissolve sodium pentobarbital at a concentration of 50 mg/mL in a liquid mixed with sodium nitrite 50%, propylene glycol 40%, and ethanol 10%, sterilize by filtering with a 0.22μm nylon filter, and put it in a sterilized glass bottle. When the concentration of sodium pentobarbital was observed while the lid was closed and stored in a dark place at room temperature, the sodium pentobarbital sodium content did not decrease by more than 0.5% per year even though it decreased significantly, and usually decreased much less than that. After about 2 years, the color of the solution turned yellow, but there was no abnormality in the pentobarbital content (Priest et al., 2015).

There is a person who ate 13g of barbiturate purchased 25 years ago and died 40 hours later. Here, 13g is a notation standard, and it is unknown how much was actually left. It is not known whether the drug this person took was pentobarbital, secobarbital, or another type of barbiturate such as phenobarbital (Admiraal et al., 2006).

It's Google Translate, so there may be typos.

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