Judah
Enlightened
- Oct 1, 2020
- 1,531
Sodium nitrite (SN), mainly used in preserving processed meats and fish, has been mentioned in murder cases, suicide cases, and accidental poisoning cases. A list of such incidents in medical literature has been documented in Sodium Nitrite Poisoning Cases, as well as anecdotal experiences from forum users[1]
Simple, step-by-step instructions
There are many ways to commit suicide by sodium nitrite. The following is an easy, quick, and pain-free recipe.
1. Take 30 mg metoclopramide (another editor suggested 800 mg of Tagamet, as well).
2. Wait 1 hour.
3. Dissolve 15 – 25 g sodium nitrite in 50 ml municipal tap water.
4. Drink the solution and relax on a bed, a couch, or a reclining chair.
How it works
Sodium nitrite, NaNO2, is a catalyst that converts the hemoglobin in blood into methemoglobin (MetHB), a molecule with a much higher affinity with oxygen. This conversion occurs when the ferrous ions in the regular hemoglobin are converted into ferric ones. Since its affinity is so high, methemoglobin does not let the oxygen flow into other tissues that need it thus depriving them of oxygen—even while you're breathing. Death, then, occurs due to hemolytic anemia or anemic hypoxia, not hypoxic hypoxia. The main reason for peacefulness of sodium nitrite method is that nitrate and nitrite reduce to nitric oxide, a vasodilator. Vasodilators relax hence dilate the smooth muscle in veins. Dilating veins will cause fall in blood pressure and loss of consciousness. (Bailey, Feelisch, Horowitz, Frenneaux & Madhani, 2014) illustrated the nitrite-derived NO signalling[1|2|3].
Alkyl nitrite functions as a source of nitric oxide, which signals for relaxation of the involuntary muscles. Alkyl nitrites (also referred to as poppers) have been used for recreational drug purposes, typically for the "high", "rush", or light headed feeling that the drug can create. Two examples of such drugs are amyl nitrite and isobutyl nitrite. Isobutyl nitrite is inhaled more often than ingested and induces profound, though transient, vasodilatation with blurred vision, headache, flushing, a "warm feeling," a widespread throbbing sensation and postural hypotension (Bradberry, Whittington, Parry & Vale, 1994). Rarely are there cases with fatal outcome of those who accidentally ingested it, used it with Viagra or other erectile dysfunction medications, applied it on the skin, or inhaled too much of it too quickly after each hit ([1][2][3], [4][5][6], and [7], to name but a few). Still, there is a huge stigma attached to someone who accidentally dies from a drug overdose.
The PPH has designated sodium nitrite ingestion as a peaceful way to end your life. It has made that statement through observing the death of 6 people who ingested a sodium nitrite drink. Peaceful means that there was minimal distress with no suffering to those who drank it. There are symptoms, however, that can be gained by drinking sodium nitrite.
Sodium nitrite poisoning symptoms include nausea, vomiting, vertigo, headaches, and tachycardia. All of these symptoms will not emerge in everyone. These symptoms will provide low level discomfort, and you will suffer no discomfort through the process. As for the physical symptoms, the color of blood, skin, fingertips, nail beds, and lips will change. The blood will take a bluish chocolate brown color, and the tips of fingers, toes, and nose will turn slightly blue from cyanosis (PubChem). In April 2019, a kindergarten teacher in China poisoned 23 children by lacing their breakfast with sodium nitrite. The only noticeable change in appearance of kindergarten students were their lips that had turned blue[1|2|3|4]. Additionally, in September 2019, four members of an Indian family committed suicide using sodium nitrite; similarly, little change to bluish[1|2|3|4|5|6] was visible in the color of their skin, their fingertips, and blood[1|2|3|4]. Also, (Warren and Blackwood, 2019) published a case report of a 25-year-old woman who had used benzocaine. The percentage of methemoglobin in her blood was 44%. The patient appeared cyanotic and had dark arterial and venous blood[1|2|3]. She was treated with intravenous methylene blue and had considerable improvement in her breathing and reduction in skin discoloration. Putting on a proper makeup[1|2|3|4] to go out in style can conceal any changes in your appearance.
On 24 May 2020, during the second part of Doxit Podcast No. 5 on the subject of the lethal salts, Fiona Stewart and Philip Nitschke described 5 eyewitness accounts Exit had received of ending one's own life by sodium nitrite.
1) George witnessed his 89-year-old wife, Susan, drinking sodium nitrite to take her life. Soon after waking up in the morning, Susan took 30 mg of omeprazole, a proton pump inhibitor—instead of antiemetic. 40 minutes later, she drank the sodium nitrite solution. She was surprised by the saltiness of the taste. About half a minute later, she vomited very slightly. She sat in bet to reduce the possibility of any more vomiting. She felt some dizziness. It took her 5 minuets to lose consciousness. She showed no signs of distress during unconsciousness. Susan died 30 minutes later, and her body was examined by a doctor 2 hours later. George, who had a witnessed the experience with sodium nitrite method, said he is confident to have sodium nitrite on the shelf so he can use it to obtain a peaceful death at the time of his choosing.
2) An 81-year-old woman took sodium nitrite to end her life alone. Her death was taken to be of natural causes. This suggests her body did not display obvious cyanosis, considering that cyanosis is a very common effect on the body as death takes place.
3) According to the sister of the deceased, Mrs. W took her life alone using sodium nitrite. Her body looked lovely and peaceful, and not brown. There have been no questions from the police or the coroner.
4) A friend of the deceased wrote, "I was not too surprised that her death was taken to be from natural causes, because I know of another Exit member, a 92-year-old man, who used sodium nitrite. He also was not glaringly showing cyanosis. Could the relatively short time to death, 22 minutes, played a role in this?"
5) A couple chose recently to go together. Their daughter wrote, "I want to let you know that my parents died together of nitrite recently. My mother was terminally ill, and dad chose not to go on without her. While I was not with them, it looked as it has been a very peaceful death."
(Park, Kim & Ha, 2020) reported 14 cases of fatal nitrite intoxication, as well as a photo[1|2|3] of the livor mortis of a South Korean man, 20, who had committed suicide using sodium nitrite in June 2018. In South Korea, there is a growning trend, since 2018, among young individuals to commit suicide using nitrite (See the summary of 14 cases of fatal nitrite intoxication[1|2|3]).
(Durão, Pedrosa & Dinis-Oliveira, 2020) reported a case of successful suicide by sodium nitrite. The deceased, a 37-year-old man, was a visitor of the Sanctioned Suicide forum. Hated by anti-choicers because of his activity on the forum, he was found dead inside his car next to a box that contained two drinking glass cups—not glass measuring cups—the medicines Primperan® (i.e., metoclopramide, 10 mg), ranitidine (75 mg), and a 35-grams-package of crystalline sodium nitrite (Fig. 1)[1|2|3]. He had purchased sodium nitrite around May 2019, when APC Pure still shipped sodium nitrite to private customers. He had also purchased a 35-grams-package of sodium nitrite from another supplier lest one of his sodium nitrite packages be confiscated by the customs services. The 37-year-old man had collected the ingredients of his suicide in a cardboard box to have everything he needed for suicide in one place, like a first-aid kit. Having all the ingredients in one place misled the authors of the article that he had ordered a "suicide kit" on the Internet.
In (Fig. 2)[1|2|3], the grey face and finger nails are normal for a body that has been dead for a while with natural causes. The abnormal part, though, was the white and grey bits (not the red patches) on the torso. The most relevant autoptic findings were the general signs of hypoxia (not asphyxia, as the authors had suggested) such as intense scleral congestion (Fig. 2A) and cyanosis of the extremities (Fig. 2B), specifically, hands and lips, and brown-gray-blue-red livor mortis in various parts of the body (Fig. 2C), some Tardieu petechiae in addition to intense polyvisceral congestion. The cause of death was due hypoxia (not asphyxia, as the authors had suggested) resulting from methemoglobinemia induced by sodium nitrite overdose. In the gastric content 16 g/L of nitrites and 24 g/L of sodium nitrite were obtained. In blood 30 ng/mL of nitrites were obtained. Since in this case nitrate level was much higher than nitrite level, sodium nitrite had been absorbed quickly. Failure to detect sodium nitrite in routine toxicological analysis can result in false negatives.
Although the authors knew they have to measure the methemoglobin levels, they did not do so. They stated, "Methemoglobin concentrations were not analyzed in our case." Then acknowledged, "as previously suggested, if the presence of nitrite is suspected in the blood, quantification of the methemoglobin levels may be more important than the nitrite or nitrate levels."
The authors noted, "symptoms such as nausea, vomiting, lethargy, shortness of breath, convulsions and coma are evident soon after intoxication, especially if levels of methemoglobinemia are higher than 60%," citing (Katabami, Hayakawa & Gando, 2016). However, (Katabami, Hayakawa & Gando, 2016) did not mention "shortness of breath" in their article, and sodium nitrite does not cause shortness of breath—because, unlike what (Durão, Pedrosa & Dinis-Oliveira, 2020) had suggested, sodium nitrite poisonings is not similar to carbon monoxide poisonings, in many ways. For start, people who experience sodium nitrite poisoning very likely will not develop brain damage.
The misinformation in (Durão, Pedrosa & Dinis-Oliveira, 2020) reached its peak when the authors stated, "In our case, autopsy results revealed brown/gray/blue/red livor mortis in various anterior and posterior parts of the body—namely, lips, hands, and shoulders. It is suggested to be an adverse consequence of the vasodilation, since sodium nitrite is an precursor of nitric oxide," citing (Bradberry, Whittington, Parry & Vale, 1994) and (Petróczi & Naughton, 2010). The authors used the same misleading technique to reach their desired results: never had (Bradberry, Whittington, Parry & Vale, 1994) and (Petróczi & Naughton, 2010) suggested that blue livor mortis is an adverse consequence of the vasodilation, because blue livor mortis is the consequence of methemoglobinemia, such in copper sulfate toxicity that results in methemoglobinemia with no vasodilation.
(Durão, Pedrosa & Dinis-Oliveira, 2020) implied that they hadn't indulged in Sanctioned Suicide or Suicide Wiki by referring to an outdated Final Exit webpage as well as a 2007 edition of The Peaceful Pill Handbook, which does not have the inorganic salts chapters (because the chapter was added in 2018). The authors of the article blamed pro-choice suicide communities for passing of sodium nitrite through the customs. They concluded, "This case also reveals the danger and the importance of preventing and fighting existing suicide support networks [read pro-choice suicide networks] over the internet [read Internet], which allow the purchase of a 'suicide kit,' [read 'suicide kit,'] by circumvent [read circumventing] the customs services."
All procedures of the research were performed according to the "ethical" and legal standards that bind the authors to report false rumors. The authors had potential conflicts including (not "include," as the authors had misspelled) employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, and royalties. Nonetheless, it is possible that the misinformation in the article be due to authors' and editors' lack of English language skills.
Sodium nitrite
The main compound for this suicide method, sodium nitrite is legal-to-own and easy-to-find, because it's widely used during curation of meats to preserve their color. Cured meats form about 5% of our nitrite intake. Currently, sodium nitrite is sold without regulation and can be bought from Amazon, eBay, or any local lab supplier. Some generous members shared[1|2|3|4] their success in doing so. And the color of the solution, 25 grams sodium nitrite in 50 ml water, can bee seen in here[1|2|3] plus the screenshot[1|2|3] of 25 grams in 100 ml water, from 6 July 2019 livestream. Please make sure that its purity is >95% and you're purchasing sodium nitrite (NaNO2)—not sodium nitrate (NaNO3). Should you not find it by looking up sodium nitrite, search for "NaNO2", "NNaO2", or "Filmerine." Either food grade or lab grade is fine. 100 grams cost €8 – 10. Sodium nitrite is described as white to yellowish powder/crystals and very soluble in water, with an unremarkable and unnoticeable salty taste. Clumps and temporary exposure to air are okay.
As long as sodium nitrite with >95% purity is available, avoid curing salts because they mostly contain table salt. Curing salts have many names such as Cure, Prague powder, Instacure, pink curing salt, or Pökelsalz; for example, Pink curing salt #1[1|2|3] or Pink curing salt #2[1|2|3]. While Prague powder #1 or #2 is only composed of 6.75% sodium nitrite, it's possible to peacefully commit suicide using 250 grams Prague powder. There will be 15.625 grams sodium nitrite in Prague powder #1 and, in Prague powder #2, an additional 10 grams sodium nitrate, which will reduce to nitrite in human body. The unpleasant symptoms of sodium chloride toxicity develop within hours after the ingestion, while the unconsciousness due to sodium nitrite happens only within minutes after the ingestion. Also, if nitrite salts, such as sodium nitrite or potassium nitrite, become unavailable, you can use nitrate salts, such as sodium nitrate or potassium nitrate (referred to as saltpeter or saltpetre), because nitrate reduces to nitrite and nitric oxide in vivo. Or use Barbicide which contains isopropyl alcohol, dimethyl benzyl ammonioum chloride, and sodium nitrite (Saha, Kane, Dargin & Nghiem, 2020). (Petróczi & Naughton, 2010) hinted several alternatives that have the same desired nitric oxide effect of sodium nitrite. The alternatives, nitric oxide-related compositions, are in 4 categories: precription drugs (e.g., nitroglycerin), nitrate containing supplements (e.g., NO-Xplode®), nutritional supplements (nitric oxide products) (e.g., NE2™, Nitrox Pump, NoX Rush, and NOX Surge), and phosphodiesterase type 5 (PDE-5) inhibitors (e.g., lodenafil, sildenafil citrate or Viagra®, tadalafil, vardenafil). PDE-5 inhibitors are dominated by Viagra®. Mixing it with other vasodilators is particularly dangerous and potentially fatal.
The estimated lethal dose of sodium nitrite in adults is approximately 2.6 g (Katabami, Hayakawa & Gando, 2016). The recommended dose from the PPH is 25 grams; however, the dose was increased on different issues, from only 5, to 12, to 15. The PPH has increased the dose to 25 grams in 14 September 2019 revision. The dose has remained 25 grams up to 14 November 2019 revision. The dose can be summarized to 15 g for underweight persons, 20 g for healthy-weight persons, and 25 g for overweight persons.
SN dose (dissolved in water before intake)
• 15 – 25 g
Sodium nitrite density is 2.168 g/cm3. Assuming that one standard teaspoon holds about 5 cm3, the required dose is equivalent to 2 teaspoons of sodium nitrite.
Antiemetics
In order to prevent vomiting in suicide attempts, dopamine blockers are used. The reasons for doing so is that the mechanism by which sodium nitrite induce nausea and vomiting are iron overload as well as NO interaction with dopaminergic neurotransmitters (Liu, Liang & Soong, 2019). One of the well-used dopamine blocker antiemetics is metoclopramide. Metoclopramide goes by many commercial names—namely, Reglan, Plasil, and Primperan. The disadvantages of metoclopramide are (1) having gastro-prokinetic properties, which empties the acidic stomach form sodium nitrite; and (2) extrapyramidal symptoms that are extremely rare in low doses and relieved with diphenhydramine.
Purchasing antiemetic will also be the bulk of the money spent during this method. It's feasible to faint and die without vomiting using only nitric oxide and sodium nitrate or successfully commit suicide without antiemetics (Hideyuki Nushida, 2014); nevertheless, vomiting hence failing is possible, too (Joosen, Stolk & Henry, 2014).
Stat dose (60 minutes before SN intake)
• 3 * 10 mg metoclopramide
or
Ahead regimen (48 hours before SN intake)
• 10 mg metoclopramide every 8 hours (i.e., 3 times per day) starting 48 hours in advance
Because the peak plasma concentration happens at about 1 – 2 hours after a single oral dose of metoclopramide, there's no significant advantage of going through the ahead regimen (except mentally preparing for the attempt).
Another popular choice of antiemetic is domperidone. Domperidone too goes by many commercial names—namely, Motilium. Considering the affinity values (Ki) at the D2 receptor (Tonini et al., 2004), the interchangeable dose of domperidone is 10 – 15 mg, reaches at peak plasma level 30 minutes following oral administration (Heykants et al., 1981).
Stat dose (30 minutes before SN intake)
• 2 * 10 mg domperidone
If you can't find the two mentioned antiemetics, don't lose hope. Other alternatives for antiemetic are olanzapine, alizapramide, chlorpromazine, and prochlorperazine. As a rule of thumb, for the stat dose each in each of the antiemetics, double up or triple up the therapeutic daily dose of the antiemetic. For example, for the stat dose, in case the leaflet of the antiemetic advises 6 mg twice a day, take 12 mg or 18 mg (if you're confidence you'll have no side effect). As mentioned earlier, serotonin antagonists only (e.g., ondansetron) or antihistamins only (e.g., diphenhydramine or dimenhydrinate) antiemetics are not effective in sodium nitrite suicide method.
If you are on any of the following antipsychotics, you don't need to take any antiemetic, because they already function as an antiemetic. The dose needed will depend on whether you take it regularly, the dose you're prescribed, and your weight. (Seeman, 2006), (Kusumi, Boku and Takahashi, 2014), and (Li, L. Snyder and E. Vanover, 2016) reported affinity values (Ki) at the D2 receptors of antipsychotics. The lower the numbers next to the drugs, the more powerful antiemetic the substance is.
Receptor Binding Affinity of Dopamine Blockers
The above table proves that antipsychotic medicines actually facilitate suicide.
Antacids
Using antacids (also known as acid regulators) is discouraged. The antacid section of Suicide Wiki is provided here only because you will encounter with antacids in the PPH. The PPH recommends decreasing your stomach's fluid volume to make the sodium nitrite absorbed more quickly. This can be accomplished with drugs like ranitidine, famotidine, or cimetidine that reduce the stomach acid quickly. The recommended dose in the PPH is 800 mg cimetidine (sold under the brand name Tagamet), which is equivalent to 3 – 4 * 75 mg ranitidine (sold under the brand name Zantac).
Stat dose (30 – 45 minutes before SN intake)
• 800 mg cimetidine (Tagamet)
or
• 3 * 75 mg ranitidine (Zantac)
The PPH previously recommended sodium bicarbonate as absorption accelerator. The PPH argued that sodium bicarbonate would raise the stomach's fluid pH. The raise in stomach's fluid pH hindered loss of consciousness in some patients—although it was expected, provided that the blood-pressure-lowering effect of orally ingested nitrite was abolished when test persons were pretreated with a proton pump inhibitor (PPI) to raise gastric pH (Montenegro et al., 2016). Similar to sodium bicarbonate, the blood pressure-lowering effect of orally ingested nitrite is abolished by a proton pump inhibitor (Piknova & Schechter, 2017). Since the release of the October 2018 revision, the PPH suggests Tagamet (instead of sodium bicarbonate) and has misguidedly argued "this effect is not related to gastric pH, but rather to the production rate of acid." While the PPH still incorrectly recommends using H2 receptor antagonists, such as cimetidine and ranitidine, simply not using them will result in a more peaceful death, owing to formation of nitric oxide, a vasodilator, in acidic (Malko, Kucernak & Lopes, 2016) gastric environment—in pH less than 6.51 (Pereira, Ferreira, Rocha, Barbosa & Laranjinha, 2013)—as shown in pathway A[1|2].
Without antacid: 3NaNO2 + 2HCl → 2NaCl + NaNO3 + 2NO + H2O
As mentioned in Doxit podcast No. 7, aired on 14 June 2020, Philip Nitschke said that he has clarified the use of antacid in the 4 June 2020 update of the PPH. In the PPH, he wrote, "Some reports mistakenly claim that acid reduction is counterproductive as it reduces NO release, hypotension and headache . . ."
Required time
The PPH claims that, during a monitored suicide with sodium nitrite, the patient was unconscious at 12 minutes and dead by 42. In south China, two girls—in the morning, being fasted—drank water contaminated with sodium nitrite. They did not feel anything suspicious, did not vomit, and fainted in 10 minutes. A further case—Shawn Shatto, a member of the site—according to her mother, Jackie Bieber, died within ~5 hours[1|2|3|4|5|6|7], given that she took it at 11:47 a.m. However, the Biebers had implied before on a radio program at the Messick's perfomace studio, A Parent's Story-Shawn Shatto[1|2|3|4|5], that Jackie had found Shawn within ~3 hours. Jackie, working down the hall, had not heard any noises coming from Shawn's room. Nor did the Biebers find any vomits. Moreover, (Workum, Bisschops & van den Berg, 2019) reported two case reports: a 27-year-old man who was passed away 2 hours after the ingestion, despite rescue attempt—and a 31-year-old man who survived due to being found 15 minutes after the ingestion. Under the compulsion of anti-choicers to make the method seem painful, the authors added, "because of the unbearable symptoms associated with suffocation, sodium nitrite is an extremely inappropriate suicide agent," omitting the fact that the loss of consciousness occurs in a couple of minutes. It's worth mentioning that the mechanism of death is suffocation in many suicide methods—pentobarbitals, phenobarbitals, opioids, cyanide, chlorine, inert gases, carbon monoxide, and hanging, to name but a few. ("ACMT 2020 Annual Scientific Meeting Abstracts – New York, NY", 2020) published a case report of a 25-year-old man who ingested 15 g sodium nitrite. He immediately had second thoughts about the attempt and called an ambulance within 10 minutes of ingestion. On paramedic arrival, he was alert, deeply cyanotic and admitted to sodium nitrite ingestion. In the emergency department, 40 minutes post-ingestion, GCS = 4, he had ashen gray skin, pulse-oximetry saturation 60% on mask high-flow oxygen, pulse 180 bpm, and BP 91/45 mmHg. He recovered without complication.
(Mudan et al., 2020) accounted five cases of severe methemoglobinemia secondary to large sodium nitrite ingestion that were reported to and managed by the California Poison Control System between May and November of 2019. The authors also confirmed the quality of a brand and complimented this webpage. In the two cases resulting in life, the patient either had used dimethyl sulfoxide (instead of antimetic) or was found early. Both recovered neurologically intact within several hours. In the three cases resulting in death, the patients progressed to cardiopulmonary arrest within 1 hour of ingestion, despite treatment with standard doses of methylene blue.
Details of the Five Sodium Nitrite Ingestion Cases Reported to CPCS
CPCS = California Poison Control System; Pt = patient; pRBCs = packed red blood cells.
Three poster presentations at the virtual 2020 North American Congress of Clinical Toxicology made it clear that emergency medicine physicians are going to up their game when it comes to diagnosing and treating methemoglobinemia quickly. It is now beyond question that they will be seeing more and more cases of severe, life-threatening methemoglobinemia that can require immediate treatment with methylene blue to prevent death. Given that cycardiopulmonary arrest usually occurs within an hour of ingestion before being treated with methylene blue, there may not be time to get a level or call the poison center (Gussow, 2020).
Consequences of failure
The effects of this poisoning are completely reversible, and having any permanent damages is highly unlikely, should you be "saved" during your attempt. Because methemoglobin creation is a natural process in human body, G6PD enzyme works to transform it back into hemoglobin again. This process can be facilitated by using the antidote for sodium nitrite, methylene blue. There are cases of people recovering from sodium nitrite poisoning without any side effects (Katabami, Hayakawa & Gando, 2016). Minute dosage of methylene blue increases oxygen from fatal 20% to healthy 90% within 30―60 minutes. Even in those cases that the ambulance was called soon enough, surviving was not certain (Harvey, Cave & Chanwai, 2010). The patient had lactic acid levels 9.6 mmol/L, which is almost 6 mmol/L higher than the minimum levels to suffer from metabolic acidosis. The reason for such low chance of injury is the fact that the brain is protected during low O2 conditions by nitric oxide (Kolluru, Prasai, Kaskas, Letchuman & Pattillo, 2016). Release of NO locally results in a proportional increase in cerebral blood flow that compensates for the reduction in blood oxygen carrying capacity (Hare, Tsui, Crawford & Patel, 2013).
Simple, step-by-step instructions
There are many ways to commit suicide by sodium nitrite. The following is an easy, quick, and pain-free recipe.
1. Take 30 mg metoclopramide (another editor suggested 800 mg of Tagamet, as well).
2. Wait 1 hour.
3. Dissolve 15 – 25 g sodium nitrite in 50 ml municipal tap water.
4. Drink the solution and relax on a bed, a couch, or a reclining chair.
How it works
Sodium nitrite, NaNO2, is a catalyst that converts the hemoglobin in blood into methemoglobin (MetHB), a molecule with a much higher affinity with oxygen. This conversion occurs when the ferrous ions in the regular hemoglobin are converted into ferric ones. Since its affinity is so high, methemoglobin does not let the oxygen flow into other tissues that need it thus depriving them of oxygen—even while you're breathing. Death, then, occurs due to hemolytic anemia or anemic hypoxia, not hypoxic hypoxia. The main reason for peacefulness of sodium nitrite method is that nitrate and nitrite reduce to nitric oxide, a vasodilator. Vasodilators relax hence dilate the smooth muscle in veins. Dilating veins will cause fall in blood pressure and loss of consciousness. (Bailey, Feelisch, Horowitz, Frenneaux & Madhani, 2014) illustrated the nitrite-derived NO signalling[1|2|3].
Alkyl nitrite functions as a source of nitric oxide, which signals for relaxation of the involuntary muscles. Alkyl nitrites (also referred to as poppers) have been used for recreational drug purposes, typically for the "high", "rush", or light headed feeling that the drug can create. Two examples of such drugs are amyl nitrite and isobutyl nitrite. Isobutyl nitrite is inhaled more often than ingested and induces profound, though transient, vasodilatation with blurred vision, headache, flushing, a "warm feeling," a widespread throbbing sensation and postural hypotension (Bradberry, Whittington, Parry & Vale, 1994). Rarely are there cases with fatal outcome of those who accidentally ingested it, used it with Viagra or other erectile dysfunction medications, applied it on the skin, or inhaled too much of it too quickly after each hit ([1][2][3], [4][5][6], and [7], to name but a few). Still, there is a huge stigma attached to someone who accidentally dies from a drug overdose.
The PPH has designated sodium nitrite ingestion as a peaceful way to end your life. It has made that statement through observing the death of 6 people who ingested a sodium nitrite drink. Peaceful means that there was minimal distress with no suffering to those who drank it. There are symptoms, however, that can be gained by drinking sodium nitrite.
Sodium nitrite poisoning symptoms include nausea, vomiting, vertigo, headaches, and tachycardia. All of these symptoms will not emerge in everyone. These symptoms will provide low level discomfort, and you will suffer no discomfort through the process. As for the physical symptoms, the color of blood, skin, fingertips, nail beds, and lips will change. The blood will take a bluish chocolate brown color, and the tips of fingers, toes, and nose will turn slightly blue from cyanosis (PubChem). In April 2019, a kindergarten teacher in China poisoned 23 children by lacing their breakfast with sodium nitrite. The only noticeable change in appearance of kindergarten students were their lips that had turned blue[1|2|3|4]. Additionally, in September 2019, four members of an Indian family committed suicide using sodium nitrite; similarly, little change to bluish[1|2|3|4|5|6] was visible in the color of their skin, their fingertips, and blood[1|2|3|4]. Also, (Warren and Blackwood, 2019) published a case report of a 25-year-old woman who had used benzocaine. The percentage of methemoglobin in her blood was 44%. The patient appeared cyanotic and had dark arterial and venous blood[1|2|3]. She was treated with intravenous methylene blue and had considerable improvement in her breathing and reduction in skin discoloration. Putting on a proper makeup[1|2|3|4] to go out in style can conceal any changes in your appearance.
On 24 May 2020, during the second part of Doxit Podcast No. 5 on the subject of the lethal salts, Fiona Stewart and Philip Nitschke described 5 eyewitness accounts Exit had received of ending one's own life by sodium nitrite.
1) George witnessed his 89-year-old wife, Susan, drinking sodium nitrite to take her life. Soon after waking up in the morning, Susan took 30 mg of omeprazole, a proton pump inhibitor—instead of antiemetic. 40 minutes later, she drank the sodium nitrite solution. She was surprised by the saltiness of the taste. About half a minute later, she vomited very slightly. She sat in bet to reduce the possibility of any more vomiting. She felt some dizziness. It took her 5 minuets to lose consciousness. She showed no signs of distress during unconsciousness. Susan died 30 minutes later, and her body was examined by a doctor 2 hours later. George, who had a witnessed the experience with sodium nitrite method, said he is confident to have sodium nitrite on the shelf so he can use it to obtain a peaceful death at the time of his choosing.
2) An 81-year-old woman took sodium nitrite to end her life alone. Her death was taken to be of natural causes. This suggests her body did not display obvious cyanosis, considering that cyanosis is a very common effect on the body as death takes place.
3) According to the sister of the deceased, Mrs. W took her life alone using sodium nitrite. Her body looked lovely and peaceful, and not brown. There have been no questions from the police or the coroner.
4) A friend of the deceased wrote, "I was not too surprised that her death was taken to be from natural causes, because I know of another Exit member, a 92-year-old man, who used sodium nitrite. He also was not glaringly showing cyanosis. Could the relatively short time to death, 22 minutes, played a role in this?"
5) A couple chose recently to go together. Their daughter wrote, "I want to let you know that my parents died together of nitrite recently. My mother was terminally ill, and dad chose not to go on without her. While I was not with them, it looked as it has been a very peaceful death."
(Park, Kim & Ha, 2020) reported 14 cases of fatal nitrite intoxication, as well as a photo[1|2|3] of the livor mortis of a South Korean man, 20, who had committed suicide using sodium nitrite in June 2018. In South Korea, there is a growning trend, since 2018, among young individuals to commit suicide using nitrite (See the summary of 14 cases of fatal nitrite intoxication[1|2|3]).
(Durão, Pedrosa & Dinis-Oliveira, 2020) reported a case of successful suicide by sodium nitrite. The deceased, a 37-year-old man, was a visitor of the Sanctioned Suicide forum. Hated by anti-choicers because of his activity on the forum, he was found dead inside his car next to a box that contained two drinking glass cups—not glass measuring cups—the medicines Primperan® (i.e., metoclopramide, 10 mg), ranitidine (75 mg), and a 35-grams-package of crystalline sodium nitrite (Fig. 1)[1|2|3]. He had purchased sodium nitrite around May 2019, when APC Pure still shipped sodium nitrite to private customers. He had also purchased a 35-grams-package of sodium nitrite from another supplier lest one of his sodium nitrite packages be confiscated by the customs services. The 37-year-old man had collected the ingredients of his suicide in a cardboard box to have everything he needed for suicide in one place, like a first-aid kit. Having all the ingredients in one place misled the authors of the article that he had ordered a "suicide kit" on the Internet.
In (Fig. 2)[1|2|3], the grey face and finger nails are normal for a body that has been dead for a while with natural causes. The abnormal part, though, was the white and grey bits (not the red patches) on the torso. The most relevant autoptic findings were the general signs of hypoxia (not asphyxia, as the authors had suggested) such as intense scleral congestion (Fig. 2A) and cyanosis of the extremities (Fig. 2B), specifically, hands and lips, and brown-gray-blue-red livor mortis in various parts of the body (Fig. 2C), some Tardieu petechiae in addition to intense polyvisceral congestion. The cause of death was due hypoxia (not asphyxia, as the authors had suggested) resulting from methemoglobinemia induced by sodium nitrite overdose. In the gastric content 16 g/L of nitrites and 24 g/L of sodium nitrite were obtained. In blood 30 ng/mL of nitrites were obtained. Since in this case nitrate level was much higher than nitrite level, sodium nitrite had been absorbed quickly. Failure to detect sodium nitrite in routine toxicological analysis can result in false negatives.
Although the authors knew they have to measure the methemoglobin levels, they did not do so. They stated, "Methemoglobin concentrations were not analyzed in our case." Then acknowledged, "as previously suggested, if the presence of nitrite is suspected in the blood, quantification of the methemoglobin levels may be more important than the nitrite or nitrate levels."
The authors noted, "symptoms such as nausea, vomiting, lethargy, shortness of breath, convulsions and coma are evident soon after intoxication, especially if levels of methemoglobinemia are higher than 60%," citing (Katabami, Hayakawa & Gando, 2016). However, (Katabami, Hayakawa & Gando, 2016) did not mention "shortness of breath" in their article, and sodium nitrite does not cause shortness of breath—because, unlike what (Durão, Pedrosa & Dinis-Oliveira, 2020) had suggested, sodium nitrite poisonings is not similar to carbon monoxide poisonings, in many ways. For start, people who experience sodium nitrite poisoning very likely will not develop brain damage.
The misinformation in (Durão, Pedrosa & Dinis-Oliveira, 2020) reached its peak when the authors stated, "In our case, autopsy results revealed brown/gray/blue/red livor mortis in various anterior and posterior parts of the body—namely, lips, hands, and shoulders. It is suggested to be an adverse consequence of the vasodilation, since sodium nitrite is an precursor of nitric oxide," citing (Bradberry, Whittington, Parry & Vale, 1994) and (Petróczi & Naughton, 2010). The authors used the same misleading technique to reach their desired results: never had (Bradberry, Whittington, Parry & Vale, 1994) and (Petróczi & Naughton, 2010) suggested that blue livor mortis is an adverse consequence of the vasodilation, because blue livor mortis is the consequence of methemoglobinemia, such in copper sulfate toxicity that results in methemoglobinemia with no vasodilation.
(Durão, Pedrosa & Dinis-Oliveira, 2020) implied that they hadn't indulged in Sanctioned Suicide or Suicide Wiki by referring to an outdated Final Exit webpage as well as a 2007 edition of The Peaceful Pill Handbook, which does not have the inorganic salts chapters (because the chapter was added in 2018). The authors of the article blamed pro-choice suicide communities for passing of sodium nitrite through the customs. They concluded, "This case also reveals the danger and the importance of preventing and fighting existing suicide support networks [read pro-choice suicide networks] over the internet [read Internet], which allow the purchase of a 'suicide kit,' [read 'suicide kit,'] by circumvent [read circumventing] the customs services."
All procedures of the research were performed according to the "ethical" and legal standards that bind the authors to report false rumors. The authors had potential conflicts including (not "include," as the authors had misspelled) employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, and royalties. Nonetheless, it is possible that the misinformation in the article be due to authors' and editors' lack of English language skills.
Sodium nitrite
The main compound for this suicide method, sodium nitrite is legal-to-own and easy-to-find, because it's widely used during curation of meats to preserve their color. Cured meats form about 5% of our nitrite intake. Currently, sodium nitrite is sold without regulation and can be bought from Amazon, eBay, or any local lab supplier. Some generous members shared[1|2|3|4] their success in doing so. And the color of the solution, 25 grams sodium nitrite in 50 ml water, can bee seen in here[1|2|3] plus the screenshot[1|2|3] of 25 grams in 100 ml water, from 6 July 2019 livestream. Please make sure that its purity is >95% and you're purchasing sodium nitrite (NaNO2)—not sodium nitrate (NaNO3). Should you not find it by looking up sodium nitrite, search for "NaNO2", "NNaO2", or "Filmerine." Either food grade or lab grade is fine. 100 grams cost €8 – 10. Sodium nitrite is described as white to yellowish powder/crystals and very soluble in water, with an unremarkable and unnoticeable salty taste. Clumps and temporary exposure to air are okay.
As long as sodium nitrite with >95% purity is available, avoid curing salts because they mostly contain table salt. Curing salts have many names such as Cure, Prague powder, Instacure, pink curing salt, or Pökelsalz; for example, Pink curing salt #1[1|2|3] or Pink curing salt #2[1|2|3]. While Prague powder #1 or #2 is only composed of 6.75% sodium nitrite, it's possible to peacefully commit suicide using 250 grams Prague powder. There will be 15.625 grams sodium nitrite in Prague powder #1 and, in Prague powder #2, an additional 10 grams sodium nitrate, which will reduce to nitrite in human body. The unpleasant symptoms of sodium chloride toxicity develop within hours after the ingestion, while the unconsciousness due to sodium nitrite happens only within minutes after the ingestion. Also, if nitrite salts, such as sodium nitrite or potassium nitrite, become unavailable, you can use nitrate salts, such as sodium nitrate or potassium nitrate (referred to as saltpeter or saltpetre), because nitrate reduces to nitrite and nitric oxide in vivo. Or use Barbicide which contains isopropyl alcohol, dimethyl benzyl ammonioum chloride, and sodium nitrite (Saha, Kane, Dargin & Nghiem, 2020). (Petróczi & Naughton, 2010) hinted several alternatives that have the same desired nitric oxide effect of sodium nitrite. The alternatives, nitric oxide-related compositions, are in 4 categories: precription drugs (e.g., nitroglycerin), nitrate containing supplements (e.g., NO-Xplode®), nutritional supplements (nitric oxide products) (e.g., NE2™, Nitrox Pump, NoX Rush, and NOX Surge), and phosphodiesterase type 5 (PDE-5) inhibitors (e.g., lodenafil, sildenafil citrate or Viagra®, tadalafil, vardenafil). PDE-5 inhibitors are dominated by Viagra®. Mixing it with other vasodilators is particularly dangerous and potentially fatal.
The estimated lethal dose of sodium nitrite in adults is approximately 2.6 g (Katabami, Hayakawa & Gando, 2016). The recommended dose from the PPH is 25 grams; however, the dose was increased on different issues, from only 5, to 12, to 15. The PPH has increased the dose to 25 grams in 14 September 2019 revision. The dose has remained 25 grams up to 14 November 2019 revision. The dose can be summarized to 15 g for underweight persons, 20 g for healthy-weight persons, and 25 g for overweight persons.
SN dose (dissolved in water before intake)
• 15 – 25 g
Sodium nitrite density is 2.168 g/cm3. Assuming that one standard teaspoon holds about 5 cm3, the required dose is equivalent to 2 teaspoons of sodium nitrite.
Antiemetics
In order to prevent vomiting in suicide attempts, dopamine blockers are used. The reasons for doing so is that the mechanism by which sodium nitrite induce nausea and vomiting are iron overload as well as NO interaction with dopaminergic neurotransmitters (Liu, Liang & Soong, 2019). One of the well-used dopamine blocker antiemetics is metoclopramide. Metoclopramide goes by many commercial names—namely, Reglan, Plasil, and Primperan. The disadvantages of metoclopramide are (1) having gastro-prokinetic properties, which empties the acidic stomach form sodium nitrite; and (2) extrapyramidal symptoms that are extremely rare in low doses and relieved with diphenhydramine.
Purchasing antiemetic will also be the bulk of the money spent during this method. It's feasible to faint and die without vomiting using only nitric oxide and sodium nitrate or successfully commit suicide without antiemetics (Hideyuki Nushida, 2014); nevertheless, vomiting hence failing is possible, too (Joosen, Stolk & Henry, 2014).
Stat dose (60 minutes before SN intake)
• 3 * 10 mg metoclopramide
or
Ahead regimen (48 hours before SN intake)
• 10 mg metoclopramide every 8 hours (i.e., 3 times per day) starting 48 hours in advance
Because the peak plasma concentration happens at about 1 – 2 hours after a single oral dose of metoclopramide, there's no significant advantage of going through the ahead regimen (except mentally preparing for the attempt).
Another popular choice of antiemetic is domperidone. Domperidone too goes by many commercial names—namely, Motilium. Considering the affinity values (Ki) at the D2 receptor (Tonini et al., 2004), the interchangeable dose of domperidone is 10 – 15 mg, reaches at peak plasma level 30 minutes following oral administration (Heykants et al., 1981).
Stat dose (30 minutes before SN intake)
• 2 * 10 mg domperidone
If you can't find the two mentioned antiemetics, don't lose hope. Other alternatives for antiemetic are olanzapine, alizapramide, chlorpromazine, and prochlorperazine. As a rule of thumb, for the stat dose each in each of the antiemetics, double up or triple up the therapeutic daily dose of the antiemetic. For example, for the stat dose, in case the leaflet of the antiemetic advises 6 mg twice a day, take 12 mg or 18 mg (if you're confidence you'll have no side effect). As mentioned earlier, serotonin antagonists only (e.g., ondansetron) or antihistamins only (e.g., diphenhydramine or dimenhydrinate) antiemetics are not effective in sodium nitrite suicide method.
If you are on any of the following antipsychotics, you don't need to take any antiemetic, because they already function as an antiemetic. The dose needed will depend on whether you take it regularly, the dose you're prescribed, and your weight. (Seeman, 2006), (Kusumi, Boku and Takahashi, 2014), and (Li, L. Snyder and E. Vanover, 2016) reported affinity values (Ki) at the D2 receptors of antipsychotics. The lower the numbers next to the drugs, the more powerful antiemetic the substance is.
Receptor Binding Affinity of Dopamine Blockers
| Drug class | D2 antagonism |
|---|---|
| Antiemetics | Domperidone (0.3–3.4 nM), Clebopride (2 nM), Metoclopramide (9.18 nM), Bromopride (14 nM), Alizapride (200 nM) |
| 1st generation antipsychotics | Benperidol (0.027 nM), Spiperone (0.053 nM), Droperidol (0.25 nM), Trifuperidol (0.4 nM), Haloperidol (2.0 nM), Chlorpromazine (2.6 nM), Bromperidol (2.1 nM), Prochlorperazine (6–8 nM), Levosulpiride (27–134 nM), Pipamperone (120 nM) |
| 2nd generation antipsychotics | Lurasidone (1.0 nM), Sestindole (2.7 nM), Paliperidone (2.8 nM), Risperidone (4.9 nM), Olanzapine (21 nM), Clozapine (144 nM), Quetiapine (245 nM) |
| Benzamide | Tiapride (320 nM) |
Antacids
Using antacids (also known as acid regulators) is discouraged. The antacid section of Suicide Wiki is provided here only because you will encounter with antacids in the PPH. The PPH recommends decreasing your stomach's fluid volume to make the sodium nitrite absorbed more quickly. This can be accomplished with drugs like ranitidine, famotidine, or cimetidine that reduce the stomach acid quickly. The recommended dose in the PPH is 800 mg cimetidine (sold under the brand name Tagamet), which is equivalent to 3 – 4 * 75 mg ranitidine (sold under the brand name Zantac).
Stat dose (30 – 45 minutes before SN intake)
• 800 mg cimetidine (Tagamet)
or
• 3 * 75 mg ranitidine (Zantac)
The PPH previously recommended sodium bicarbonate as absorption accelerator. The PPH argued that sodium bicarbonate would raise the stomach's fluid pH. The raise in stomach's fluid pH hindered loss of consciousness in some patients—although it was expected, provided that the blood-pressure-lowering effect of orally ingested nitrite was abolished when test persons were pretreated with a proton pump inhibitor (PPI) to raise gastric pH (Montenegro et al., 2016). Similar to sodium bicarbonate, the blood pressure-lowering effect of orally ingested nitrite is abolished by a proton pump inhibitor (Piknova & Schechter, 2017). Since the release of the October 2018 revision, the PPH suggests Tagamet (instead of sodium bicarbonate) and has misguidedly argued "this effect is not related to gastric pH, but rather to the production rate of acid." While the PPH still incorrectly recommends using H2 receptor antagonists, such as cimetidine and ranitidine, simply not using them will result in a more peaceful death, owing to formation of nitric oxide, a vasodilator, in acidic (Malko, Kucernak & Lopes, 2016) gastric environment—in pH less than 6.51 (Pereira, Ferreira, Rocha, Barbosa & Laranjinha, 2013)—as shown in pathway A[1|2].
Without antacid: 3NaNO2 + 2HCl → 2NaCl + NaNO3 + 2NO + H2O
As mentioned in Doxit podcast No. 7, aired on 14 June 2020, Philip Nitschke said that he has clarified the use of antacid in the 4 June 2020 update of the PPH. In the PPH, he wrote, "Some reports mistakenly claim that acid reduction is counterproductive as it reduces NO release, hypotension and headache . . ."
Required time
The PPH claims that, during a monitored suicide with sodium nitrite, the patient was unconscious at 12 minutes and dead by 42. In south China, two girls—in the morning, being fasted—drank water contaminated with sodium nitrite. They did not feel anything suspicious, did not vomit, and fainted in 10 minutes. A further case—Shawn Shatto, a member of the site—according to her mother, Jackie Bieber, died within ~5 hours[1|2|3|4|5|6|7], given that she took it at 11:47 a.m. However, the Biebers had implied before on a radio program at the Messick's perfomace studio, A Parent's Story-Shawn Shatto[1|2|3|4|5], that Jackie had found Shawn within ~3 hours. Jackie, working down the hall, had not heard any noises coming from Shawn's room. Nor did the Biebers find any vomits. Moreover, (Workum, Bisschops & van den Berg, 2019) reported two case reports: a 27-year-old man who was passed away 2 hours after the ingestion, despite rescue attempt—and a 31-year-old man who survived due to being found 15 minutes after the ingestion. Under the compulsion of anti-choicers to make the method seem painful, the authors added, "because of the unbearable symptoms associated with suffocation, sodium nitrite is an extremely inappropriate suicide agent," omitting the fact that the loss of consciousness occurs in a couple of minutes. It's worth mentioning that the mechanism of death is suffocation in many suicide methods—pentobarbitals, phenobarbitals, opioids, cyanide, chlorine, inert gases, carbon monoxide, and hanging, to name but a few. ("ACMT 2020 Annual Scientific Meeting Abstracts – New York, NY", 2020) published a case report of a 25-year-old man who ingested 15 g sodium nitrite. He immediately had second thoughts about the attempt and called an ambulance within 10 minutes of ingestion. On paramedic arrival, he was alert, deeply cyanotic and admitted to sodium nitrite ingestion. In the emergency department, 40 minutes post-ingestion, GCS = 4, he had ashen gray skin, pulse-oximetry saturation 60% on mask high-flow oxygen, pulse 180 bpm, and BP 91/45 mmHg. He recovered without complication.
(Mudan et al., 2020) accounted five cases of severe methemoglobinemia secondary to large sodium nitrite ingestion that were reported to and managed by the California Poison Control System between May and November of 2019. The authors also confirmed the quality of a brand and complimented this webpage. In the two cases resulting in life, the patient either had used dimethyl sulfoxide (instead of antimetic) or was found early. Both recovered neurologically intact within several hours. In the three cases resulting in death, the patients progressed to cardiopulmonary arrest within 1 hour of ingestion, despite treatment with standard doses of methylene blue.
Details of the Five Sodium Nitrite Ingestion Cases Reported to CPCS
| Pt | Age, Years | Sex | Estimated Amount Ingested (g) | Initial Blood Pressure (mm Hg) | Initial Heart Rate (beats/min) | Initial Oxygen Saturation | Peak Methemoglobin Level | Treatment | Outcome |
|---|---|---|---|---|---|---|---|---|---|
| A | 18 | M | 15 | 109/58 | 95 | 90% (Post-methylene blue) | 70.8% | Methylene blue (1.5 mg/kg) | Survived |
| B | 16 | F | 60 | 101/59 | 128 | 76% | 73% | Methylene blue (6 mg/kg), 2 units pRBCs | Survived |
| C | 27 | M | 15 | 116/68 | 72 | 68% | 32.4% | Methylene blue (2 mg/kg) | Died |
| D | 16 | F | Unknown | N/A | N/A | N/A | 30% | Methylene blue (2 mg/kg), 1 unit pRBCs | Died |
| E | 25 | M | 113 | 98/64 | 95 | 80% | Undetectably high | Methylene blue (1 mg/kg) | Died |
Three poster presentations at the virtual 2020 North American Congress of Clinical Toxicology made it clear that emergency medicine physicians are going to up their game when it comes to diagnosing and treating methemoglobinemia quickly. It is now beyond question that they will be seeing more and more cases of severe, life-threatening methemoglobinemia that can require immediate treatment with methylene blue to prevent death. Given that cycardiopulmonary arrest usually occurs within an hour of ingestion before being treated with methylene blue, there may not be time to get a level or call the poison center (Gussow, 2020).
Consequences of failure
The effects of this poisoning are completely reversible, and having any permanent damages is highly unlikely, should you be "saved" during your attempt. Because methemoglobin creation is a natural process in human body, G6PD enzyme works to transform it back into hemoglobin again. This process can be facilitated by using the antidote for sodium nitrite, methylene blue. There are cases of people recovering from sodium nitrite poisoning without any side effects (Katabami, Hayakawa & Gando, 2016). Minute dosage of methylene blue increases oxygen from fatal 20% to healthy 90% within 30―60 minutes. Even in those cases that the ambulance was called soon enough, surviving was not certain (Harvey, Cave & Chanwai, 2010). The patient had lactic acid levels 9.6 mmol/L, which is almost 6 mmol/L higher than the minimum levels to suffer from metabolic acidosis. The reason for such low chance of injury is the fact that the brain is protected during low O2 conditions by nitric oxide (Kolluru, Prasai, Kaskas, Letchuman & Pattillo, 2016). Release of NO locally results in a proportional increase in cerebral blood flow that compensates for the reduction in blood oxygen carrying capacity (Hare, Tsui, Crawford & Patel, 2013).
