Barbiturates such as phenobarbital were long used as anxiolytics and hypnotics, but today have been largely replaced by benzodiazepines for these purposes because of less potential for lethal overdoses. However, barbiturates are still used as anticonvulsants, as para-operative sedatives (ex. sodium thiopental), and analgesics for cluster headaches/ migraines (ex. fioricet).
Prescribing protocols. The high risk of addiction and abuse associated with barbiturates, their extreme toxicity relative to alternatives such as benzodiazepines, and their potentiation of other gabaminergic and sedative drugs (including alcohol) are all concerns with long term barbiturate use even when used on an as-needed basis. For this reason, many states have mandatory protocols for barbiturate prescription to assure patient compliance with usage instructions. Though protocols differ among jurisdictions, and not all states require all preventative measures, common requirements include:
Routine drug testing to ensure the patient is using the drug (not diverting it) and has not been using other prescription or street drugs the doctor is not aware of Allowing only one pharmacy per patient to provide the drug Reporting all other prescription drugs to the prescribing doctor (sometimes blocking the prescription if other sedatives or gabaminergics are used) Requiring patients to accept pharmacist counseling Increased scheduling of barbiturates (treating them as schedule 2 or 3 drugs, which may prevent doctors from adding automatic refills) Treating barbiturates as second line agents (requiring alternative treatment attempts before prescribing them) Specifying a maximum amount of pills or total dose of pills in each prescription. Doctors often use these practices even when not legally required, as they are consistent with best-practice medical guidelines, and limit physician liability in the event of abuse or overdose.
Doctors are also told to re-evaluate the need for the prescription before each fill is written. It is not uncommon for prescribing doctors to require patients to enter a narcotics contract before receiving the drug. These contracts often include the above protocols as well as forbidding the patients to accept any barbiturate or opiate out-patient prescriptions from any other doctor (including emergency room doctors) for any purpose (including pre-medications for medical services such as anxiolytics prior to dental appointments) unless they have received prior permission from the doctor with whom the contract was entered (it is also considered a felony in most states to accept narcotics from multiple doctors); patients are generally but not always permitted to accept single doses of narcotics from emergency personnel when they are administered directly by that doctor (in the case of IV/IM administration) or the patient is directly observed when taking the drug (in the case of oral/rectal administration). In many cases, doctors also forbid patients from consuming alcohol while accepting treatment. The definition of narcotic varies among doctors, but always include opiates/opioids and barbiturates, with benzodiazepines and amphetamines often being included as well, and occasionally broad-term drug categories such as sedatives, muscle relaxers, and anxiolytics of any mechanism. Violation of narcotic contracts generally result in immediate and permanent dismissal of the patient from the practice and, when applicable (ex. diversion of the drug or collecting narcotics from multiple prescribers/practices), a report issued by the doctor to law enforcement. Occasionally, doctors accept patients who have been previously discharged for the use of street drugs if the patient has undergone (or is undergoing) treatment for their addiction, often with the additional requirement of much more frequent drug tests than would otherwise be required.
When another doctor (usually a specialist or an E.R. doctor) believes that the patient is in need of another narcotic (ex. for acute pain control after injury/surgery, treatment of epilepsy/anxiety/insomnia, pre-medication, etc.) it is common practice for them to contact the provider with whom the patient has signed a narcotics contract and have that doctor prescribe the medication according to the requesting doctors suggestion, although they may sometimes suggest a different drug or dosage due to concerns about drug interactions or known sensitivities to the suggested drug. In some cases the second doctor may be given permission to prescribe the drug themselves when the drug falls under the definition of a narcotic under the terms of the narcotics contract but not under the states legal definition as long as the second doctor informs the first whenever a prescription of that drug is issued (this is common with prescriptions of amphetamines, benzodiazepines, and z-drugs issued by a psychiatrist).