Translation from German
"Selbstbestimmt Sterben - Handreichung für einen rationalen Suizid (German Edition)
Jessica Düber
Amitriptyline guide
"Tricyclic antidepressants
General info
Tricyclic antidepressants are psychotropic drugs with a general mood-lifting effect that are used to treat depressive disorders. They act by inhibiting - in a less selective manner - the reuptake of the neurotransmitters serotonin, norepinephrine and dopamine into the nerve cells of the brain, so that more of the aforementioned neurotransmitters are available. Death from overdose occurs in the form of cardiac arrest following cardiac arrhythmias, possibly along with respiratory arrest. The duration between ingestion of the drug and the onset of death is between 12 and 48 hours. This relatively long time to onset of death is related to the fact that tricyclic antidepressants slow down the metabolism, and thus it may take longer for the body to completely absorb the active ingredient (the active ingredient inhibits its own absorption, so to speak). The use of tricyclic antidepressants for self-determined dying is listed in the WOZZ - Handbook (cf. Admiraal, Chabot, Ogden, Loenen, van, Pennings: Ways to a humane, self-determined dying, Amsterdam, 2008, pp.90 - 92) and also in Chabot (cf. Chabot: Dignified Dying. A Guide. 2014, pp.95 - 96). However, in the absence of sufficiently documented cases of successful implementation, Chabot lists the use of the substance as not meeting the criteria for peaceful, self-determined dying. He points out, however, that according to toxicologist Pennings, use of the substance in appropriate doses is very likely to cause death in the manner described above ("According to the toxicologist Pennings, in appropriate doses these drugs are very likely to cause death by cardiac arrest, and possibly by depression of respiration (apnea) as well" (cited in Chabot: Dignified Dying. A Guide. 2014, p.95)). Docker also formulates that there are methods for which more comprehensive documentation is available, but that the use of tricyclic antidepressants may be considered when the choice of other methods is limited, for whatever reason ("Although there are numerous cases of suicide with tricyclics alone, there are so many variables that they are not a first choice as a stand-alone self-deliverance drug. (...)
Amitriptyline works differently in different people. It is easy to classify a drug as reliable or unreliable when the evidence is unclear or inconclusive. Amitriptyline was mentioned only in passing in previous editions of Five Last Acts because there are now methods such as helium for which there is clearer and more conclusive evidence. But for one reason or another, some people will not always have so many options. If you have few other options and can swallow 5 or 6 g (not milligrams!) of amitriptyline tablets, then at least you have that option. That's a lot of tablets, even if they are crushed. Your body weight is a factor in determining the lethal dose of this drug, so if you are very heavy, you will need more (up to 7 g)" (quoted from Docker: Five Last Acts - The Exit Path. 2015. pp.363 - 365). Because the process of dying may be prolonged, it is particularly important when using tricyclic antidepressants to ensure that no life-saving measures are initiated for a period of at least 48 hours.
Tolerance
Tricyclic antidepressants do not induce tolerance even when taken continuously (e.g., when used regularly to treat a depressive disorder). Therefore, prior withdrawal is not necessary. Since tricyclic antidepressants require combined use with benzodiazepines, withdrawal from benzodiazepines may be necessary.
Docker writes of a necessary withdrawal from tricyclic antidepressants; a recommendation that should not confuse one, as it is a different context. The described, necessary withdrawal is about the use of depressant tricyclic antidepressants (which have sleep inducing effects and thus can be used as a sleep aid) for a suicide with a plastic bag - a method that the authors of the WOZZ - book advise against (cf. Admiraal, Chabot, Ogden, Loenen, van, Pennings: Wege zu einem humanen, selbstbestimmten Sterben, Amsterdam, 2008, p.127 - 130). This will be discussed in more detail later in this paper. Under no circumstances are tricyclic antidepressants suitable as sleeping pills if (prolonged) dying is to be brought about with this medication as well, and thus a prolonged, deep sleep has utmost priority. Docker's formulation for weaning off tricyclic antidepressants here is as follows: "If you have sedative tricyclics (those from the first list), especially if you have amitriptyline, they may be considered a suitable sedative if you take precautions. Firstly, if you have been taking them for a therapeutic reason, you need to stay off them for a few weeks to ensure you have not become acclimatised to them. Then, a few weeks before using them for self-deliverance, you need to do the Estimating Dosages experiment to see if a small dose knocks you out for several hours of daytime sleep. With this amount as a base increase planned self-deliverance dose by a factor of ten if you are using them with the plastic bag. Individual reaction to tricyclics varies" (quoted from Docker: Five Last Acts - The Exit Path. 2015. p.363).
Necessity of taking a benzodiazepine
Although some active ingredients of the tricyclic antidepressants (especially the active ingredients of the amitriptyline type, which have a more psychomotor depressant effect) have a sleep-inducing effect and are sometimes used as a sleep aid, they do not lead to a sufficiently deep and long sleep for self-determined dying. It is therefore necessary to combine the use of the tricyclic antidepressant with a benzodiazepine. This is particularly important because, as described above, the dying phase can last up to 48 hours. When tricyclic antidepressants are used for self-determined dying, as with the use of chloroquine, unpleasant side effects may occur, the conscious witnessing of which may be prevented or even suppressed by the prior use of a benzodiazepine. The unpleasant side effects of an overdose of tricyclic antidepressants include a greatly increased temperature (it is also important for people possibly accompanying the dying process to know this and to react calmly to it). Epileptic seizures can also be triggered by an overdose; however, these are suppressed by the benzodiazepine taken in combination.
Taking a fast-acting benzodiazepine is not absolutely necessary, since the onset of action or the onset of the unpleasant side effects of tricyclic antidepressants is not as rapid as is the case, for example, with chloroquine. However, there is no reason why a fast-acting benzodiazepine should not be taken in addition to the long-acting benzodiazepine if this is desired.
Necessity of taking an antiemetic
Taking an antiemetic is definitely necessary
Lethal dose
The lethal dose of all mentioned tricyclic antidepressants is given with a quantity between 6g and 7,5g.
In the book of the WOZZ - Foundation a dose of 6g is mentioned (cf. Admiraal, Chabot, Ogden, Loenen, van, Pennings: Wege zu einem humanen, selbstbestimmten Sterben, Amsterdam, 2008, p.91). Chabot gives a lethal dose of 7.5g (cf. Chabot: Dignified Dying.
A Guide. 2014, p.96). The dose of the long-acting benzodiazepine taken in combination should be at least 500mg (cf. Admiraal, Chabot, Ogden, Loenen, van, Pennings: Ways to a humane, self-determined dying, Amsterdam, 2008, p.92 and Chabot: Dignified Dying.
A Guide. 2014, p.96).
Intake
Taking the antiemetic (e.g. from 24 hours before planned taking of the lethal medication, one tablet of metoclopramide à 10mg every 6 hours / the last tablet should be taken about 1 hour before taking the lethal medication).
Do not eat anything from about 12 hours before the scheduled intake of the lethal drugs (drinking is possible).
Pulverize the drugs (you can do this the day before and store the crushed substances airtight and dark in a screw-top jar; tricyclic antidepressants are not as bitter as chloroquine and can therefore - instead of just being crushed - simply be pulverized in an electric coffee grinder).
About 30min before taking the lethal drugs, you can eat a snack (e.g., a slice of toast)
The lethal drugs in crushed form (e.g. 7.5g tricyclic antidepressants) can be stirred into a small bowl of pudding, soy yogurt, or fruit puree along with the crushed long-acting benzodiazepine (e.g. 500mg diazepam).
The fast-acting benzodiazepine (e.g., 100mg midazolam or lorazepam) is stirred into a separate small bowl of pudding, yogurt, or fruit puree - the use of a fast-acting benzodiazepine is optional here, as described above.
1 to 2 glasses of liquid are provided for swallow down.
It´s best to take the substances in an upright sitting position in bed, with supportive pillows placed on the left and right sides.
The bowls are spooned up quickly one after the other, with the bowl containing the fast-acting benzodiazepine (optional) spooned up last.
Then rinse with one, at most two glasses of liquid and, if necessary, consume a small amount of alcohol (alcohol is not absolutely necessary)."
This translation of the book is not meant to encourage you to commit suicide and to use this method. The reader acts on his own responsibility.
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