Two cases of severe gamma-hydroxybutyrate withdrawal delirium on a psychiatric unit: recommendations for management

Many psychiatric professionals are unfamiliar with gamma-hydroxybutyrate (GHB), an increasingly popular drug of abuse. GHB withdrawal can lead to psychosis and agitation, and patients may present to psychiatric facilities for treatment. Withdrawal may progress to delirium, with the potential for severe or even fatal medical complications. Therefore, it is imperative for psychiatric professionals to understand how to treat these patients. In this article, we describe two cases of severe GHB withdrawal syndrome that were treated in our inpatient psychiatric unit. These are among the most severe cases reported. Pertinent literature is reviewed and suggestions for treatment are discussed.

Gamma-hydroxybutyrate versus chlorprothixene/phenobarbital sedation in children undergoing MRI studies

BACKGROUND

Few clinical studies have assessed gamma-hydroxybutyrate and chlorprothixene/phenobarbital sedation in children. This prospective trial compared the two regimes in children, in particular concerning differences in recovery time.

METHODS

28 pediatric oncology patients undergoing elective MRI studies at a university hospital were randomly assigned to either receive gamma-hydroxybutyrate or chlorprothixene/phenobarbital sedation. Time to induce deep sedation (Ramsay score of 5) and recovery time, the incidence of failure of sedation, the frequency of side effects, the need for therapeutic interventions, and the number of patients receiving additional midazolam were recorded. Analysis of hemodynamic parameters was performed at five defined time points.

RESULTS

All 28 MRI studies were successfully completed. Recovery time was significantly shorter with gamma-hydroxybutyrate (p < 0.01). There were more side effects with chlorprothixene/phenobarbital, in particular tachycardia and hyperexcitation. Vomiting was the side effect most often seen in gamma-hydroxybutyrate sedation. Therapeutic interventions were not required in any patient. Additional midazolam was necessary to maintain satisfactory sedation in six children receiving gamma-hydroxybutyrate and four receiving chlorprothixene/phenobarbital.

CONCLUSIONS

Due to its significantly shorter recovery time, gamma-hydroxybutyrate is a reasonable sedative drug for children undergoing non-invasive diagnostic procedures, and is superior to chlorprothixene/phenobarbital. In pediatric oncology patients gamma-hydroxybutyrate appears to be associated more often with vomiting. The long recovery time and its great variability make chlorprothixene/phenobarbital a less valuable alternative.

The influence of gender and food on the pharmacokinetics of sodium oxybate oral solution in healthy subjects

Sodium oxybate (Xyrem; gamma-hydroxybutyrate) oral solution was recently approved in the United States for the treatment of cataplexy in patients with narcolepsy. Two single-center, randomized, open-label studies in healthy volunteers receiving single oral 4.5-g doses of sodium oxybate evaluated effects of (1) gender on oxybate pharmacokinetics and (2) food on its oral bioavailability. In the latter study, one dose was administered after an overnight fast, another after a high-fat meal; 1 week separated treatments. Sodium oxybate pharmacokinetics was not significantly different between sexes. However, food significantly altered the bioavailability of oxybate by decreasing mean peak plasma concentration, increasing median time-to-peak concentration, and decreasing the area under the plasma concentration-time curve. Food did not affect elimination and urinary excretion of unchanged drug. No dose adjustment of sodium oxybate based on sex is indicated. Although significant food effects were observed, these are minimized in patients by the nocturnal dosing of sodium oxybate hours after the evening meal at a consistent time interval following food ingestion.

What are club drugs? Here's a quick look

The National Institute on Drug Abuse in Bethesda, MD, provides a brief overview on the most common designer drugs and how they are used, how they affect users, and what their dangers are.

Trends in illicit drug emergencies: the emerging role of gamma-hydroxybutyrate

BACKGROUND

Previously used as a general anesthetic, gamma-hydroxybutyrate is now used as a recreational drug. Not surprisingly, an increasing number of acute overdose cases requiring emergency medical care have been reported and described, especially in the United States.

OBJECTIVES

To determine the number and percentage of gamma-hydroxybutyrate overdoses over a 15-month period and to describe the clinical hallmarks and course of this new drug in overdose.

METHODS

All toxicological emergencies, including those caused by illicit drug consumption, were recorded for 15 months in an urban public hospital emergency department. Accurate toxicological history was obtained from the patients and, if gamma-hydroxybutyrate was suspected, confirmation was performed by urine mass spectrometry. The study data were compared with data recorded in the same emergency department in 1989.

RESULTS

The total number of toxicological emergencies attended in our emergency department have remained unchanged during the last decade, with a significant decrease in number of opiate overdoses and an increase in the number of cocaine, amphetamine, and gamma-hydroxybutyrate overdoses. During the study period, 104 gamma-hydroxybutyrate overdoses presented to the emergency department (3.1% of all toxicological emergencies), ranking second in illicit drugs requiring emergency consultation. The profile of a patient with gamma-hydroxybutyrate intoxication is well defined: a young individual (23 +/- 5 years), male (64%), emergency department presentation on weekends (90%), with simultaneous ethanol consumption (73%) and ingestion of additional illicit drugs (86%), decrease of consciousness being the main complaint in all cases [16% with Glasgow Coma Scale (GCS) = 3]. Complete recovery without sequelae occurred in all cases.

CONCLUSION

Health authorities must be aware of the hazards of recreational gamma-hydroxybutyrate, and physicians must be cognizant of this recent cause of coma among youths presenting to the emergency departments.

Gamma hydroxybutyric acid (GHB) intoxication

Gamma hydroxybutyric acid (GHB) is a naturally occurring analog of gamma-aminobutyric acid (GABA) that has been used in research and clinical medicine for many years. In the past decade it has become very popular as a dietary supplement and recreational drug. Acute overdose leads to profound alteration of mental status and variable amounts of respiratory depression. With proper management, most patients recover fully within six hours. However, respiratory arrest and death have been reported in severe GHB intoxication. In addition to acute overdose, there is a GHB withdrawal syndrome that is similar to sedative/hypnotic and ethanol withdrawal. Recently several congeners of GHB, gamma butyrolactone and 1,4-butanediol, have emerged as drugs of abuse and show toxidromes similar to GHB. Emergency physicians should be familiar with the presentation and management of GHB-related emergencies.

Club drugs: methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate

The abuse of methylenedioxymethamphetamine (MDMA), flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate (GHB) is discussed. Club drugs are chemical substances used recreationally in social settings. Use is increasingly frequent among young people, especially during all-night dance parties. All four agents have been classified as controlled substances. MDMA ("ecstasy") is available as a tablet, a capsule, and a powder; formulations may contain many adulterants. MDMA increases the release of neurotransmitters. The desired effects are euphoria, a feeling of intimacy, altered visual perception, enhanced libido, and increased energy. The most common adverse effects are agitation, anxiety, tachycardia, and hypertension. More serious adverse effects include arrhythmias, hyperthermia, and rhabdomyolysis. Flunitrazepam is a potent benzodiazepine. At higher doses, the drug can cause lack of muscle control and loss of consciousness. Other adverse effects are hypotension, dizziness, confusion, and occasional aggression. Ketamine is a dissociative anesthetic used primarily in veterinary practice. It may be injected, swallowed, snorted, or smoked. Like phencyclidine, ketamine interacts with the N-methyl-D-aspartate channel. Analgesic effects occur at lower doses and amnestic effects at higher doses. Cardiovascular and respiratory toxicity may occur, as well as confusion, hostility, and delirium. GHB, a naturally occurring fatty acid derivative of gamma-aminobutyric acid, was introduced as a dietary supplement. Increasing doses progressively produce amnesia, drowsiness, dizziness, euphoria, seizures, coma, and death. Flunitrazepam, ketamine, and GHB have been used to facilitate sexual assault. Supportive care is indicated for most cases of club drug intoxication. The increasing abuse of MDMA, flunitrazepam, ketamine hydrochloride, and GHB, particularly by young people in social settings such as clubs, should put health care professionals on guard to recognize and manage serious reactions.

GHB use among Australians: characteristics, use patterns and associated harm

The aim of this study was to examine the characteristics of gamma-hydroxybutyrate (GHB) users, their GHB and other drug use patterns, and the harms associated with GHB use. Seventy-six GHB users were recruited and administered a structured interview on GHB use and related harms. GHB users appeared to be a stable, highly educated and well-functioning group. They had had extensive experience with a range of drugs, and GHB was typically used in conjunction with other drugs. Despite the fact that most GHB users had not had a long or extensive experience with GHB use, the proportion reporting significant negative side effects when using GHB was high (99% reported at least one), and the mean number of side effects ever experienced was 6.5. Notably, half (52%) reported becoming unconscious, 53% reported vomiting, 58% reported profuse sweating, and 8% reported having a fit or seizure. The high rate of problems reported by a group with limited use of this drug suggests that in a context of polydrug use, GHB use is associated with significant risks to users.

Pulmonary oedema caused by "liquid ecstasy" ingestion

In this case report we describe the first recorded case of alveolar gas exchange impairment caused by "liquid ecstasy" ingestion, and perhaps inhalation, by a 4 year old child. The pulmonary gas diffusion disturbance was sufficiently prolonged to raise the suspicion of a direct toxic effect on the alveolar-capillary membrane.

[New Drugs: Ectasy and Gamma-Hydroxy-Butyrate (GHB)]

For several years the "raves" and "tecno" parties are accompanied of a growing consumption of such substances as Ecstasy and Gamma-Hidroxi-Butirato (GHB). In this article, their authors describe the secondary and toxic effects of those drugs. These data should alert about the risk of considering this new way of substance abuse as a banal fact.

Gamma-hydroxybutyric acid: patterns of use, effects and withdrawal

Gamma-hydroxybutyric acid (GHB) is gaining popularity as a drug of abuse. Reports of toxicity and lethality associated with GHB use have increased. This survey study was designed to identify patterns of GHB use, its effects, and withdrawal syndrome. A survey inquiring about the effects of GHB was administered to 42 users. The results showed that GHB was used to increased feelings of euphoria, relaxation, and sexuality. Adverse effects occurred more frequently in daily users and polydrug users than in occasional GHB users. Loss of consciousness was reported by 66%, overdose by 28%, and amnesia by 13% of participants during GHB use and by 45% after GHB use. Three daily users developed a withdrawal syndrome that presented with anxiety, agitation, tremor, and delirium. Participants described GHB intoxication as having similarities to sedative-hypnotic or alcohol intoxication. Regular use has been shown to produce tolerance and dependence. Participants dependent on GHB reported using multiple daily doses around the clock. High frequency users appeared at the greatest risk for developing withdrawal delirium and psychosis after abrupt discontinuation of GHB use.

Effects of the putative antagonist NCS382 on the behavioral pharmacological actions of gammahydroxybutyrate in mice

RATIONALE

Gammahydroxybutyrate (GHB) is an endogenous chemical found in the human brain that when administered systemically readily crosses the blood-brain barrier and produces behavioral effects. Some previously reported observations, including reports of specific antagonism by NCS382 (6,7,8,9-tetrahydro-5-[H]-benzocycloheptene-5- ol-4-ylidene acetic acid), support the hypothesis that GHB is a neurotransmitter with its own receptor system. In addition to its uncertain physiological role, the recent interest in GHB has been engendered by its illicit use and abuse.

OBJECTIVES

To further characterize the behavioral effects of GHB and to evaluate NCS382 for its potential antagonistic effects.

METHODS

Following the administration of GHB alone and in combination with NCS382, mice were tested in a Functional Observational Battery (FOB) and for their effects on locomotor activity and on schedule-maintained behavior. Additionally, spontaneous and NCS382-precipitated withdrawal in rats chronically treated with GHB was examined.

RESULTS

In the FOB, GHB generally produced depressant-like effects that were generally not reversed by NCS382. GHB also dose dependently reduced locomotor activity and rates of operant behavior, which were generally not reversed by co-administrations with NCS382. Neither spontaneous nor NCS382-precipitated signs of physical dependence were observed following chronic GHB administration.

CONCLUSION

GHB dose dependently produced depressant-like effects on learned and unlearned behavior. The putative GHB antagonist NCS382 failed to convincingly antagonize these effects. Physical dependence was not evident following spontaneous withdrawal or NCS382 challenge. Taken together, these results suggest that NCS382's ability to antagonize GHB's effects may be very limited.

[GHB--dangerous, addictive and uncontrollable "party drug"]

This report reviews the pharmacology, toxicity and abuse pattern of gamma-hydroxybutyrate (GHB). The legislative changes pertaining to this substance are also addressed. Examples of abuse, driving under the influence and fatal intoxication are given. It is concluded that GHB is widely abused, particularly among the younger generation, and that further cases of severe intoxication are likely to occur as long as the substance is easily available from countless sources, including via the Internet. Despite the classification of GHB as a narcotic in Sweden and several other countries, continued problems are expected since the precursors gamma-butyrolactone (GBL) and 1,4-butanediol (BD) are widely--and legally--available.

GHB and driving impairment

Gamma hydroxybutyrate (GHB) was identified in the blood of 13 subjects arrested for impaired driving. GHB concentrations ranged from 26 to 155 mg/L (mean 87 mg/L, median 95 mg/L). In eight cases, GHB was the only drug detected, and signs of impairment were consistent with those of a CNS depressant, including erratic driving (weaving, swerving, ignoring road signs), confusion, incoherent speech, unresponsiveness, lack of balance, unsteady coordination, poor performances on field sobriety tests, and varying states of wakefulness. Given the ability of GHB to induce sleep and unconsciousness, it is evident from these cases that recreational use of the drug has the potential to impair a person's driving ability.

It's a rave new world: rave culture and illicit drug use in the young

Illicit drug use by young people has changed in the last decade, with the increasing use of "designer" or "club" drugs such as ecstasy. Keeping abreast of current trends in illicit drug use prepares the primary care clinician to recognize the clinical effects of drug use, to manage drug emergencies, and to detect addictive behavior. Today's widely used drugs, their street names, their effects, and how to manage overdoses are reviewed.

GHB: an important pharmacologic and clinical update

Gamma-hydroxybutyrate (GHB) intoxication is a significant cause of morbidity and mortality in patients taking the drug for recreational purposes. Due to the recent increase in emergency room visits, hospital admissions, and deaths, it has become necessary to re-examine the pharmacology, pharmacokinetics, pharmacodynamics, clinical manifestations, and potential adverse effects associated with GHB use. We present an important pharmacologic and clinical update on GHB.