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

-Hydroxybutyrate (GHB) in Humans: Pharmacodynamics and Pharmacokinetics

Despite gamma-hydroxybutyrate (GHB) therapeutic uses and the increasing concern about its toxicity, few studies have addressed GHB dose-related effects under controlled administration and their relationship with its pharmacokinetics. The study design was double-blind, randomized, crossover, and controlled. As a pilot pharmacology phase I study, increasing doses of GHB were given. Single oral sodium GHB doses (40, 50, 60, and 72 mg/kg) were administered to eight volunteers. Plasma and urine were analyzed for GHB by gas chromatography-mass spectrometry. Physiological effects, psychomotor performance, and subjective effects were examined simultaneously. GHB produced dose-related changes in subjective effects as measured by questionnaires and VAS. GHB showed a mixed stimulant-sedative pattern, with initially increased scores in subjective feeling of euphoria, high, and liking followed by mild-moderate symptoms of sedation with impairment of performance and balance. Mean peak GHB plasma concentrations were 79.1, 83.1, 113.5, and 130.1 mug/L for 40, 50, 60, and 72 mg/kg, respectively. GHB-mediated physiological and subjective effects were dose dependent and related to GHB plasma concentrations. GHB urinary excretion was mainly related to administered doses. GHB-mediated subjective and physiological effects seem dose dependent and related to GHB plasma concentrations. Results suggest a high abuse liability of GHB in the range of dose usually consumed.

Clinical vs. laboratory identification of drugs of abuse in patients admitted for acute poisoning

OBJECTIVE

The extent of drug abuse in patients admitted for self-poisonings is uncertain. The aim of this study was to assess the pattern of drugs of abuse among patients admitted for acute poisoning according to age and gender, and to study the concordance between the clinical assessments by the physicians on duty and the drug analyses.

METHODS

Prospective cross sectional study of all patients (n = 405, 52% males, median age 31 years) treated for acute poisoning in our department during one year (2001). The physician on-call classified type of drug of abuse by history and clinical assessment. This was later compared to urine and blood samples analysed for ethanol, benzodiazepines, opiates, cocaine, ecstasy, GHB, amphetamine and cannabis.

RESULTS

In 320 admissions (79%), the comparison between clinical diagnosis and laboratory analyses could be performed. A total of 478 drugs were suspected and 621 were found. The main toxic agents found were benzodiazepines (49.7%), ethanol (40.3%), opiates (35.3%), cannabis (23.8%) and amphetamine (21.3%). Ninety-two had used drugs of abuse. The agreement between clinical assessments and laboratory findings was best for GHB and ethanol (kappa = 0.43), and for opiates (k = 0.38). For benzodiazepines and cannabis, the concordance was poor (k = 0.18 and 0.10, respectively). However, the correct clinical evaluation for these substances was 59% and 77%, respectively.

CONCLUSIONS

Drugs of abuse were more frequently found than suspected clinically. Benzodiazepines, ethanol and opiates were most common. The agreement between clinical assessment and drug analyses was moderate to low. Physicians seem to underestimate the use of these drugs.

Urgencias por cocaína: un problema emergente

BACKGROUND AND OBJECTIVE

The consumption of cocaine has increased in Spain in recent years, leading to a probable increase in overdoses. The associated use of other drugs of abuse may be increasing the toxicity of cocaine, and therefore, increasing consultations to the emergency department (ED).

PATIENTS AND METHOD

We collected patients seen by the ED of our hospital who reported cocaine consumption in the previous hours. The relationship between cocaine consumption and the reason for attending the ED was analysed. We reviewed the medical records of a sample of overdoses to determine the clinical profile.

RESULTS

During the period 2002-2004, 745 patients were detected (average age 31 years, 68% males). The annual distribution was 223 cases in 2002, 232 in 2003, and 290 in 2004. Fifty-three percent of patients attended the ED at the weekend and 53% from 0:00 to 12:00 h. The main drugs associated with cocaine consumption were ethyl alcohol (38%), opiates (14%), cannabis (13%) and amphetamine derivatives (9%). Cocaine was the substance causing clinical symptoms in 70% of cases. The main reasons for attending the ED were anxiety or agitation (48%) and thoracic pain or palpitations (25%). Eleven percent of cases required hospital admission (19 intensive care unit) and 3 patients died.

CONCLUSIONS

The consumption of cocaine, almost always associated with other drugs of abuse, has generated an increase in patients attending the ED. Although mortality is low, cocaine consumption generates substantial morbidity and frequent hospital admissions.

Clinical features of gamma-hydroxybutyrate and gamma-butyrolactone toxicity and concomitant drug and alcohol use

OBJECTIVE

To describe the clinical features of gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL) toxicity.

METHODS

Retrospective case-study of 65 GHB and GBL intoxications seen in an urban emergency department.

RESULTS

63% of intoxications occurred in male patients. The median age was 24 years (range 16-41 years). 65% co-ingested alcohol or illicit drugs, mostly MDMA and cocaine. 83% presented with coma. The mean+/-S.D. time to regain consciousness among comatose patients was 111+/-61 min and was significantly longer in patients who co-abused illicit drugs such as cocaine or MDMA (155+/-60 min). Bradycardia occurred in 38%, hypotension in 6% and hypothermia in 48%. Agitation was observed in 17% of all patients and was significantly more frequent in patients with alcohol co-use (29%). Vomiting occurred in 31% of all patients and tended to be more frequent in patients who co-used alcohol (39%). Management of GHB and GBL overdose was supportive. Four patients needed admission to an intensive care unit for mechanical ventilation (6%).

CONCLUSIONS

Overdosing of GHB and GBL frequently results in non-reactive coma reflecting the severity of poisoning. Multiple drug use is common and significantly influences the clinical presentation.

Agitation is common in γ-hydroxybutyrate toxicity

Gamma-Hydroxybutyrate (GHB)-related compounds are most commonly described as depressants, with emphasis on somnolence, obtundation, stupor, and coma (SOSC). We sought to demonstrate the full spectrum of clinical presentations of GHB intoxication, including agitation and other nonsedative effects. Our observational study identified 66 patients with GHB toxicity, 40 of whom manifested agitation; 25 had agitation before or after SOSC, 10 had agitation alternating abruptly with SOSC, and 5 had agitation only. Fourteen presentations also included "bizarre" or self-injurious behaviors. Of 40 presentations with agitation, 19 had stimulant co-intoxicants confirmed by screen (14) or history (5). The remaining 21 patients with agitation were negative for stimulants by screen (12) or history (9). Gas chromatography/mass spectrometry detected GHB in 25 cases; 12 manifested agitation, 4 of which also screened negative for stimulants. Clinicians should broaden their definitions of GHB toxicity to include nonsedative effects such as agitation, combativeness, and bizarre or self-injurious behavior.

Recent trends in the use of "club drugs": an Australian review

The use of "club drugs" such as MDMA, ketamine, and GHB appears to have increased in Western countries over the last 20 years, and Australia is no exception to that trend. While levels of use appear to be relatively low in the general population, among users of these drugs a number of adverse health and psychological problems, including dependence, have been reported. MDMA or ecstasy is the third most commonly used illicit drug in Australia, and relatively more information is available on its use in Australia than of drugs such as GHB or ketamine. Although there are no population level data available, levels of ketamine use in the general population appear to be lower than those of MDMA. In addition, the harms reported by recreational users are not excessive and the mortality rate is low. At the individual level, many of those who experiment find the effects aversive and do not persist. The harms that require further investigation are the association between ketamine and unsafe sex and injecting behaviors, the neurotoxic effects, and use in situations where there is a heightened risk of accidental death when the user's cognition is grossly impaired. In contrast, while least is known of the epidemiology of GHB use, there is mounting evidence suggesting significant acute and long-term risks associated with the use of this drug. This suggests an urgent need for international research on the patterns of use, health, and psychosocial consequences of GHB use. In order to address public health issues associated with a range of club drug use, there is a need for research to identify the trends in population prevalence of these drugs. This could be most easily achieved by the inclusion of MDMA, ketamine, and GHB in household surveys that are currently collected routinely in a number of countries.

Club drugs: los viejos fármacos son las nuevas drogas de la fiesta

During the last few years the term club drugs has been used for defining an heterogeneous group of chemical substances in permanent evolution, that are consumed for recreational purposes. These substances have been extensively used, firstly by the Rave culture and later by the so called Club culture. These movements are characterized by the search of amplified sensations, by means of the combination of electronic music, marathon dancing and substance abuse. After years with a predominating consumption of designer amphetamines in these groups, it seems that the use of another type of substances is increasing, fundamentally drugs with hallucinogenic effects. This review focus in four of these substances; ketamine, dextromethorphan, nitrous oxide and gamma-hydroxybutyric acid (GHB, liquid ecstasy), and includes a discussion of their pharmacology, recreational use, adverse effects and patient management. These drugs are, at he same time, drugs of abuse and medicines with concrete indications in therapeutics, with an important increase of their consumption in the last few years. The Rave and Club cultures are also described.

Acute toxic effects of club drugs

This article summarizes the short-term physiological toxicity and the adverse behavioral effects of four substances (GHB, ketamine, MDMA, and Rohypnol) that have been used at latenight dance clubs. The two primary data sources were case studies of human fatalities and experimental studies with laboratory animals. A safety ratio was calculated for each substance based on its estimated lethal dose and its customary recreational dose. GHB (gamma-hydroxybutyrate) appears to be the most physiologically toxic; Rohypnol (flunitrazepam) appears to be the least physiologically toxic. The single most risk-producing behavior of club drug users is combining psychoactive substances, usually involving alcohol. Hazardous drug-use sequelae such as accidents, aggressive behavior, and addiction were not factored into the safety ratio estimates.

Street drug abuse leading to critical illness

Critical care physicians are frequently confronted with intoxicated patients who have used street drugs. In the last decade there has been an upward trend in the use of these substances, particularly amongst adolescents and young adults in large urban areas. In excess quantities all street drugs can lead to critical illness. Early and appropriate medical attention by emergency medicine physicians and intensivists can improve outcomes. In this review article we intend to familiarize critical care physicians with the most common street drugs such as amphetamines, ecstasy, cocaine, gamma hydroxybutyrate, opioids, and phencyclidine.