101
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Busardò FP, Pichini S, Giorgetti R. Considerations regarding the development and validation of chromatographic mass spectrometric methods for GHB analysis in forensic toxicology. Forensic Sci Int 2018; 288:e27-e28. [DOI: 10.1016/j.forsciint.2018.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/12/2018] [Indexed: 11/30/2022]
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102
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Liao PC, Chang HM, Chen LY. Clinical management of gamma-hydroxybutyrate (GHB) withdrawal delirium with CIWA-Ar protocol. J Formos Med Assoc 2018; 117:1124-1127. [PMID: 29933901 DOI: 10.1016/j.jfma.2018.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 11/30/2022] Open
Abstract
Gamma-hydroxybutyrate (GHB) is a synthetic drug used mainly for recreational purpose. Although the prevalence of GHB abuse is low in Taiwan, GHB has become increasingly popular in certain subpopulations such as clubbers and men who have sex with men (MSM). GHB dependence could be associated with severe withdrawal syndrome including hallucinations and delirium. Despite systematic studies on detoxification and management of GHB withdrawal have been performed, no validated measurement for severity of GHB withdrawal syndrome is available. Here we present a case of GHB withdrawal delirium that was treated successfully with fixed and symptom-triggered benzodiazepine dosing regimen based on Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale. The utilization of CIWA-Ar in such cases could offer useful guidance for benzodiazepine dosing. To the best of our knowledge, this is the first case report of GHB withdrawal delirium in Taiwan.
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Affiliation(s)
- Po-Chiao Liao
- Department of Psychiatry, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hu-Ming Chang
- Taipei City Psychiatric Center, Taipei City Hospital, Addiction Psychiatry Department, Taipei, Taiwan
| | - Lian-Yu Chen
- Taipei City Psychiatric Center, Taipei City Hospital, Addiction Psychiatry Department, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.
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103
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Jones AW, Holmgren A, Kugelberg FC, Busardò FP. Relationship Between Postmortem Urine and Blood Concentrations of GHB Furnishes Useful Information to Help Interpret Drug Intoxication Deaths. J Anal Toxicol 2018; 42:587-591. [DOI: 10.1093/jat/bky041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/28/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- A W Jones
- Department of Clinical Pharmacology, University of Linköping, 58185 Linköping, Sweden
| | - A Holmgren
- Division of Forensic Toxicology, National Board of Forensic Toxicology, 58758 Linköping, Sweden
| | - F C Kugelberg
- Department of Clinical Pharmacology, University of Linköping, 58185 Linköping, Sweden
- Division of Forensic Toxicology, National Board of Forensic Toxicology, 58758 Linköping, Sweden
| | - F P Busardò
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
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104
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GHB side effects: The need to clearly document drug dose and administration history. J Forensic Leg Med 2018. [DOI: 10.1016/j.jflm.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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105
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Inpatient Gamma-Hydroxybutyrate Detoxification: A Case Report Describing Day-to-day Therapeutic Management. J Addict Med 2018; 11:231-234. [PMID: 28125446 PMCID: PMC5457833 DOI: 10.1097/adm.0000000000000294] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gamma-hydroxybutyrate (GHB) is a synthetic drug increasingly used by consumers of psychoactive substances. The sought after psychoactive effects of GHB have resulted in an increase in recreational use in Europe. GHB is considered to have a high dependence potential, and abrupt discontinuation after long-term use can result in a severe withdrawal syndrome. Despite a large number of publications related to GHB withdrawal and detoxification, to date, no evidence-based protocol or consensual international therapeutic guidelines are available (over and above the administration of benzodiazepines). We hereby present a day-to-day description of inpatient GHB detoxification management, from admission to discharge. CASE SUMMARY This case report pertains to a 47-year-old patient hospitalized for a severe GHB use disorder. The patient had independently made several unsuccessful attempts to stop GHB use. Following to these failures, the patient was oriented to our addiction department for inpatient detoxification. Withdrawal symptoms appeared 4 hours after the last dose of GHB, and consisted of diaphoresis, coenesthetic hallucinations, tremors, motor instability, tachycardia, and a hypertensive peak. Symptoms were successfully managed with diazepam titration and nonpharmacological treatment. The duration of hospitalization was 13 days. At discharge, detoxification was complete and the patient was engaged in relapse prevention therapy. Three months after discharge, the patient had maintained abstinence. CONCLUSIONS GHB withdrawal, which can be severe, is better prevented or attenuated by daily medical monitoring and adjustment of treatment dosage. Failure of outpatient detoxification should be included in the indication criteria in the guidelines for inpatient detoxification.
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106
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Pichini S, Busardò FP. Comment on “Direct Monitoring of Exogenous γ-Hydroxybutyric Acid in Body Fluids by NMR Spectroscopy”: Several Issues to Consider When Quantifying γ-Hydroxybutyric Acid in Biological Matrixes. Anal Chem 2018; 90:1044-1045. [DOI: 10.1021/acs.analchem.7b03450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Simona Pichini
- National
Centre on Addiction and Doping, Istituto Superiore di Sanità, 00161,Rome, Italy
| | - Francesco Paolo Busardò
- Unit
of Forensic Toxicology (UoFT), Department of Anatomical, Histological,
Forensic and Orthopedic Sciences, Sapienza University, 00185, Rome, Italy
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107
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Joyce N, MacNeela P, Sarma K, Ryall G, Keenan E. The Experience and Meaning of Problematic ‘G’ (GHB/GBL) Use in an Irish Context: an Interpretative Phenomenological Analysis. Int J Ment Health Addict 2017. [DOI: 10.1007/s11469-017-9851-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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108
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Dias AS, Castro AL, Melo P, Tarelho S, Domingues P, Franco JM. A fast method for GHB-GLUC quantitation in whole blood by GC-MS/MS (TQD) for forensic purposes. J Pharm Biomed Anal 2017; 150:107-111. [PMID: 29220733 DOI: 10.1016/j.jpba.2017.11.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 11/24/2017] [Accepted: 11/28/2017] [Indexed: 11/24/2022]
Abstract
γ-Hydroxybutyric acid (GHB) is an endogenous compound with a historical use, both in licit and illicit terms. Importantly, the post-mortem behavior of GHB has been studied due to the possibility of using this compound as a biomarker for estimating the post-mortem interval (PMI). However, the post-mortem behavior of the recently discovered glucuronated GHB metabolite (GHB-GLUC) has not been studied. Nevertheless, GHB-GLUC may also have potential both to assist in PMI determination and also to increase the window of detection of GHB consumption. In this work, for the first time, a reliable method using GC-MS/MS for the quantification of GHB-GLUC in whole blood samples was developed and validated, with a simple, fast and cheap sample pretreatment. The method proved to be specific, precise, linear in a work range between 200 and 5000ng/mL, with LOD and LOQ of 52.65ng/mL and 200ng/mL, respectively, and an extraction recovery of 51%. Furthermore, the method was applied to a set of real post-mortem blood samples non-related with GHB intoxication and the obtained results were also discussed.
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Affiliation(s)
- Ana S Dias
- National Institute of Legal Medicine and Forensic Sciences, Portugal; Centro de Espectrometria de Massa, Departamento de Química & QOPNA, Universidade de Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.
| | - André L Castro
- National Institute of Legal Medicine and Forensic Sciences, Portugal.
| | - Paula Melo
- National Institute of Legal Medicine and Forensic Sciences, Portugal.
| | - Sónia Tarelho
- National Institute of Legal Medicine and Forensic Sciences, Portugal.
| | - Pedro Domingues
- Centro de Espectrometria de Massa, Departamento de Química & QOPNA, Universidade de Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.
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109
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Antonelli M, Ferrulli A, Sestito L, Vassallo GA, Tarli C, Mosoni C, Rando MM, Mirijello A, Gasbarrini A, Addolorato G. Alcohol addiction - the safety of available approved treatment options. Expert Opin Drug Saf 2017; 17:169-177. [PMID: 29120249 DOI: 10.1080/14740338.2018.1404025] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Alcohol Use Disorders (AUD) is a leading cause of mortality and morbidity worldwide. At present disulfiram, naltrexone and acamprosate are approved for the treatment of AUD in U.S. and Europe. Nalmefene is approved in Europe and sodium oxybate is approved in Italy and Austria only. Baclofen received a 'temporary recommendation for use' in France. AREAS COVERED The safety of the above mentioned medications on liver, digestive system, kidney function, nervous system, pregnancy and lactation and their possible side effects are described and discussed. EXPERT OPINION Mechanism of action and metabolism of these drugs as well as patients' clinical characteristics can affect the safety of treatment. All approved medications are valid tools for the treatment of AUD in patients without advanced liver disease. For some drugs, attention should be paid to patients with renal failure and medications may be used with caution, adjusting the dosage according to kidney function. In patients with AUD and advanced liver disease, at present only baclofen has been formally tested in randomized controlled trials showing its safety in this population.
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Affiliation(s)
- Mariangela Antonelli
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Anna Ferrulli
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy.,b Department of Endocrinology and Metabolic Disease , IRCCS Policlinico San Donato , Milan , Italy
| | - Luisa Sestito
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Gabriele A Vassallo
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Claudia Tarli
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Carolina Mosoni
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Maria M Rando
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Antonio Mirijello
- c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
| | - Antonio Gasbarrini
- d Department of Internal Medicine, Gastroenterology and Hepatology , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Giovanni Addolorato
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy.,d Department of Internal Medicine, Gastroenterology and Hepatology , Università Cattolica del Sacro Cuore , Rome , Italy
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110
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Abstract
The causes of high anion gap metabolic acidosis (HAGMA) are well described in the literature. However, sometimes more frequent causes of HAGMA cannot explain its occurrence.In the case of HAGMA and severe neurological depression in the absence of other causes of HAGMA, clinicians should consider an intoxication with gamma-hydroxybutyrate (GHB) as a possible cause.GHB is endogenous to the mammalian central nervous system (CNS). Synthetic GHB was initially used as an anesthetic but is now only licensed for medical use in a limited number of indications such as the treatment of narcolepsy. Because of its euphoric effects, it became popular for recreational use under the street names: Liquid Ecstasy, Georgia Home Boy, and Liquid G.We describe the clinical case of a patient who suffered from severe neurological depression and HAGMA.
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111
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Busardò FP, Mannocchi G, Giorgetti R, Pellegrini M, Baglio G, Zaami S, Marinelli E, Pichini S. Stability of endogenous GHB in vitreous humor vs peripheral blood in dead bodies. Forensic Sci Int 2017; 274:64-69. [DOI: 10.1016/j.forsciint.2016.12.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/09/2016] [Accepted: 12/19/2016] [Indexed: 01/05/2023]
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112
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Tittarelli R, Pichini S, Pedersen DS, Pacifici R, Moresco M, Pizza F, Busardò FP, Plazzi G. Ultra-high-performance liquid chromatography tandem mass spectrometry determination of GHB, GHB-glucuronide in plasma and cerebrospinal fluid of narcoleptic patients under sodium oxybate treatment. Forensic Sci Int 2017; 274:70-74. [DOI: 10.1016/j.forsciint.2017.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/09/2017] [Accepted: 01/14/2017] [Indexed: 12/13/2022]
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113
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Dignam G, Bigham C. Novel psychoactive substances: a practical approach to dealing with toxicity from legal highs. BJA Educ 2017. [DOI: 10.1093/bjaed/mkw068] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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114
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The everlasting issue of GHB cut-offs in biological samples: How important it is to be careful when interpreting values. Forensic Sci Int 2017; 279:e14-e15. [PMID: 28284677 DOI: 10.1016/j.forsciint.2017.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/22/2017] [Indexed: 11/23/2022]
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115
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Mehling LM, Piper T, Spottke A, Heidbreder A, Young P, Madea B, Thevis M, Hess C. GHB-O-β-glucuronide in blood and urine is not a suitable tool for the extension of the detection window after GHB intake. Forensic Toxicol 2017. [DOI: 10.1007/s11419-016-0352-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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116
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Busardò FP, Kyriakou C, Marchei E, Pacifici R, Pedersen DS, Pichini S. Ultra-high performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) for determination of GHB, precursors and metabolites in different specimens: Application to clinical and forensic cases. J Pharm Biomed Anal 2017; 137:123-131. [PMID: 28110168 DOI: 10.1016/j.jpba.2017.01.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 12/27/2016] [Accepted: 01/07/2017] [Indexed: 11/25/2022]
Abstract
Gamma-hydroxybutyric acid (GHB) acts as a precursor and metabolite of the inhibitory central nervous system (CNS) neurotransmitter gamma-aminobutyric acid (GABA). Sodium salt of GHB has been used as a medication for narcolepsy and alcohol withdrawal. Moreover, GHB and its precursor gamma-butyrolactone (GBL), are illegal recreational drugs of abuse. A procedure based on ultra-high-performance liquid chromatography tandem mass spectrometry has been developed and validated in plasma, urine, cerebrospinal fluid and hair for acute and chronic exposure to GHB and in seized preparations coming from black market. In biological matrices, GHB was investigated together with its glucuronide (GHB-Gluc) as a potential marker of exposure, GABA as endogenous precursor and metabolite and GBL as eventual exogenous precursor. GBL was sought together with GHB in illegal preparations. Chromatographic separation was achieved at ambient temperature using a reverse-phase column and an isocratic elution with two solvents: 0.1% formic acid in water and pure methanol. Multiple reaction monitoring (MRM) was used. The method was linear for all analytes under investigation from limit of quantification (LOQ) to 500μgmL-1 plasma, urine and cerebrospinal fluid, from LOQ to 100ngmg-1 hair and from LOQ to 10mgmL-1 illicit preparations with good correlation coefficients (r2=0.99) for all substances. Recovery of analytes under investigation was always higher than 75% and intra-assay and inter-assay precision and accuracy were always better than 15%. The validated method was then successfully applied to real specimens from either forensic (one post-mortem urine sample taken from a GHB fatal intoxication case) or clinical cases (cerebrospinal fluid, plasma and hair samples collected from narcoleptic patients under sodium oxybate treatment). Finally, illicit preparations, seized by police forces were also checked for GHB amount and eventual presence of prodrug GBL.
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Affiliation(s)
- Francesco Paolo Busardò
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, V. Le Regina Elena 336, 00161 Rome, Italy.
| | - Chrystalla Kyriakou
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, V. Le Regina Elena 336, 00161 Rome, Italy
| | - Emilia Marchei
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, V. le Regina Elena 299, 00161 Rome, Italy
| | - Roberta Pacifici
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, V. le Regina Elena 299, 00161 Rome, Italy
| | - Daniel Sejer Pedersen
- Faculty of Health and Medical Sciences, Department of Drug Design and Pharmacology, Jagtvej 162, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Simona Pichini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, V. le Regina Elena 299, 00161 Rome, Italy
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117
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Giorgetti R, Tagliabracci A, Schifano F, Zaami S, Marinelli E, Busardò FP. When "Chems" Meet Sex: A Rising Phenomenon Called "ChemSex". Curr Neuropharmacol 2017; 15:762-770. [PMID: 27855594 PMCID: PMC5771052 DOI: 10.2174/1570159x15666161117151148] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/17/2016] [Accepted: 11/04/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The term "chemsex" was coined to indicate the voluntary intake of psychoactive and non psychoactive drugs in the context of recreational settings to facilitate and/or to enhance sexual intercourses mostly among men who have sex with other men (MSM). OBJECTIVE The authors aimed to review the mechanisms of action, the toxicity and the pattern of use and abuse of substances involved in "chemsex" practice together with the sociocultural background underlying it and the health-related consequences that they may have. RESULTS Gamma-hydroxybutyrate, gamma-butyrolactone,1,4-butanediol, mephedrone, methamphetamine, sildenafil, tadalafil, vardenafil and alkyl nitrites have been described in their role of "chemsex drugs" including pharmacological action and in their implication to impair capacities to chose sexual partners and consensual sex. Moreover, it has been demonstrated that sexual activity over protracted length of time under the influence of chemsex drugs can result in rectal trauma or penile abrasions and a significant increase of the risk of transmission of sexual transmitted diseases, especially in case of condomless intercourses, which are frequent in this context, representing therefore a serious health threat. CONCLUSION One of the major problems to establish health policy priority interventions for chemsex is the lack of available epidemiological data on the issue. Finally, social actions should be taken in order to break down the barriers that currently exist among chemsex drug users in accessing services, including the shame and stigma often associated with drug use. In conclusion, more specific resources to face high risks of infections and HIV transmission are required in bisexual and homosexual individuals having SUID: sex under the influence of drugs.
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Affiliation(s)
- Raffaele Giorgetti
- Section of Legal Medicine, Università Politecnica delle Marche, Ancona, Italy
| | | | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, College Lane Campus, University of Hertfordshire, Hatfield, Herts, AL10 9AB, UK
| | - Simona Zaami
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Enrico Marinelli
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Paolo Busardò
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
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118
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Kamal RM, van Noorden MS, Wannet W, Beurmanjer H, Dijkstra BAG, Schellekens A. Pharmacological Treatment in γ-Hydroxybutyrate (GHB) and γ-Butyrolactone (GBL) Dependence: Detoxification and Relapse Prevention. CNS Drugs 2017; 31:51-64. [PMID: 28004314 DOI: 10.1007/s40263-016-0402-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The misuse of γ-hydroxybutyrate (GHB) for recreational purposes has resulted in an increase in GHB-related problems such as intoxications, dependence and withdrawal in several countries in Europe, Australia and the US over the last decade. However, prevalence rates of misuse of GHB and its precursor, γ-butyrolactone (GBL), are still relatively low. In this qualitative review paper, after a short introduction on the pharmacology of GHB/GBL, followed by a summary of the epidemiology of GHB abuse, an overview of GHB dependence syndrome and GHB/GBL withdrawal syndrome is provided. Finally, the existing literature on management of GHB detoxification, both planned and unplanned, as well as the available management of GHB withdrawal syndrome, is summarized. Although no systematic studies on detoxification and management of withdrawal have been performed to date, general recommendations are given on pharmacological treatment and preferred treatment setting.
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Affiliation(s)
- Rama M Kamal
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Toernooiveld 5, 6525 ED, Nijmegen, The Netherlands.
- Novadic-Kentron Addiction Care Network, Hogedwarsstraat 3, PO Box 243, 5260 AE, Vught, The Netherlands.
| | | | - Wim Wannet
- Scientific Research Committee IrisZorg, Kronenburgsingel 545, 6831 GM, Arnhem, The Netherlands
| | - Harmen Beurmanjer
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Toernooiveld 5, 6525 ED, Nijmegen, The Netherlands
- Novadic-Kentron Addiction Care Network, Hogedwarsstraat 3, PO Box 243, 5260 AE, Vught, The Netherlands
| | - Boukje A G Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Toernooiveld 5, 6525 ED, Nijmegen, The Netherlands
| | - Arnt Schellekens
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Toernooiveld 5, 6525 ED, Nijmegen, The Netherlands
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119
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Kailainathan R, Wong A, Greene S, Koutsogiannis Z. Recognition of gamma-hydroxybutyric acid withdrawal: Rapid progression and prolonged symptomatology. Emerg Med Australas 2016; 29:119-120. [PMID: 28032458 DOI: 10.1111/1742-6723.12721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/28/2016] [Accepted: 11/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Anselm Wong
- Emergency Medicine, Austin Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Victorian Poisons Information Centre, Melbourne, Victoria, Australia.,Toxicology Department, Austin Health, Melbourne, Victoria, Australia
| | - Shaun Greene
- Emergency Medicine, Austin Health, Melbourne, Victoria, Australia.,Victorian Poisons Information Centre, Melbourne, Victoria, Australia.,Toxicology Department, Austin Health, Melbourne, Victoria, Australia
| | - Zeff Koutsogiannis
- Emergency Medicine, Austin Health, Melbourne, Victoria, Australia.,Victorian Poisons Information Centre, Melbourne, Victoria, Australia.,Toxicology Department, Austin Health, Melbourne, Victoria, Australia
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120
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Varlet V. Drug Vaping: From the Dangers of Misuse to New Therapeutic Devices. TOXICS 2016; 4:toxics4040029. [PMID: 29051432 PMCID: PMC5606648 DOI: 10.3390/toxics4040029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/02/2016] [Accepted: 12/13/2016] [Indexed: 11/24/2022]
Abstract
Users of e-cigarettes are unwitting volunteers participating in a worldwide epidemiological study. Because of the obvious benefits of e-cigarettes compared with traditional cigarette smoking, these electronic devices have been introduced all around the world to support tobacco smoking cessation. Same potential harm reduction could be considered by cannabis vaping for marijuana smokers. However, the toxicities of liquids and aerosols remain under investigation because although the use of e-cigarettes is likely to be less harmful than traditional cigarette smoking, trace levels of contaminants have been identified. Simultaneously, other electronic devices, such as e-vaporisers, e-hookahs or e-pipes, have been developed and commercialised. Consequently, misuse of electronic devices has increased, and experimentation has been documented on Internet web fora. Although legal and illegal drugs are currently consumed with these e-devices, no scientific papers are available to support the observations reported by numerous media and web fora. Moreover, building on illegal drug vaping and vaporisation with e-devices (vaping misuse), legal drug vaping (an alternative use of vaping) could present therapeutic benefits, as occurs with medical cannabis vaporisation with table vaporisers. This review seeks to synthesise the problems of e-cigarette and liquid refill toxicity in order to introduce the dangers of illegal and legal drugs consumed using vaping and vaporisation for recreational purposes, and finally, to present the potential therapeutic benefits of vaping as a new administration route for legal drugs.
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Affiliation(s)
- V Varlet
- Forensic Toxicology and Chemistry Unit, University Centre of Legal Medicine Lausanne-Geneva, Lausanne CH-1011, Switzerland.
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121
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Busardò FP, Vaiano F, Mannocchi G, Bertol E, Zaami S, Marinelli E. Twelve months monitoring of hair GHB decay following a single dose administration in a case of facilitated sexual assault. Drug Test Anal 2016; 9:953-956. [PMID: 27682186 DOI: 10.1002/dta.2100] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 09/22/2016] [Accepted: 09/24/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Francesco P Busardò
- Unit of Forensic Toxicology (UoFT) - Department of Anatomical Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy
| | - Fabio Vaiano
- Department of Health Science, University of Florence, Italy
| | - Giulio Mannocchi
- Unit of Forensic Toxicology (UoFT) - Department of Anatomical Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy
| | | | - Simona Zaami
- Department of Anatomical Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy
| | - Enrico Marinelli
- Unit of Forensic Toxicology (UoFT) - Department of Anatomical Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy
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122
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Post-mortem concentrations of drugs determined in femoral blood in single-drug fatalities compared with multi-drug poisoning deaths. Forensic Sci Int 2016; 267:96-103. [DOI: 10.1016/j.forsciint.2016.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/26/2016] [Accepted: 08/05/2016] [Indexed: 11/17/2022]
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123
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Lingford-Hughes A, Patel Y, Bowden-Jones O, Crawford MJ, Dargan PI, Gordon F, Parrott S, Weaver T, Wood DM. Improving GHB withdrawal with baclofen: study protocol for a feasibility study for a randomised controlled trial. Trials 2016; 17:472. [PMID: 27677382 PMCID: PMC5039898 DOI: 10.1186/s13063-016-1593-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/27/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND GHB (gamma-hydroxybutyrate) and its pro-drugs GBL (gamma-butyrolactone) and 1,4-butanediol (1,4-BD) are central nervous system depressants whose street names include 'G' and 'liquid ecstasy'. They are used recreationally predominately for their stimulant and pro-sexual effects or for sedation to help with sleep and/or to 'come down' after using stimulant recreational drugs. Although overall population prevalence is low (0.1 %), in some groups such as men who have sex with men, GHB/GBL use may reach 20 %. GHB/GBL dependence may be associated with severe withdrawal with individuals presenting either acutely to emergency departments or to addiction services for support. Benzodiazepines are currently prescribed for GHB/GBL detoxification but do not prevent all complications, such as behavioural disinhibition, that may require hospitalisation or admission to a high dependency/intensive care unit. The GABAB receptor mediates most effects of GHB/GBL and the GABAB agonist, baclofen, has shown promise as an adjunct to benzodiazepines in reducing withdrawal severity when prescribed both during withdrawal and as a 2-day 'preload' prior to detoxification. The key aim of this feasibility study is provide information about recruitment and characteristics of the proposed outcome measure (symptom severity, complications including delirium and treatment escalation) to inform an application for a definitive randomised placebo controlled trial to determine the role of baclofen in the management of GHB/GBL withdrawal and whether starting baclofen 2 days earlier improves outcomes further. METHODS/DESIGN This is a prospective, randomised, double-blind, placebo-controlled feasibility study that will recruit participants (aged over 18 years) who are GHB/GBL-dependent and wish to undergo planned GHB/GBL detoxification or are at risk of acute withdrawal and are inpatients requiring unplanned withdrawal. We aim to recruit 88 participants: 28 unplanned inpatients and 60 planned outpatients. During detoxification we will compare baclofen 10 mg three times a day with placebo as an adjunct to the usual benzodiazepine regimen. In the planned outpatient arm, we will also compare a 2-day preload of baclofen 10 mg three times a day with placebo. Ratings of GHB/GBL withdrawal, sleep, depression, anxiety as well as GHB/GBL use will be collected. The main data analyses will be descriptive about recruitment and characterising the impact of adding baclofen to the usual benzodiazepine regimen on measures and outcomes of GHB/GBL withdrawal to provide estimates of variability and effect size. A qualitative approach will evaluate research participant and clinician acceptability and data collected to inform cost-effectiveness. DISCUSSION This feasibility study will inform a randomised controlled trial to establish whether adding baclofen to a benzodiazepine regimen reduces the severity and complications of GHB/GBL withdrawal. TRIAL REGISTRATION ISRCTN59911189 . Registered 14 October 2015. PROTOCOL v3.1, 1 February 2016.
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Affiliation(s)
- Anne Lingford-Hughes
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK. .,Centre for Psychiatry, Division of Brain Sciences, Imperial College London, Burlington Danes Building, Hammersmith Hospital site, Du Cane Rd, London, W12 0NN, UK.
| | - Yash Patel
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK
| | - Owen Bowden-Jones
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK
| | - Mike J Crawford
- Central North West London NHS Foundation Trust's Club Drug Clinic, 69 Warwick Rd, London, SW5 9HB, UK.,Centre for Psychiatry, Division of Brain Sciences, Imperial College London, Burlington Danes Building, Hammersmith Hospital site, Du Cane Rd, London, W12 0NN, UK
| | - Paul I Dargan
- Guy's and St. Thomas NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Fabiana Gordon
- Statistical Advisory Service, School Of Public Health, Imperial College London, London, UK
| | - Steve Parrott
- Department of Health Sciences, The University of York, York, UK
| | - Tim Weaver
- Department of Mental Health, Social Work and Integrative Medicine, Middlesex University, London, UK
| | - David M Wood
- Guy's and St. Thomas NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
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124
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Pichini S, Marchei E, Pacifici R, Marinelli E, Busardò FP. Chemsex intoxication involving sildenafil as an adulterant of GHB. Drug Test Anal 2016; 9:956-959. [DOI: 10.1002/dta.2054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Simona Pichini
- Department of Therapeutic Research and Medicines Evaluation; Istituto Superiore di Sanità; Viale Regina Elena 299 00161 Rome Italy
| | - Emilia Marchei
- Department of Therapeutic Research and Medicines Evaluation; Istituto Superiore di Sanità; Viale Regina Elena 299 00161 Rome Italy
| | - Roberta Pacifici
- Department of Therapeutic Research and Medicines Evaluation; Istituto Superiore di Sanità; Viale Regina Elena 299 00161 Rome Italy
| | - Enrico Marinelli
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences; Sapienza University of Rome; Viale Regina Elena 336 00185 Rome Italy
| | - Francesco Paolo Busardò
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences; Sapienza University of Rome; Viale Regina Elena 336 00185 Rome Italy
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125
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Presentations to an urban emergency department in Switzerland due to acute γ-hydroxybutyrate toxicity. Scand J Trauma Resusc Emerg Med 2016; 24:107. [PMID: 27581664 PMCID: PMC5007834 DOI: 10.1186/s13049-016-0299-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/24/2016] [Indexed: 12/02/2022] Open
Abstract
Background γ-Hydroxybutyrate (GHB) is a drug of abuse with dose-dependent sedative effects. Systematic data on the acute toxicity of GHB from emergency department (ED) presentations over a long period of time are currently missing from the literature. The present study described the clinical features of GHB toxicity. Methods Retrospective case series of GHB intoxications seen in an urban ED. Results From January 2002 to September 2015, 78 GHB-related intoxication cases were recorded (71 % male patients). The mean ± SD age was 29 ± 8 years. The co-use of alcohol and/or other illicit drugs was reported in 65 % of the cases. Neurological symptoms other than central nervous system depression included agitation (40 %) and clonus (21 %). The most frequent reasons for admission were coma (64 %) and agitation (23 %). The median time to regain consciousness was 90 min (range, 3–400 min). Sudden recovery was reported in 25 cases (32 %). Coma was not significantly associated with polyintoxication. Coma occurred in 77 % of the alcohol co-users and in 62 % ofthe non-alcohol users (p=0.052). The mean recovery time in comatose patients was 142 min in patients with co-use of alcohol compared with 89 min in patients without alcohol co-use (p=0.07). Alcohol co-use was not significantly associated with nausea/vomiting (p=0.07). The co-use of stimulants was not significantly associated with non-responsive coma (Glasgow Coma Scale = 3) or mean recovery time. Analytical confirmation of GHB was available in 37 cases (47 %), with additional quantitative analysis in 20 cases. The median GHB concentration was 240 mg/L (range, 8.3–373 mg/L). Intoxication was severe in 72 % of the cases. No fatalities occurred, and 72 % of the patients were discharged directly home from the ED. Discussion There were trend associations between alcohol co-use and frequency and length of coma and nausea/vomiting which did not reach the significance level (all p=0.05-0.07) but may nevertheless be clinically relevant. As the exact time of use is not always known, and co-use of other substances can affect the severity of poisoning, no definitive conclusions can be drawn regarding the association between GHB concentration and severity. Conclusion Impaired consciousness and agitation were typical findings of GHB intoxication. The co-use of alcohol and/or other illicit substances is common but was not significantly associated with the severity of the intoxications in our study.
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126
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Wernli C, Finochiaro S, Volken C, Andresen-Streichert H, Buettler A, Gygax D, Salomons GS, Jansen EE, Ainslie GR, Vogel KR, Gibson KM. Targeted screening of succinic semialdehyde dehydrogenase deficiency (SSADHD) employing an enzymatic assay for γ-hydroxybutyric acid (GHB) in biofluids. Mol Genet Metab Rep 2016. [PMID: 28649510 PMCID: PMC5470939 DOI: 10.1016/j.ymgmr.2016.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
HYPOTHESIS An enzymatic assay for quantification of γ-hydroxybutyric acid (GHB) in biofluids can be employed for targeted screening of succinic semialdehyde dehydrogenase deficiency (SSADHD) in selected populations. RATIONALE We used a two-tiered study approach, in which the first study (proof of concept) examined 7 urine samples derived from patients with SSADHD and 5 controls, and the second study (feasibility study) examined a broader sample population of patients and controls, including plasma. OBJECTIVE Split samples of urine and plasma (anonymized) were evaluated by enzymatic assay, gas chromatography alone (proof of concept) and gas chromatography-mass spectrometry, and the results compared. METHOD Multiple detection methods have been developed to detect GHB. We evaluated an enzymatic assay which employs recombinant GHB dehydrogenase coupled to NADH production, the latter quantified on a Cobas Integra 400 Plus. Results: In our proof of concept study, we analyzed 12 urine samples (5 controls, 7 SSADHD), and in the feasibility study we evaluated 33 urine samples (23 controls, 10 SSADHD) and 31 plasma samples (14 controls, 17 SSADHD). The enzymatic assay carried out on a routine clinical chemistry analyzer was robust, revealing excellent agreement with instrumental methods in urine (GC-FID: r = 0.997, p ≤ 0.001; GC-MS: r = 0.99, p ≤ 0.001); however, the assay slightly over-estimated GHB levels in plasma, especially those in which GHB levels were low. Conversely, correlations for the enzymatic assay with comparator methods for higher plasma GHB levels were excellent (GC-MS; r = 0.993, p ≤ 0.001). CONCLUSION We have evaluated the capacity of this enzymatic assay to identify patients with SSADHD via quantitation of GHB. The data suggests that the enzymatic assay may be a suitable screening method to detect SSADHD in selected populations using urine. In addition, the assay can be used in basic research the elucidate the mechanism of the underlying disease or monitor GHB- levels for the evaluation of drug candidates. SYNOPSIS An enzymatic assay for GHB in biofluids was evaluated as a screening method for SSADHD and found to be reliable in urine, but in need of refinement for application to plasma.
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Key Words
- CV, coefficient of variation
- Enzymatic enzyme assay
- GABA, gamma-aminobutyric acid
- GC-FID, gas chromatography-flame ionization detector
- GC–MS, gas chromatography–mass spectrometry
- GHB, gamma-hydroxybutyrate (also γ-hydroxybutyric acid)
- GHBDH, GHB-dehydrogenase
- IDM, isotope dilution method
- LLOQ, lower limit of quantification
- LOD, limit of detection
- NADH, nicotinamide adenine dinucleotide, reduced form
- SSADHD, succinic semialdehyde dehydrogenase deficiency
- Succinic semialdehyde dehydrogenase
- Succinic semialdehyde dehydrogenase deficiency
- r, correlation coefficient (Pearson)
- γ-hydroxybutyric acid
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Affiliation(s)
- C Wernli
- University of Applied Sciences and Arts, Northwestern Switzerland School of Life Sciences, Institute for Chemistry and Bioanalytics, Switzerland
| | - S Finochiaro
- Bildungszentrum Gesundheit Basel-Stadt, Münchenstein, Switzerland.,Zentrallabor, Kantonsspital Baselland, Bruderholz, Switzerland
| | - C Volken
- Zentrallabor, Kantonsspital Baselland, Bruderholz, Switzerland
| | - H Andresen-Streichert
- University Medical Center Hamburg-Eppendorf Institute of Legal Medicine, Department of Toxicology, Hamburg, Germany
| | - A Buettler
- University of Applied Sciences and Arts Northwestern Switzerland School of Life Sciences, Institute for Chemistry and Bioanalytics Muttenz, Switzerland
| | - D Gygax
- University of Applied Sciences and Arts Northwestern Switzerland School of Life Sciences, Institute for Chemistry and Bioanalytics Muttenz, Switzerland
| | - G S Salomons
- Metabolic Unit, Department of Clinical Chemistry, VU University Mediscal Center, Neuroscience Campus, Amsterdam, The Netherlands
| | - E E Jansen
- Metabolic Unit, Department of Clinical Chemistry, VU University Mediscal Center, Neuroscience Campus, Amsterdam, The Netherlands
| | - G R Ainslie
- Division of Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, WA, USA
| | - K R Vogel
- Division of Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, WA, USA
| | - K M Gibson
- Division of Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, WA, USA
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127
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Busardò FP, Bertol E, Mannocchi G, Tittarelli R, Pantano F, Vaiano F, Baglio G, Kyriakou C, Marinelli E. Determination of GHB levels in breast milk and correlation with blood concentrations. Forensic Sci Int 2016; 265:172-81. [DOI: 10.1016/j.forsciint.2016.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022]
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128
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White CM. Pharmacologic, Pharmacokinetic, and Clinical Assessment of Illicitly Used γ-Hydroxybutyrate. J Clin Pharmacol 2016; 57:33-39. [PMID: 27198055 DOI: 10.1002/jcph.767] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 11/11/2022]
Abstract
γ-Hydroxybutyrate (GHB) is a common drug of abuse and poses important health risks to users in the form of respiratory, cardiovascular, mental, or traumatic adverse events. GHB has non-dose-proportional effects and pharmacologic effects such as sedation and retrograde amnesia, which can incapacitate people targeted for assault. It has Krebs cycle metabolism, rapid clearance, relative hydrophilicity, and unique drug interactions. Promptly seeking medical attention during intentional or inadvertent overdose is critical to survival, as is prompt supportive care once medical personnel are alerted. People drugged before assault also need to promptly notify authorities because the period to detect the drug in the urine or blood is brief and the ultimate metabolites are carbon dioxide and water. After acute treatment has passed, withdrawal could be severe in chronic abusers that could harm the patient directly or drive them back into reuse.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy and Hartford Hospital Department of Pharmacy, Storrs, CT, USA
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129
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Caputo F, Maremmani AGI, Addolorato G, Domenicali M, Zoli G, D'Amore A, Maremmani I, Bernardi M. Sodium oxybate plus nalmefene for the treatment of alcohol use disorder: A case series. J Psychopharmacol 2016; 30:402-9. [PMID: 26860331 DOI: 10.1177/0269881116629126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The treatment of alcohol use disorder still remains a challenge. The efficacy of the combined pharmacological treatment for alcohol use disorder has been widely investigated with controversial results. The aim of our case series was to investigate the effect of nalmefene in patients not responding to sodium oxybate therapy. We describe seven cases of consecutive patients affected by alcohol use disorder, and treated with sodium oxybate (50 mg/kg per day) who did not achieve complete alcohol abstinence after at least one month of pharmacological treatment. Then, in partial- and non-responder patients to sodium oxybate treatment, administration of nalmefene, 18 mg as needed, was commenced. Our data show that, during the first month of the combined treatment of sodium oxybate plus nalmefene, patients were able to achieve alcohol abstinence (two patients), to suppress (five cases) or reduce (two patients) episodes of heavy drinking days, and to suppress the onset of craving for sodium oxybate (one patient). Likely, nalmefene may act in modulating the excessive reward effect of sodium oxybate, which may be responsible for the persistence of alcohol intake and for the onset of craving for sodium oxybate. However, controlled clinical trials to confirm the safety and efficacy of sodium oxybate plus nalmefene in treating alcohol use disorder are warranted.
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Affiliation(s)
- Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy 'G Fontana' Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Bologna, Italy
| | - Angelo G I Maremmani
- Vincent P Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Giovanni Addolorato
- Alcohol Use Disorders Unit, Department of Internal Medicine, Catholic University of Rome, Rome, Italy
| | - Marco Domenicali
- 'G Fontana' Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Bologna, Italy
| | - Giorgio Zoli
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy
| | - Antonio D'Amore
- Centre for The Treatment of Alcoholism, Region of Campania, Aversa, Italy
| | - Icro Maremmani
- Vincent P Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Mauro Bernardi
- 'G Fontana' Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Bologna, Italy
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130
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Busardò FP. The importance of hair testing in GHB facilitated sexual assault cases. J Forensic Leg Med 2016; 39:74-5. [DOI: 10.1016/j.jflm.2016.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
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131
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Caputo F, Vignoli T, Tarli C, Domenicali M, Zoli G, Bernardi M, Addolorato G. A Brief Up-Date of the Use of Sodium Oxybate for the Treatment of Alcohol Use Disorder. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E290. [PMID: 26959045 PMCID: PMC4808953 DOI: 10.3390/ijerph13030290] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/08/2016] [Accepted: 02/23/2016] [Indexed: 01/01/2023]
Abstract
The treatment of alcohol use disorder (AUD) with sodium oxybate (SMO) or gamma-hydroxybutyric acid (GHB) was introduced in Italy and Austria more than 20 years and 15 years ago, respectively, and it is now widely employed to treat alcohol withdrawal syndrome (AWS) and to maintain alcohol abstinence. These indications derive from its similar structure to the inhibitory neurotransmitter γ-amino-butyric acid (GABA), exerting an ethanol-mimicking effect, because it binds to GABAB receptors. Craving for, and abuse of, SMO remain a controversial issue; even though these unfavorable effects are evident in poly-drug addicted patients and in those with psychiatric diagnosis of borderline personality disorder. In addition, despite cases of severe intoxication and deaths being widely documented when GHB is used as "street drug"; its clinical use remains safe. Thus, the aim of the present review is to examine the role of SMO in the treatment of AUD, its possible implications in reducing alcohol consumption, and cases of abuse, and severe intoxication due to SMO during its clinical use in the treatment of AUD.
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Affiliation(s)
- Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara 44042, Italy.
- "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Bologna 40130, Italy.
| | - Teo Vignoli
- Unit for Addiction Treatment, Department of Mental Health, Lugo, Ravenna 48022, Italy.
| | - Claudia Tarli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Catholic University of Rome, Rome 00168, Italy.
| | - Marco Domenicali
- "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Bologna 40130, Italy.
| | - Giorgio Zoli
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara 44042, Italy.
| | - Mauro Bernardi
- "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Bologna 40130, Italy.
| | - Giovanni Addolorato
- Alcohol Use Disorders Unit, Department of Internal Medicine, Catholic University of Rome, Rome 00168, Italy.
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132
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Jones AW. Impact of Trauma, Massive Blood Loss and Administration of Resuscitation Fluids on a Person's Blood-Alcohol Concentration and Rate of Ethanol Metabolism. Acad Forensic Pathol 2016; 6:77-88. [PMID: 31239874 DOI: 10.23907/2016.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/30/2015] [Accepted: 12/05/2015] [Indexed: 11/12/2022]
Abstract
Excessive drinking and drunkenness are tightly linked to many types of intentional and unintentional injuries involving trauma and blood loss, which often necessitate emergency medical intervention. This article considers the impact of trauma, massive blood loss, and the administration of life-saving replacement fluids on a person's blood alcohol concentration (BAC) and rate of ethanol metabolism. Both German and English language journals were reviewed and results from animal experiments, human studies, and actual victims of trauma undergoing life-saving treatment were considered. If trauma-related bleeding occurs when some ingested alcohol remains unabsorbed in the stomach, then under these circumstances continued absorption into portal venous blood is delayed, owing to altered splanchnic circulation. Hemodilution caused by administration of replacement fluids has only minimal effects on a preexisting BAC, because ethanol distributes into the total body water (TBW) compartment, which represents 50-60% of body weight. After hypovolemia there is a transfer of fluids from tissue compartments into the blood, which becomes more like plasma in composition with lower hematocrit and hemoglobin content. Unless the trauma or emergency treatment impedes hepatic blood flow, the rate of ethanol metabolism is not expected to differ from normal values, namely 0.10-0.25 g/L/h (0.01-0.025 g% per h). If ethanol is fully absorbed and distributed in all body fluids and tissues, neither massive blood loss nor administration of resuscitating fluids is expected to have any significant effect on a preexisting BAC or the rate of ethanol metabolism.
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Affiliation(s)
- Alan W Jones
- Department of Clinical Pharmacology, Faculty of Medicine, University of Linköping, Sweden
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133
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Bosch OG, Seifritz E. The behavioural profile of gamma-hydroxybutyrate, gamma-butyrolactone and 1,4-butanediol in humans. Brain Res Bull 2016; 126:47-60. [PMID: 26855327 DOI: 10.1016/j.brainresbull.2016.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 01/28/2016] [Accepted: 02/02/2016] [Indexed: 01/24/2023]
Abstract
Gamma-hydroxybutyrate (GHB) is a putative neurotransmitter, a drug of abuse, and a medical treatment for narcolepsy and other neuropsychiatric disorders. Its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD) are endogenously converted to GHB and thereby exert their psychobehavioural effects. In humans, GHB has a wide spectrum of properties ranging from stimulation and euphoria in lower doses, to sedation, deep sleep, and coma after ingestion of high doses. However, behavioural studies in healthy volunteers remain scarce and are usually limited to psychomotor performance testing. Most available data arise from either qualitative studies with illicit users or clinical trials examining therapeutic properties of GHB (then usually termed sodium oxybate). Here, we present an overview of the behavioural effects of GHB, GBL, and 1,4-BD in these three populations. GHB and its precursors strongly influence behaviours related to core human autonomic functions such as control of food intake, sexual behaviour, and sleep-wake regulation. These effects are instrumentalised by illicit users and clinically utilised in neuropsychiatric disorders such as narcolepsy, fibromyalgia, and binge-eating syndrome. Considering the industry withdrawal from psychopharmacology development, repurposing of drugs according to their behavioural and clinical profiles has gained increasing relevance. As such, GHB seems to be an attractive candidate as an experimental therapeutic in depression.
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Affiliation(s)
- Oliver G Bosch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Zurich University Hospital for Psychiatry, Lenggstrasse 31, 8032 Zurich, Switzerland.
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Zurich University Hospital for Psychiatry, Lenggstrasse 31, 8032 Zurich, Switzerland
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134
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Mehling LM, Johansen SS, Wang X, Doberentz E, Madea B, Hess C. Drug facilitated sexual assault with lethal outcome: GHB intoxication in a six-year-old girl. Forensic Sci Int 2016; 259:e25-31. [DOI: 10.1016/j.forsciint.2015.12.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
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135
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Maitre M, Klein C, Mensah-Nyagan AG. Mechanisms for the Specific Properties of γ-Hydroxybutyrate in Brain. Med Res Rev 2016; 36:363-88. [PMID: 26739481 DOI: 10.1002/med.21382] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 11/17/2015] [Accepted: 11/25/2015] [Indexed: 12/12/2022]
Abstract
γ-Hydroxybutyrate (GHB) is both a natural brain compound with neuromodulatory properties at central GABAergic synapses (micromolar concentration range) and also a drug (Xyrem(R) ) clinically used for the treatment of various neurological symptoms (millimolar dose range). However, this drug has abuse potential and can be addictive for some patients. Here, we review the basic mechanistic role of endogenous GHB in brain as well as the properties and mechanisms of action for therapeutic clinical doses of exogenous GHB. Several hypotheses are discussed with a preference for a molecular mechanism that conciliates most of the findings available. This conciliatory model may help for the design of GHB-like drugs active at lower doses and devoid of major side effects.
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Affiliation(s)
- Michel Maitre
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine, 11 rue Humann, 67000, Strasbourg, France
| | - Christian Klein
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine, 11 rue Humann, 67000, Strasbourg, France
| | - Ayikoe G Mensah-Nyagan
- Biopathologie de la Myéline, Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine, 11 rue Humann, 67000, Strasbourg, France
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