Baclofen in gamma-hydroxybutyrate withdrawal: patterns of use and online availability

A case of severe and prolonged γ-hydroxybutyrate (GHB) withdrawal syndrome successfully managed with a slow benzodiazepine and baclofen taper

INTRODUCTION

γ-hydroxybutyrate (GHB) is a GABA-B agonist that rapidly produces effects that are likened to both alcohol and MDMA/ecstasy. GHB use can lead to neuroadaptation with a characteristic withdrawal syndrome. There is currently a paucity of data on the progression of GHB withdrawal, however, due to the drug's short half-life it is generally considered to be typically 5-7 days, although some cases can be severe and complicated by life threatening delirium. Here, we present a case of severe GHB withdrawal, which recurred on multiple occasions over 56 days, despite initial clinical stabilisation on each occasion and toxicological evidence of abstinence from GHB between episodes.

CASE PRESENTATION

A male patient in his 30s presented with agitated delirium on a background of severe GHB use disorder with a 15-year history of daily high dose GHB use. Following 3 hospital admissions over 8 weeks, all requiring intravenous sedation and tracheal intubation, the patient's withdrawal delirium was successfully treated with a slow benzodiazepine and baclofen wean over a period of 6 months. Relapse to GHB use between hospitalisations was excluded toxicologically via blood analysis performed at an institute of forensic pathology.

DISCUSSION AND CONCLUSIONS

This case highlights that GHB withdrawal can be more prolonged than previously reported in the literature and in some cases may require slow and prolonged tapering of treatment to prevent re-emergence of delirium. Similar to previous case reports, benzodiazepines and GABA-B receptor agonists appear to be appropriate drug classes to manage GHB withdrawal.

GHB: a life-threatening drug complications and outcome of GHB detoxification treatment-an observational clinical study

BACKGROUND

GHB (gammahydroxybutyrate) and its precursors are popular recreational drugs due to their sedative, anxiolytic and sexually stimulating effects. Their use has been steadily increasing in recent years. The detoxification process is complex and prone to high rates of complications while little is known about the pathophysiology. This study aims to elucidate the characteristics of GHB-addicted patients and to evaluate the risks and complications of GHB withdrawal treatment.

METHODS

This observational study describes prospectively the socioeconomic status, clinical history and course of inpatient detoxification treatment of a group of 39 patients suffering from GHB substance use disorder. Detoxification treatment took place in a highly specialized psychiatric inpatient unit for substance use disorders.

RESULTS

GHB patients were characterised by being young, well-educated and by living alone. More than 50% of the patients had no regular income. The patients were male and female in equal numbers. Detoxification treatment was complicated, with high rates of delirium (30.8%) and high need for intensive care (20.5%).

CONCLUSIONS

In our sample, GHB users were young, well-educated people and male and female in equal number. Detoxification proved to be dangerous for GHB-addicted patients. The presence of delirium and the need for transfer to an intensive care unit during detoxification treatment was extraordinarily high, even with appropriate clinical treatment. The reasons for this remain unknown. Therefore an intensive care unit should be available for GHB detoxification treatment. Further studies are needed to evaluate the options for prophylactic treatment of delirium during detoxification.

Misuse of Over the Counter and Prescription Only Medication by Adults Accessing Specialist Treatment Services in the UK: A Narrative Synthesis

Background

Concerns about the misuse of over the counter (OTC) and prescription only medication (POM) are due to their impact upon physical/mental wellbeing, drug interactions and drug-related deaths. Improving an understanding of the pattern of use by people accessing specialist substance misuse services (SMSs) should enable improvements to treatment provision.

Aim

To review the literature on the misuse of OTC/POM among adults accessing SMS, including the pattern of use, types of medication and associated characteristics.

Methods

This review is reported in line with PRISMA. The protocol has been registered on PROSPERO (CRD42020135216) and separately published. A search of Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases and grey literature was undertaken. Only English language publications outlining OTC/POM misuse by adults in receipt of psychological/pharmacological interventions for substance misuse were included. Two reviewers conducted the title, abstract and full-text reviews using predetermined selection criteria and a piloted data extraction form to ensure a consistent approach. A third reviewer resolved disagreements and the Mixed Methods Appraisal Tool assessed for bias. Ethical approval was not required.

Results

Thirteen studies with notable heterogeneity were included in the narrative synthesis after non-UK-based and ineligible publications were excluded, from the 143 potentially relevant papers. To reduce bias all studies were included in the analysis and GRADE-CERQual was applied. 'High confidence' was identified for all review findings, despite moderate methodological limitations. Antihistamine, benzodiazepine and opioid misuse was mentioned most frequently. Usage patterns and supply sources varied. Adverse consequences and polypharmacy are concerning. Withdrawal symptoms perpetuated misuse, often alongside illicit substance use, comorbid psychiatric/pain disorders and street drug shortages.

Conclusion

OTC/POM misuse is common amongst adults accessing SMS. A renewed approach to withdrawal management is required. The limited number of studies may impact on generalisability but allowed for a more detailed review. Restricting to UK studies improved relevance due to drug market variations and availability of medicines in different countries. Further UK-based research on OTC/POM misuse in SMS is needed to build upon the current paucity in the published literature.

Online Pharmacies Selling Prescription Drugs: Systematic Review

Introduction: The patronage of online pharmacies is rapidly growing, driven by the convenience and cheaper costs of purchasing prescription drugs electronically, especially under the lockdown situation. However, there are issues regarding the quality of the prescription drugs sold online and the legitimacy of online pharmacies. The use of prescription drugs without the supervision of a licensed health care practitioner may potentially harm consumers. Objectives: This systematic review was conducted to improve the body of knowledge on three main aspects of online pharmacies: (1) type and characteristics of the online pharmacies selling drugs; (2) the quality of pharmaceutical drugs purchased online; and (3) the characteristics of consumers of online pharmacies. Methods: Based on a pre-defined search strategy, PubMed and Scopus were utilised to search articles written in the English language published between January 2009 and February 2020. Studies focusing on the sale of prescription drugs were included. The terms used for the literature search were “online pharmacy”, “internet pharmacy”, “e-pharmacy”, “prescription”, “quality”, “medication safety”, and “counterfeit medicine”. These terms were used alone and in combination with Boolean operators. The institutional webpages including the World Health Organization (WHO) and the United States Food and Drug Administration (USFDA) were also examined for any additional studies. No methodological limitations in terms of study design were applied. A standardised data collection form was used to compile the data. Results: Based on the inclusion and exclusion criteria, a total of 46 articles were eligible and included in the final analysis. There were 27 articles on types and characteristic of online pharmacies, 13 articles on the quality of prescription drugs sold from online pharmacies, and 11 articles on consumers purchasing prescription drugs from online pharmacies. Readers should note that five articles discussed both the types and characteristics of online pharmacies, and the quality of the drugs sold from the outlets. The response rate (products received out of the number of orders) ranged from 20% to 100%, whereas the proportion of consumers buying prescription drugs online ranged from 2.3% to 13%. Reasons for online purchase of prescription drugs include the difficulty of obtaining a prescription for certain medications such as opioid analgesics, cheaper cost, since the costs associated with seeing a physician to obtain a prescription are reduced, and the need to obtain drugs such as opioid analgesics and benzodiazepine for misuse. Conclusions: Almost half of the online pharmacies are not properly regulated and fraudulent issues were uncovered. To address this issue, stricter regulation by World Health Organization and implementation should be carried out together with frequent monitoring of the licensure system and pharmacy verification on every online pharmacy, this would reduce the number of illegal or illegitimate online pharmacy.

Surveying Over the Counter and Prescription Only Medication Misuse in Treatment Services During COVID-19

Background:

A greater understanding of Over the Counter (OTC) and Prescription Only Medication (POM) misuse amongst adults accessing substance misuse services (SMS) during COVID-19 is required to identify how SMS can better meet the needs of the people who require treatment.

Aim:

To use a questionnaire to explore OTC/POM misuse during COVID-19 in adults accessing community SMS in England.

Methods:

In 2020 to 2021 anonymous self-administered online/paper questionnaires which collated quantitative and qualitative data were completed. They were piloted for suitability and ethical approval was obtained. Thematic analysis was conducted for qualitative data and chi-square tests used to assess the relationship between quantitative variables.

Results:

Participants were Caucasian (94.6% British), majority male (58.9%), aged 18 to 61 years. Most were prescribed medication for problematic substance use, with a 92.5% self-reported adherence rate. The misuse of benzodiazepines (22.2%) codeine products (30.8%) and pregabalin (14.5%) predominated and 37.5% misused 2 or more medicines. Administration was usually oral and concomitant use of other substances was common: alcohol 44.6% (52% daily), tobacco/vaping 73.2% and illicit substances 58.9%. There were statistically significant associations identified, including between changes during COVID-19 to OTC/POM misuse and illicit use. Only 56 questionnaires were included in the analysis: we believe this low number was because of infection control measures, limited footfall in services, pressures on staff limiting their capacity to distribute the paper questionnaires and reliance upon telephone consultations limiting online distribution. Increasing OTC/POM misuse and obtaining illicit supplies were reported when access to usual supplies were restricted; however, changes to doses/dispensing arrangement liberalisation in response to COVID-19 were positively viewed.

Conclusion:

OTC/POM misuse, including polypharmacy and concomitant use of other substances occurred during COVID-19: SMS need to be vigilant for these issues and mitigate the associated risks for example with harm reduction interventions. Further qualitative research is required to explore the issues identified.

Misuse of medication in adult substance misuse services: a systematic review protocol

INTRODUCTION

There is a growing concern about the misuse of over the counter (OTC) and prescription only medication (POM) because of the impact on physical and mental health, drug interactions, overdoses and drug-related deaths. These medicines include opioid analgesics, anxiolytics such as pregabalin and diazepam and antidepressants. This protocol outlines how a systematic review will be undertaken (during June 2021), which aims to examine the literature on the pattern of OTC and POM misuse among adults who are accessing substance misuse treatment services. It will include the types of medication being taken, prevalence and demographic characteristics of people who access treatment services.

METHODS AND ANALYSIS

An electronic search will be conducted on the Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases as well as grey literature. Two independent reviewers will conduct the initial title and abstract screenings, using predetermined criteria for inclusion and exclusion. If selected for inclusion, full-text data extraction will be conducted using a pilot-tested data extraction form. A third reviewer will resolve disagreements if consensus cannot be reached. Quality and risk of bias assessment will be conducted for all included studies. A qualitative synthesis and summary of the data will be provided. If possible, a meta-analysis with heterogeneity calculation will be conducted; otherwise, Synthesis Without Meta-analysis will be undertaken for quantitative data. The reporting of this protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be peer reviewed, published and shared verbally, electronically and in print, with interested clinicians and policymakers.

PROSPERO REGISTRATION NUMBER

CRD42020135216.

Successful Management of Gamma-hydroxybutyrate (GHB) Withdrawal Using Baclofen as a Standalone Therapy: A Case Report

BACKGROUND

Gamma-hydroxybutyrate (GHB)-a GABA-B agonist-can lead to a use disorder, and a withdrawal syndrome similar to that of alcohol. At present, evidence is lacking for how to best manage GHB withdrawal, and often clinicians rely on alcohol withdrawal management approaches, using medications like benzodiazepines (BZD). However, BZD doses needed to control GHB withdrawal symptoms are typically much higher than those required for alcohol, posing significant safety risks. Novel approaches include the use of baclofen as an adjunct to BZD, allowing reductions in BZD requirements. While the use of baclofen as monotherapy may result in even greater risk reductions, research to support this approach is limited.

CASE

We present a case of a 26-year-old female with severe GHB use disorder and history of severe withdrawal symptoms, whose withdrawal was successfully, managed using baclofen alone.

CONCLUSION

In keeping with other case reports, baclofen appears to have potential to be used in the management of GHB withdrawal. Here, we presented a case of severe GHB withdrawal which was managed solely by baclofen. Clinical research is needed to evaluate baclofen's potential as a standalone treatment for GHB withdrawal.