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Procida A, Honeychurch KC. Smartphone‐based colorimetric determination of gamma‐butyrolactone and gamma‐hydroxybutyrate in alcoholic beverage samples. J Forensic Sci 2022; 67:1697-1703. [PMID: 35368091 PMCID: PMC9324852 DOI: 10.1111/1556-4029.15042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/07/2022] [Accepted: 03/22/2022] [Indexed: 12/01/2022]
Abstract
Gamma‐hydroxybutyrate (GBH) is a popular recreational drug. Its strong sedative and amnesic effects have led to drug‐facilitated sexual assaults, poisonings, overdose, and death. As a result, legislation has restricted its availability leading to GHB, consumers switching to its pro‐drug, gamma‐butyrolactone (GBL). Consequently, there is a growing need for methods capable of their determination in complex samples such as beverages. Previous studies have shown the possibility to colorimetrically qualitatively determine both GBH and GBL by the formation of the lactone and its reaction with hydroxylamine and ferric chloride to give a purple‐colored complex. In this present investigation, we have shown the possibility of using this approach to both quantify GBL and GHB using both UV/Vis spectrometry and by the application of the camera of a smartphone to record images of the purple color developed. Via subsequent use of a downloadable free App, to extract the numerical values of the Red, Green, and Blue (RGB) color components, it was shown possible to construct a calibration curve and to quantitatively determine the concentration of the drugs present in fortified alcoholic beverage samples. It was found that by simple mathematical normalization of the RGB values the effects of camera distance and elimination could be readily overcome. Using the smartphone approach, GBL determinations on a sample of lager beer gave a mean recovery of 103% (%CV = 0.70%, n = 5) at a concentration of 0.56 mg/ml indicating the method holds promise for the determination of GBL and GHB in such samples.
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Affiliation(s)
- Anselmo Procida
- Department of Applied Sciences, Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Kevin C. Honeychurch
- Department of Applied Sciences, Faculty of Health and Applied Sciences University of the West of England Bristol UK
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Abid M, Kietzerow J, Iwersen-Bergmann S, Schnitgerhans T, Andresen-Streichert H. Characteristics and dose-effect relationship of clinical gamma-hydroxybutyrate intoxication: A case series. J Forensic Sci 2021; 67:416-427. [PMID: 34523720 DOI: 10.1111/1556-4029.14880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/20/2021] [Accepted: 08/17/2021] [Indexed: 11/27/2022]
Abstract
Gamma-Hydroxybutyrate (GHB) overdoses cause respiratory depression, coma, or even death. Symptoms and severity of poisoning depend on blood-concentrations and individual factors such as tolerance. A retrospective case study was conducted, evaluating GHB intoxication cases. GHB-concentrations in blood and urine were determined by gas chromatography-mass spectrometry (GC-MS) along with, in part, via enzymatic assay. GHB-concentrations, demographic data, and additional drug use, as well as specific clinical information, were evaluated. The correlation between GHB-levels in blood and associated symptoms were examined. In total, 75 cases originating from the Emergency Departments (EDs) of Hamburg and surrounding hospitals were included. Fifty-four of the patients (72%) were male. The mean GHB-concentration in blood was 248 mg/L (range 21.5-1418 mg/L). Out of the group with detailed clinical information (n = 18), the comatose group (n = 10/18) showed a mean of 244 mg/L (range 136-403 mg/L), which was higher than that of the somnolent and awake patients. Of the comatose collective, 70% (n = 7) showed co-use of one or more substances, with the additional use of cocaine being the most frequently detected (n = 5). In conclusion, a moderate dose-effect relationship was observed, although, there was some overlap in dosage concentration levels of GHB in awake and comatose patients. In GHB-intoxication cases, co-use was common as were clinical effects such as acidosis, hypotension, and impact on the heart rate. Timely analytical determination of the GHB-concentration in blood could support correct diagnosis of the cause of unconsciousness.
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Affiliation(s)
- Madelaine Abid
- Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jana Kietzerow
- Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Stefanie Iwersen-Bergmann
- Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tino Schnitgerhans
- Department of Internal Medicine, Asklepios-Klinik Nord - Heidberg, Hamburg, Germany
| | - Hilke Andresen-Streichert
- Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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Wang X. Potential application of BC3 nanotubes as a gamma-hydroxybutyric acid drug sensor: A DFT study. COMPUT THEOR CHEM 2021. [DOI: 10.1016/j.comptc.2021.113299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Severe Metabolic Failures After Recreational Ingestion of γ-Butyrolactone. J Clin Psychopharmacol 2021; 40:624-626. [PMID: 33009224 DOI: 10.1097/jcp.0000000000001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stefani M, Fulde S, McCrohon J, Roberts DM. Transient accelerated idioventricular rhythm after 1,4-butanediol exposure. Clin Toxicol (Phila) 2020; 58:1071-1072. [DOI: 10.1080/15563650.2020.1728296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, Australia
- St Vincent’s Clinical School, University of NSW, Sydney, Australia
| | - Sascha Fulde
- St Vincent’s Clinical School, University of NSW, Sydney, Australia
- Department of Emergency Medicine, St Vincent’s Hospital, Sydney, Australia
| | - Jane McCrohon
- St Vincent’s Clinical School, University of NSW, Sydney, Australia
- Department of Cardiology, St Vincent’s Hospital, Sydney, Australia
| | - Darren M. Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, Australia
- St Vincent’s Clinical School, University of NSW, Sydney, Australia
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Luo Q, Nazarian Shahrbabaki A. γ-Hydroxybutyric acid drug recognition by palladium decorated silicon carbide monolayer. INORG CHEM COMMUN 2020. [DOI: 10.1016/j.inoche.2020.108135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Umar M, Morey S, Gerostamoulos D, Wong A. Massive gamma hydroxybutyrate overdose resulting in severe metabolic acidosis requiring continuous venovenous haemofiltration. Emerg Med Australas 2020; 32:898-899. [PMID: 32767539 DOI: 10.1111/1742-6723.13599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Sarah Morey
- Department of Toxicology, Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia
| | - Dimitri Gerostamoulos
- Department of Toxicology, Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre, Austin Toxicology and Emergency Department, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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Ling-Yan W, Ai-Min L, Hamreh S. Gamma-butyrolactone drug detection by Al-doped BC 3 nanotubes: A density functional theory study. J Mol Graph Model 2020; 99:107632. [PMID: 32417724 DOI: 10.1016/j.jmgm.2020.107632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/20/2020] [Accepted: 05/01/2020] [Indexed: 11/29/2022]
Abstract
Potential application of a pristine and Al-doped BC3 nanotube (Al-BC3NT) is explored in detection of gamma-butyrolactone (GBL) drug using DFT calculations. The GBL drug weakly adsorbed of the pristine BC3NT with adsorption energy (Ead) of -11.7 kcal/mol. The electronic properties of pristine BC3NT were not altered sensibly by the GBL adsorption, indicating that this tube is not a sensor. By Al-doping in the structure of BC3NT, the GBL interaction was strengthened (Ead = -21.8 kcal/mol). The Eg of Al-BC3NT dramatically declined from 2.38 to 1.93 eV, by GBL interaction. The electrical conductance of GBL/Al-BC3NT was 681 times higher than that of the bare Al-BC3NT. Thus, the Al-BC3NT yields an electronic signal after the GBL drug adsorption, being a promising electronic sensor. The recovery time for GBL drug desorption from the Al-BC3NT surface was predicted to be short (0.9 s). The interaction between the GBL and Al-BC3NT was strengthened in the ethanol solvent, and the Ead became more negative (-28.9 kcal/mol).
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Affiliation(s)
- Wang Ling-Yan
- Chenzhou Vocational Technical College, ChenZhou, Hunan, 423000, China.
| | - Liu Ai-Min
- Chenzhou Vocational Technical College, ChenZhou, Hunan, 423000, China
| | - Sajad Hamreh
- Department of Physics, Tarbiat Modares University, Tehran, Iran
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Abstract
Context: 1,4-butanediol (1,4-BD) is a gamma-hydroxybutyrate (GHB) analogue with a similarly narrow therapeutic window that is becoming a more common cause of recreational overdose. Reports of confirmed exposures are limited.Case details: A 44 year-old man who had consumed alcohol subsequently became unconscious after ingesting what was thought to be GHB. The presentation was not entirely consistent with GHB poisoning, including a longer duration of unconsciousness and features that mimicked toxic alcohol exposure including a high anion gap metabolic acidosis (HAGMA) and osmol gap. The patient was treated supportively with intubation, haemodiafiltration and intravenous ethanol until the diagnosis was refined using specific laboratory testing. The concentration of 1,4-BD was the highest reported in the literature and the outcome favourable.Discussion: This case highlights pharmacokinetic issues peculiar to 1,4-BD, including the interaction with ethanol which delays the onset of psychoactive effects from 1,4-BD's metabolite GHB, and dose-dependent pharmacokinetics. In overdose, 1,4-BD can induce a HAGMA and other features of toxic alcohol poisoning. Managing an unconscious patient with these features can prompt certain treatments until the diagnosis is refined, which can require specific laboratory testing to identify the culprit. The actual risk of toxic alcohol and other causes is adjusted on a case-by-case basis from the history of exposure and local epidemiology of substance use and poisoning.
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Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
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Smith RL, Cohen SM, Fukushima S, Gooderham NJ, Hecht SS, Guengerich FP, Rietjens IMCM, Bastaki M, Harman CL, McGowen MM, Taylor SV. The safety evaluation of food flavouring substances: the role of metabolic studies. Toxicol Res (Camb) 2018; 7:618-646. [PMID: 30090611 PMCID: PMC6062396 DOI: 10.1039/c7tx00254h] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/21/2018] [Indexed: 12/13/2022] Open
Abstract
The safety assessment of a flavour substance examines several factors, including metabolic and physiological disposition data. The present article provides an overview of the metabolism and disposition of flavour substances by identifying general applicable principles of metabolism to illustrate how information on metabolic fate is taken into account in their safety evaluation. The metabolism of the majority of flavour substances involves a series both of enzymatic and non-enzymatic biotransformation that often results in products that are more hydrophilic and more readily excretable than their precursors. Flavours can undergo metabolic reactions, such as oxidation, reduction, or hydrolysis that alter a functional group relative to the parent compound. The altered functional group may serve as a reaction site for a subsequent metabolic transformation. Metabolic intermediates undergo conjugation with an endogenous agent such as glucuronic acid, sulphate, glutathione, amino acids, or acetate. Such conjugates are typically readily excreted through the kidneys and liver. This paper summarizes the types of metabolic reactions that have been documented for flavour substances that are added to the human food chain, the methodologies available for metabolic studies, and the factors that affect the metabolic fate of a flavour substance.
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Affiliation(s)
- Robert L Smith
- Molecular Toxicology , Imperial College School of Medicine , London SW7 2AZ , UK
| | - Samuel M Cohen
- Dept. of Pathology and Microbiology , University of Nebraska Medical Centre , 983135 Nebraska Medical Centre , Omaha , NE 68198-3135 , USA
| | - Shoji Fukushima
- Japan Bioassay Research Centre , 2445 Hirasawa , Hadano , Kanagawa 257-0015 , Japan
| | - Nigel J Gooderham
- Dept. of Surgery and Cancer , Imperial College of Science , Sir Alexander Fleming Building , London SW7 2AZ , UK
| | - Stephen S Hecht
- Masonic Cancer Centre and Dept. of Laboratory Medicine and Pathology , University of Minnesota , Cancer and Cardiovascular Research Building , 2231 6th St , SE , Minneapolis , MN 55455 , USA
| | - F Peter Guengerich
- Department of Biochemistry , Vanderbilt University School of Medicine , 638B Robinson Research Building , 2200 Pierce Avenue , Nashville , Tennessee 37232-0146 , USA
| | - Ivonne M C M Rietjens
- Division of Toxicology , Wageningen University , Tuinlaan 5 , 6703 HE Wageningen , The Netherlands
| | - Maria Bastaki
- Flavor and Extract Manufacturers Association , 1101 17th Street , NW Suite 700 , Washington , DC 20036 , USA . ; ; Tel: +1 (202)293-5800
| | - Christie L Harman
- Flavor and Extract Manufacturers Association , 1101 17th Street , NW Suite 700 , Washington , DC 20036 , USA . ; ; Tel: +1 (202)293-5800
| | - Margaret M McGowen
- Flavor and Extract Manufacturers Association , 1101 17th Street , NW Suite 700 , Washington , DC 20036 , USA . ; ; Tel: +1 (202)293-5800
| | - Sean V Taylor
- Flavor and Extract Manufacturers Association , 1101 17th Street , NW Suite 700 , Washington , DC 20036 , USA . ; ; Tel: +1 (202)293-5800
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Soichot M, Devos P, Malissin I, Grondin C, Oppon C, Bourgogne E, Mégarbane B. Intoxication massive à la γ-butyrolactone (GBL) : une étiologie méconnue d’acidose métabolique sévère à trou anionique élevé. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2017.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kamal RM, van Noorden MS, Franzek E, Dijkstra BAG, Loonen AJM, De Jong CAJ. The Neurobiological Mechanisms of Gamma-Hydroxybutyrate Dependence and Withdrawal and Their Clinical Relevance: A Review. Neuropsychobiology 2016; 73:65-80. [PMID: 27003176 DOI: 10.1159/000443173] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/29/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE x03B3;-Hydroxybutyrate (GHB) has gained popularity as a drug of abuse. In the Netherlands the number of patients in treatment for GHB dependence has increased sharply. Clinical presentation of GHB withdrawal can be life threatening. We aim, through this overview, to explore the neurobiological pathways causing GHB dependency and withdrawal, and their implications for treatment choices. METHODS In this work we review the literature discussing the findings from animal models to clinical studies focused on the neurobiological pathways of endogenous but mainly exogenous GHB. RESULTS Chronic abuse of GHB exerts multifarious neurotransmitter and neuromodulator effects on x03B3;-aminobutyric acid (GABA), glutamate, dopamine, serotonin, norepinephrine and cholinergic systems. Moreover, important effects on neurosteroidogenesis and oxytocin release are wielded. GHB acts mainly via a bidirectional effect on GABAB receptors (GABABR; subunits GABAB1 and GABAB2), depending on the subunit of the GIRK (G-protein-dependent ion inwardly rectifying potassium) channel involved, and an indirect effect of the cortical and limbic inputs outside the nucleus accumbens. GHB also activates a specific GHB receptor and β1-subunits of α4-GABAAR. Reversing this complex interaction of neurobiological mechanisms by the abrupt cessation of GHB use results in a withdrawal syndrome with a diversity of symptoms of different intensity, depending on the pattern of GHB abuse. CONCLUSION The GHB withdrawal symptoms cannot be related to a single mechanism or neurological pathway, which implies that different medication combinations are needed for treatment. A single drug class, such as benzodiazepines, gabapentin or antipsychotics, is unlikely to be sufficient to avoid life-threatening complications. Detoxification by means of titration and tapering of pharmaceutical GHB can be considered as a promising treatment that could make polypharmacy redundant.
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Affiliation(s)
- Rama M Kamal
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
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36th International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 24-27 May, 2016, Madrid, Spain. Clin Toxicol (Phila) 2016; 54:344-519. [DOI: 10.3109/15563650.2016.1165952] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gamma hydroxybutyrate (GHB), gamma butyrolactone (GBL) and 1,4-butanediol (1,4-BD; BDO): A literature review with a focus on UK fatalities related to non-medical use. Neurosci Biobehav Rev 2015; 53:52-78. [PMID: 25843781 DOI: 10.1016/j.neubiorev.2015.03.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 03/08/2015] [Accepted: 03/25/2015] [Indexed: 11/22/2022]
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van Amsterdam J, Brunt T, Pennings E, van den Brink W. Risk assessment of GBL as a substitute for the illicit drug GHB in the Netherlands. A comparison of the risks of GBL versus GHB. Regul Toxicol Pharmacol 2014; 70:507-13. [PMID: 25204614 DOI: 10.1016/j.yrtph.2014.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 12/15/2022]
Abstract
In the Netherlands, γ-hydroxybutyric acid (GHB) was recently banned, but γ-butyrolactone (GBL) was not. As such, GBL remained a legal alternative to GHB. This review compares the risks of GBL and GHB. Pure GBL is per unit of volume about threefold stronger and therefore threefold more potent than currently used GHB-preparations in the Netherlands. Like GHB, GBL use hardly leads to organ toxicity, although, as with GHB, frequent GBL use may lead to repeated comas that may result in residual impairments in cognitive function and memory. Little is known about the prevalence of GBL use in Europe, but the recent increase in improper trading in GBL confirms that users of GHB gradually switch to the use of GBL. This shift may result in an increase in the number GBL dependent users, because the dependence potential of GBL is as great as that of GHB. Severe withdrawal symptoms and a high relapse rate are seen following cessation of heavy GBL use. GBL-dependent users seem to be severe (dependent, problematic) GHB users who started using GBL, the legal GHB substitute. Subjects who are solely dependent to GBL are rarely reported. About 5-10% of the treatment seeking GHB dependent subjects also use GBL and this subpopulation forms a vulnerable group with multiple problems. Fatal accidents with GBL are rarely reported, but non-fatal GHB (or GBL) overdoses frequently occur for which supportive treatment is needed. It is recommended to monitor the recreational use of GBL, the rate of GBL dependence treatment, and the improper trading of GBL.
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Affiliation(s)
- Jan van Amsterdam
- Amsterdam Institute for Addiction Research, Academic Medical Center University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands; Amsterdam Institute for Addiction Research, Academic Medical Center, P.O. Box 75867, 1070 AW Amsterdam, The Netherlands.
| | - Tibor Brunt
- Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Da Costakade 45, 3521 VS Utrecht, The Netherlands
| | - Ed Pennings
- The Maastricht Forensic Institute, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Wim van den Brink
- Amsterdam Institute for Addiction Research, Academic Medical Center University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands; Amsterdam Institute for Addiction Research, Academic Medical Center, P.O. Box 75867, 1070 AW Amsterdam, The Netherlands
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Determination of gamma-hydroxybutyric acid in biofluids using a one-step procedure with “in-vial” derivatization and headspace-trap gas chromatography–mass spectrometry. J Chromatogr A 2013; 1296:84-92. [DOI: 10.1016/j.chroma.2013.04.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/09/2013] [Accepted: 04/11/2013] [Indexed: 01/15/2023]
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XXXIII International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 28–31 May 2013, Copenhagen, Denmark. Clin Toxicol (Phila) 2013. [DOI: 10.3109/15563650.2013.785188] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Zhai D, Agrawalla BK, Eng PSF, Lee SC, Xu W, Chang YT. Development of a fluorescent sensor for an illicit date rape drug – GBL. Chem Commun (Camb) 2013; 49:6170-2. [DOI: 10.1039/c3cc43153c] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Schep LJ, Knudsen K, Slaughter RJ, Vale JA, Mégarbane B. The clinical toxicology of γ-hydroxybutyrate, γ-butyrolactone and 1,4-butanediol. Clin Toxicol (Phila) 2012; 50:458-70. [PMID: 22746383 DOI: 10.3109/15563650.2012.702218] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Gamma-hydroxybutyrate (GHB) and its precursors, gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD), are drugs of abuse which act primarily as central nervous system (CNS) depressants. In recent years, the rising recreational use of these drugs has led to an increasing burden upon health care providers. Understanding their toxicity is therefore essential for the successful management of intoxicated patients. We review the epidemiology, mechanisms of toxicity, toxicokinetics, clinical features, diagnosis, and management of poisoning due to GHB and its analogs and discuss the features and management of GHB withdrawal. METHODS OVID MEDLINE and ISI Web of Science databases were searched using the terms "GHB," "gamma-hydroxybutyrate," "gamma-hydroxybutyric acid," "4-hydroxybutanoic acid," "sodium oxybate," "gamma-butyrolactone," "GBL," "1,4-butanediol," and "1,4-BD" alone and in combination with the keywords "pharmacokinetics," "kinetics," "poisoning," "poison," "toxicity," "ingestion," "adverse effects," "overdose," and "intoxication." In addition, bibliographies of identified articles were screened for additional relevant studies including nonindexed reports. Non-peer-reviewed sources were also included: books, relevant newspaper reports, and applicable Internet resources. These searches produced 2059 nonduplicate citations of which 219 were considered relevant. EPIDEMIOLOGY There is limited information regarding statistical trends on world-wide use of GHB and its analogs. European data suggests that the use of GHB is generally low; however, there is some evidence of higher use among some sub-populations, settings, and geographical areas. In the United States of America, poison control center data have shown that enquiries regarding GHB have decreased between 2002 and 2010 suggesting a decline in use over this timeframe. MECHANISMS OF ACTION GHB is an endogenous neurotransmitter synthesized from glutamate with a high affinity for GHB-receptors, present on both on pre- and postsynaptic neurons, thereby inhibiting GABA release. In overdose, GHB acts both directly as a partial GABA(b) receptor agonist and indirectly through its metabolism to form GABA. TOXICOKINETICS GHB is rapidly absorbed by the oral route with peak blood concentrations typically occurring within 1 hour. It has a relatively small volume of distribution and is rapidly distributed across the blood-brain barrier. GHB is metabolized primarily in the liver and is eliminated rapidly with a reported 20-60 minute half-life. The majority of a dose is eliminated completely within 4-8 hours. The related chemicals, 1,4-butanediol and gamma butyrolactone, are metabolized endogenously to GHB. CLINICAL FEATURES OF POISONING: GHB produces CNS and respiratory depression of relatively short duration. Other commonly reported features include gastrointestinal upset, bradycardia, myoclonus, and hypothermia. Fatalities have been reported. MANAGEMENT OF POISONING: Supportive care is the mainstay of management with primary emphasis on respiratory and cardiovascular support. Airway protection, intubation, and/or assisted ventilation may be indicated for severe respiratory depression. Gastrointestinal decontamination is unlikely to be beneficial. Pharmacological intervention is rarely required for bradycardia; however, atropine administration may occasionally be warranted. WITHDRAWAL SYNDROME: Abstinence after chronic use may result in a withdrawal syndrome, which may persist for days in severe cases. Features include auditory and visual hallucinations, tremors, tachycardia, hypertension, sweating, anxiety, agitation, paranoia, insomnia, disorientation, confusion, and aggression/combativeness. Benzodiazepine administration appears to be the treatment of choice, with barbiturates, baclofen, or propofol as second line management options. CONCLUSIONS GHB poisoning can cause potentially life-threatening CNS and respiratory depression, requiring appropriate, symptom-directed supportive care to ensure complete recovery. Withdrawal from GHB may continue for up to 21 days and can be life-threatening, though treatment with benzodiazepines is usually effective.
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Affiliation(s)
- Leo J Schep
- National Poisons Centre, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
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