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Dufayet L, Bargel S, Bonnet A, Boukerma AK, Chevallier C, Evrard M, Guillotin S, Loeuillet E, Paradis C, Pouget AM, Reynoard J, Vaucel JA. Gamma-hydroxybutyrate (GHB), 1,4-butanediol (1,4BD), and gamma-butyrolactone (GBL) intoxication: A state-of-the-art review. Regul Toxicol Pharmacol 2023; 142:105435. [PMID: 37343712 DOI: 10.1016/j.yrtph.2023.105435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
γ-hydroxybutyrate (GHB) is synthesized endogenously from γ-aminobutyric acid (GABA) or exogenously from 1,4-butanediol (butane-1,4-diol; 1,4-BD) or γ-butyrolactone (GBL). GBL, and 1,4-BD are rapidly converted to GHB. The gastric absorption time, volume of distribution, and half-life of GHB are between 5 and 45 min, 0.49 ± 0.9 L/kg, and between 20 and 60 min, respectively. GHB and its analogues have a dose-dependent effect on the activation of GHB receptor, GABA-B, and GABA localized to the central nervous system. After ingestion, most patients present transient neurological disorders (lethal dose: 60 mg/kg). Chronic GHB consumption is associated with disorders of use and a withdrawal syndrome when the consumption is discontinued. GHB, GBL, and 1,4-BD are classified as narcotics but only the use of GHB is controlled internationally. They are used for drug facilitated (sexual) assault, recreational purposes, slamsex, and chemsex. To confirm an exogenous intake or administration of GHB, GBL, or 1-4-BD, the pre-analytical conservation is crucial. The antemortem cutoff doses for detection are 5 and 5-15 mg/L, with detection windows of 6 and 10 h in the blood and urine, respectively Control of GHB is essential to limit the number of users, abuse, associated risks, and death related to their consumption.
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Affiliation(s)
- Laurene Dufayet
- Unité Médico-judiciaire, Hôtel-Dieu, APHP, 75001, Paris, France; Centre Antipoison de Paris - Fédération de Toxicologie (FeTox), Hôpital Fernand-Widal, APHP, 75010, Paris, France; INSERM, UMRS-1144, Faculté de Pharmacie, 75006, Paris, France; UFR de Médecine, Université de Paris, 75010, Paris, France.
| | - Sophie Bargel
- Section Toxicologie - Sécurité Routière, Laboratoire de Police Scientifique de Lille, SNPS, France
| | - Anastasia Bonnet
- Centre Antipoison de Toulouse, CHU de Toulouse, Toulouse, France
| | | | | | - Marion Evrard
- Centre Antipoison de Nancy, CHRU de Nancy, Nancy, France
| | - Sophie Guillotin
- Centre Antipoison de Toulouse, CHU de Toulouse, Toulouse, France
| | | | - Camille Paradis
- Centre Antipoison de Bordeaux CHU de Bordeaux, Bordeaux, France
| | | | - Julien Reynoard
- Pharmacologie Clinique CAP-TV, APHM, Hôpitaux Sud, Marseille, France
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Wolf CJH, Venselaar H, Spoelder M, Beurmanjer H, Schellekens AFA, Homberg JR. An Overview of the Putative Structural and Functional Properties of the GHBh1 Receptor through a Bioinformatics Approach. Life (Basel) 2023; 13:life13040926. [PMID: 37109455 PMCID: PMC10142108 DOI: 10.3390/life13040926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
The neurotransmitter γ-hydroxybutyric acid (GHB) is suggested to be involved in neuronal energy homeostasis processes, but the substance is also used as a recreational drug and as a prescription medication for narcolepsy. GHB has several high-affinity targets in the brain, commonly generalized as the GHB receptor. However, little is known about the structural and functional properties of GHB receptor subtypes. This opinion article discusses the literature on the putative structural and functional properties of the GHBh1 receptor subtype. GHBh1 contains 11 transmembrane helices and at least one intracellular intrinsically disordered region (IDR). Additionally, GHBh1 shows a 100% overlap in amino acid sequence with the Riboflavin (vitamin B2) transporter, which opens the possibility of a possible dual-function (transceptor) structure. Riboflavin and GHB also share specific neuroprotective properties. Further research into the GHBh1 receptor subtype may pave the way for future therapeutic possibilities for GHB.
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Affiliation(s)
- Casper J. H. Wolf
- Department of Psychiatry, Radboudumc, 6525 GC Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Donders Institute for Brain Cognition and Behaviour, Radboudumc, 6525 EN Nijmegen, The Netherlands
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), 6525 HR Nijmegen, The Netherlands
| | - Hanka Venselaar
- Center for Molecular and Biomolecular Informatics, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Marcia Spoelder
- Department of Primary and Community Care, Radboudumc, 6525 GC Nijmegen, The Netherlands
| | - Harmen Beurmanjer
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), 6525 HR Nijmegen, The Netherlands
- Behavioural Science Institute, Radboud University, 6525 GD Nijmegen, The Netherlands
- Novadic-Kentron Addiction Care, 5261 LX Vught, The Netherlands
| | - Arnt F. A. Schellekens
- Department of Psychiatry, Radboudumc, 6525 GC Nijmegen, The Netherlands
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), 6525 HR Nijmegen, The Netherlands
| | - Judith R. Homberg
- Department of Cognitive Neuroscience, Donders Institute for Brain Cognition and Behaviour, Radboudumc, 6525 EN Nijmegen, The Netherlands
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Inpatient GHB withdrawal management in an inner-city hospital in Sydney, Australia: a retrospective medical record review. Psychopharmacology (Berl) 2023; 240:127-135. [PMID: 36508055 PMCID: PMC9816228 DOI: 10.1007/s00213-022-06283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
RATIONALE Regular consumption of gamma-hydroxybutyrate (GHB) may result in a dependence syndrome that can lead to withdrawal symptoms. There are limited data on medications to manage GHB withdrawal. OBJECTIVES To examine characteristics associated with delirium and discharge against medical advice (DAMA), in the context of implementing a GHB withdrawal management protocol at an inner-city hospital in 2020. METHODS We retrospectively reviewed records (01 January 2017-31 March 2021), and included admissions that were ≥ 18 years of age, admitted for GHB withdrawal, and with documented recent GHB use. Admissions were assessed for demographics, medications administered, features of delirium, ICU admission, and DAMA. Exploratory analyses were conducted to examine factors associated (p < 0.2) with features of delirium and DAMA. RESULTS We identified 135 admissions amongst 91 patients. Medications administered included diazepam (133 admissions, 98.5%), antipsychotics (olanzapine [70 admissions, 51.9%]), baclofen (114 admissions, 84%), and phenobarbital (8 admissions, 5.9%). Features of delirium were diagnosed in 21 (16%) admissions. Delirium was associated with higher daily GHB consumption prior to admission, while duration of GHB use, time from presentation to first dose of diazepam, and concomitant methamphetamine use were inversely associated with delirium. DAMA occurred amongst 41 (30%) admissions, and was associated with a longer time from presentation to first dose of baclofen, while being female and receiving a loading dose of diazepam were inversely associated. CONCLUSIONS This study adds to the literature in support of the safety and feasibility of diazepam and baclofen for the management of GHB withdrawal. Prospective, randomised trials are required.
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Acide γ-Hydroxybutyrique (GHB), γ-butyrolactone (GBL) et 1,4-butanediol (1,4-BD) : revue de la littérature des aspects pharmacologiques, cliniques, analytiques et médico-légaux. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2022. [DOI: 10.1016/j.toxac.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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van Amsterdam J, Brunt TM, Pereira FR, Crunelle CL, van den Brink W. Cognitive Impairment Following Clinical or Recreational Use of Gammahydroxybutyric Acid (GHB): A Systematic Review. Curr Neuropharmacol 2022; 20:809-819. [PMID: 34151766 PMCID: PMC9878963 DOI: 10.2174/1570159x19666210610094352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/24/2021] [Accepted: 05/05/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND GHB (gamma-hydroxybutyric acid; sodium oxybate) is a general anaesthetic that is clinically used for the treatment of narcolepsy, cataplexy, alcohol withdrawal and alcohol relapse prevention. In addition, GHB is recreationally used. Most clinical and recreational users regard GHB as an innocent drug devoid of adverse effects, despite its high dependence potential and possible neurotoxic effects. At high doses, GHB may lead to a comatose state. This paper systematically reviews possible cognitive impairments due to clinical and recreational GHB use. METHODS PubMed and PsychINFO were searched for literature data about the acute and residual cognitive deficits following GHB use. This review is conducted using the PRISMA protocol. RESULTS A total of 43 reports covering human and animal data on GHB-induced cognitive impairments were eligible and reviewed. This systematic review found no indication for cognitive impairments after clinical GHB use. However, it supports the view that moderate GHB use may result in acute short-term cognitive impairments, whereas regular high-dose GHB use and/or multiple GHB-induced comas are probably neurotoxic resulting in long-term residual cognitive impairments. CONCLUSION These results emphasize the need for awareness among clinicians and recreational users to minimize negative health consequences of recreational GHB use, particularly when high doses are used and GHB-induced comas occur.
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Affiliation(s)
- Jan van Amsterdam
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands;,Address correspondence to this author at the Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands; E-mails: ;
| | - Tibor M. Brunt
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Filipa R. Pereira
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Cleo L. Crunelle
- Department of Psychiatry, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Wim van den Brink
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
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Tay E, Lo WKW, Murnion B. Current Insights on the Impact of Gamma-Hydroxybutyrate (GHB) Abuse. Subst Abuse Rehabil 2022; 13:13-23. [PMID: 35173515 PMCID: PMC8843350 DOI: 10.2147/sar.s315720] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/05/2022] [Indexed: 01/23/2023] Open
Affiliation(s)
- Emma Tay
- Drug Health Services, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Wing Kwan Winky Lo
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bridin Murnion
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Correspondence: Bridin Murnion, Drug Health Services, Western Sydney Local Health District, 4A Fleet Street, North Parramatta, NSW, 2151, Australia, Tel +61 2 9840 3888, Fax +61 2 9840 3927, Email
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Ishikawa O, Hahn S, Greenberg H. Pharmacologic Therapy for Narcolepsy. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Narcolepsy is a lifelong disorder that adversely affects daytime function and quality of life. Major symptoms include excessive daytime sleepiness with irrepressible sleep attacks and cataplexy. Recent developments in the understanding of the pathobiology of narcolepsy, as well as the neuronal systems involved in the regulation of wakefulness have led to development of new pharmacologic approaches to therapy. In this paper, we review available pharmacologic treatments for narcolepsy as well as agents currently under investigation.
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Kjærgaard MF, Videbech P, Nørbæk JJ, Ebdrup BH. Gamma-hydroxybutyric acid-induced organic delirium complicated by polydrug use successfully treated with electroconvulsive therapy: a case report. J Med Case Rep 2021; 15:596. [PMID: 34911580 PMCID: PMC8675448 DOI: 10.1186/s13256-021-03182-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 11/03/2021] [Indexed: 12/03/2022] Open
Abstract
Background Patients with gamma-hydroxybutyric acid withdrawal symptoms are at high risk of developing organic delirium, which can be fatal. The recommended first-line treatment is benzodiazepines, but treatment-resistant cases are frequent. Here we describe a case of successful bilateral electroconvulsive therapy in a patient with severe and highly agitated acute organic delirium induced by gamma-hydroxybutyric acid withdrawal and complicated by polydrug use resistant to first-line treatment. To our knowledge, this is the first report on the effect of electroconvulsive therapy on treatment-resistant delirium caused by gamma-hydroxybutyric acid withdrawal. Case presentation A 21-year-old Danish man diagnosed with untreated attention deficit hyperactivity disorder developed severely agitated acute organic delirium caused by gamma-hydroxybutyric acid withdrawal in a Danish psychiatric ward. The patient was subjected to physical restraints and transferred to the intensive care unit for treatment. During the next 10 days, the patient showed no clinical improvement despite first-line, high-dose benzodiazepines along with intense supportive treatment with propofol, phenobarbital, and antipsychotics. On day 11, bilateral frontotemporal electroconvulsive therapy treatment was initiated and full clinical recovery was obtained after four sessions. Discussion The full clinical remission after four electroconvulsive therapy sessions, strongly supports that electroconvulsive therapy may be an effective treatment when severe delirium induced by gamma-hydroxybutyric acid withdrawal is resistant to conventional first-line treatment with benzodiazepines. Moreover, this case illustrates that clinically effective seizures were achieved despite intensive concurrent exposure to anticonvulsive drugs. Therefore, this case report encourages consideration of electroconvulsive therapy in patients with gamma-hydroxybutyric acid delirium who are resistant to psychopharmacological treatment.
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Affiliation(s)
- Mads F Kjærgaard
- Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Poul Videbech
- Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark.,Center for Neuropsychiatric Depression Research, CNSR & Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Mental Health Centre Glostrup, University of Copenhagen, Nordstjernevej 41, DK-2600, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Nørbæk
- Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Bjørn H Ebdrup
- Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark. .,Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, and Center for Neuropsychiatric Schizophrenia Research, CNSR, Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark. .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Characterization of the GHB Withdrawal Syndrome. J Clin Med 2021; 10:jcm10112333. [PMID: 34073640 PMCID: PMC8199158 DOI: 10.3390/jcm10112333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022] Open
Abstract
The gamma-hydroxybutyric acid (GHB) withdrawal syndrome can have a fulminant course, complicated by severe complications such as delirium or seizures. Detoxification by tapering with pharmaceutical GHB is a safe way to manage GHB withdrawal. However, a detailed description of the course of the GHB withdrawal syndrome is currently lacking. This study aimed to (1) describe the course of GHB withdrawal symptoms over time, (2) assess the association between vital signs and withdrawal symptoms, and (3) explore sex differences in GHB withdrawal. In this observational multicenter study, patients with GHB use disorder (n = 285) were tapered off with pharmaceutical GHB. The most reported subjective withdrawal symptoms (SWS) were related to cravings, fatigue, insomnia, sweating and feeling gloomy. The most prevalent objective withdrawal symptoms (OWS) were related to cravings, fatigue, tremors, sweating, and sudden cold/warm feelings. No association between vital signs and SWS/OWS was found. Sex differences were observed in the severity and prevalence of specific withdrawal symptoms. Our results suggest that the GHB withdrawal syndrome under pharmaceutical GHB tapering does not strongly differ from withdrawal syndromes of other sedative drugs. The lack of association between vital signs and other withdrawal symptoms, and the relative stability of vitals over time suggest that vitals are not suitable for withdrawal monitoring. The reported sex differences highlight the importance of a personalized approach in GHB detoxification.
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Dijkstra BAG, Beurmanjer H, Goudriaan AE, Schellekens AFA, Joosten EAG. Unity in diversity: A systematic review on the GHB using population. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103230. [PMID: 33892279 DOI: 10.1016/j.drugpo.2021.103230] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Over the past decades gamma-hydroxybutyrate (GHB) has emerged as a popular drug with high potential of (ab)use due to its euphoric and relaxing effects. An overview of different populations using GHB is urgently needed, since this would enable development of adequate prevention and treatment policies to diminish the risks associated with GHB use. We systematically reviewed literature on different GHB using populations, comparing demographic characteristics, GHB use patterns, psychosocial aspects and psychiatric comorbidity. METHODS We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using Rayyan software. Original studies published from January 1997 up to October 2019 on GHB use were included. Out of 80 full-text articles, 60 articles of 51 unique studies were included. Most studies included people using GHB 1) presenting at emergency departments (n = 22), 2) recruited from the general population (n = 11), or 3) presenting at addiction care (n = 8). RESULTS Three main sub-populations of people using GHB are described in the literature: people using GHB recreationally without adverse effects; people using GHB recreationally with adverse effects, and people with dependence on GHB. These groups show considerable overlap in gender, age range, and comorbid substance use, as well as amount of GHB use per occasion. Differences are related to frequency and function of GHB use, the number of comas experienced, as well as work status, and psychiatric comorbidity. CONCLUSION Policy interventions should aim at preventing the transition from recreational substance use to GHB use, as most users are experienced recreational substance users prior to starting GHB use. When people use GHB regularly, interventions should aim at reducing the level of GHB use and preventing GHB use-related harm. Longitudinal studies and population-based probability sampling are required for more insight in the dynamics of GHB use in different sub-populations, and the transition from one group to the other, ultimately leading to dependence on GHB.
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Affiliation(s)
- B A G Dijkstra
- Nijmegen Institute for Scientist-Practitioner in Addiction (NISPA), Radboud University, Nijmegen, the Netherlands; Radboudumc, Department of Psychiatry, Nijmegen, the Netherlands; Novadic-Kentron Addiction Treatment Center, Vught, the Netherlands.
| | - H Beurmanjer
- Nijmegen Institute for Scientist-Practitioner in Addiction (NISPA), Radboud University, Nijmegen, the Netherlands; Novadic-Kentron Addiction Treatment Center, Vught, the Netherlands
| | - A E Goudriaan
- Jellinek and Arkin, Amsterdam, the Netherlands; Amsterdam University Medical Center, Department of Psychiatry, University of Amsterdam, Amsterdam, the Netherlands
| | - A F A Schellekens
- Nijmegen Institute for Scientist-Practitioner in Addiction (NISPA), Radboud University, Nijmegen, the Netherlands; Radboudumc, Department of Psychiatry, Nijmegen, the Netherlands
| | - E A G Joosten
- Nijmegen Institute for Scientist-Practitioner in Addiction (NISPA), Radboud University, Nijmegen, the Netherlands; Radboudumc, Department of Psychiatry, Nijmegen, the Netherlands
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Vos CF, Pop-Purceleanu M, van den Berg MJW, Schellekens AFA. Successful treatment of severe, treatment resistant GHB withdrawal through thiopental-coma. Subst Abus 2020; 42:33-38. [PMID: 33044905 DOI: 10.1080/08897077.2020.1827124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND In patients with gamma-hydroxybutyrate (GHB) use disorder (GUD), withdrawal can have a fulminant course with rapid progression of severe, potentially life-threatening complications. Case: We present a 45-year old man with severe GHB withdrawal, resistant to conventional treatment with pharmaceutical GHB, high doses of benzodiazepines and baclofen. GHB withdrawal finally responded to thiopental-induced coma therapy, with burst suppression pattern on electroencephalography (EEG). The patient fully recovered, without withdrawal or residual neuropsychiatric symptoms. Discussion: To our knowledge, this is the first case report in which barbiturates were used to induce a coma to treat severe, treatment resistant GHB withdrawal. This case suggests barbiturate coma therapy might be considered in severe GHB withdrawal which does not respond to conventional treatment.
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Affiliation(s)
- Cornelis F Vos
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monica Pop-Purceleanu
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Arnt F A Schellekens
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Radboud University, Nijmegen, The Netherlands
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12
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Beurmanjer H, Luykx JJ, De Wilde B, van Rompaey K, Buwalda VJA, De Jong CAJ, Dijkstra BAG, Schellekens AFA. Tapering with Pharmaceutical GHB or Benzodiazepines for Detoxification in GHB-Dependent Patients: A Matched-Subject Observational Study of Treatment-as-Usual in Belgium and The Netherlands. CNS Drugs 2020; 34:651-659. [PMID: 32319006 PMCID: PMC7275016 DOI: 10.1007/s40263-020-00730-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The gamma-hydroxybutyric acid (GHB) withdrawal syndrome often has a fulminant course, with a rapid onset and swift progression of severe complications. In clinical practice, two pharmacological regimens are commonly used to counteract withdrawal symptoms during GHB detoxification: tapering with benzodiazepines (BZDs) or tapering with pharmaceutical GHB. In Belgium, standard treatment is tapering with BZDs, while in the Netherlands, pharmaceutical GHB is the preferred treatment method. Though BZDs are cheaper and readily available, case studies suggest GHB tapering results in less severe withdrawal and fewer complications. OBJECTIVES This study aimed to compare two treatments-as-usual in tapering methods on withdrawal, craving and adverse events during detoxification in GHB-dependent patients. METHODS In this multicentre non-randomised indirect comparison of two treatments-as-usual, patients with GHB dependence received BZD tapering (Belgian sample: n = 42) or GHB tapering (Dutch sample: n = 42, matched historical sample). Withdrawal was assessed using the Subjective and Objective Withdrawal Scales, craving was assessed with a Visual Analogue Scale and adverse events were systematically recorded. Differences in withdrawal and craving were analysed using a linear mixed-model analysis, with 'days in admission' and 'detoxification method' as fixed factors. Differences in adverse events were analysed using a Chi-square analysis. RESULTS Withdrawal decreased over time in both groups. Withdrawal severity was higher in patients receiving BZD tapering (subjective mean = 36.50, standard deviation = 21.08; objective mean = 8.05, standard deviation = 4.68) than in patients receiving pharmaceutical GHB tapering (subjective mean = 15.90; standard deviation = 13.83; objective mean = 3.72; standard deviation = 2.56). No differences in craving were found. Adverse events were more common in the BZD than the GHB group, especially delirium (20 vs 2.5%, respectively). CONCLUSIONS These results support earlier work that BZD tapering might not always sufficiently dampen withdrawal in GHB-dependent patients. However, it needs to be taken into account that both treatments were assessed in separate countries. Based on the current findings, tapering with pharmaceutical GHB could be considered for patients with GHB dependence during detoxification, as it has potentially less severe withdrawal and fewer complications than BZD tapering.
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Affiliation(s)
- Harmen Beurmanjer
- Novadic-Kentron Addictioncare, Hogedwarsstraat 3, 5261, AE, Vught, The Netherlands. .,Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands.
| | - J. J. Luykx
- Ziekenhuis Netwerk Antwerpen (ZNA), Borgerhout, Belgium
| | - B. De Wilde
- Ziekenhuis Netwerk Antwerpen (ZNA), Borgerhout, Belgium ,University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - V. J. A. Buwalda
- Novadic-Kentron Addictioncare, Hogedwarsstraat 3, 5261 AE Vught, The Netherlands
| | - C. A. J. De Jong
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - B. A. G. Dijkstra
- Novadic-Kentron Addictioncare, Hogedwarsstraat 3, 5261 AE Vught, The Netherlands ,Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - A. F. A. Schellekens
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands ,Department of Psychiatry, RadboudUmc, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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Raposo Pereira F, McMaster MTB, de Vries YAT, van den Brink W, van Wingen GA. Demographic and Clinical Characteristics of Regular GHB-Users with and without GHB-Induced Comas. Subst Use Misuse 2020; 55:2148-2155. [PMID: 32772606 DOI: 10.1080/10826084.2020.1793368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Gamma hydroxybutyric acid (GHB) has been used recreationally for nearly three decades and its chronic use is frequently associated with serious adverse events including GHB-intoxication with GHB-induced comas. Moreover, despite its low prevalence, the number of individuals with GHB-use disorders is steadily increasing. However, the risk-factors associated with chronic GHB-use or the development of a GHB-use disorders remain poorly understood. Purpose: This study aims to profile two types of GHB-users, those with and those without GHB-induced comas. Methods: We included 27 GHB users with ≥4 GHB-induced comas (GHB-Coma), 27 GHB users without a coma (GHB-NoComa), and 27 polydrug users who never used GHB (No-GHB). Participants completed self-reported questionnaires in order to assess their demographic and clinical features, and their use profile of GHB and other drugs. Results: The typical GHB user in our sample was young, single, living alone, well-educated, and a student. The GHB-Coma group had lower self-control and reported higher negative affect than the GHB-NoComa group. GHB-Coma participants were heavier GHB users and mostly used GHB alone at home, whereas the GHB-NoComa group mostly used GHB with friends and in nightclubs. Remarkably, the majority of participants were not concerned about potential neurocognitive impairments induced by GHB-intoxication and/or GHB-induced comas. Conclusion: In this assessment, different profiles for recreational users with and without GHB-induced comas were well expressed. Their description contributes to a better understanding of the risk factors associated with recreational GHB-use, GHB-induced coma, and the development of GHB-use disorders.
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Affiliation(s)
- Filipa Raposo Pereira
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands.,Amsterdam Brain and Cognition, University of Amsterdam, The Netherlands
| | - Minni T B McMaster
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands.,Amsterdam Brain and Cognition, University of Amsterdam, The Netherlands
| | - YvonD A T de Vries
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Wim van den Brink
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands.,Amsterdam Brain and Cognition, University of Amsterdam, The Netherlands
| | - Guido A van Wingen
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands.,Amsterdam Brain and Cognition, University of Amsterdam, The Netherlands
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14
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van Mechelen JC, Dijkstra B, Vergouwen A. Severe illicit gamma-hydroxybutyric acid withdrawal in a pregnant woman: what to do? BMJ Case Rep 2019; 12:12/12/e230997. [PMID: 31796453 PMCID: PMC7001713 DOI: 10.1136/bcr-2019-230997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This case report presents the case of a 29 weeks pregnant woman in her late twenties who was seen at the emergency department of a hospital with a seizure of unknown cause. By anamnesis and hetero-anamnesis the use of illicit gamma-hydroxybutyric acid (GHB) was revealed. Examination showed dilated pupils, sweating, tremor, tachycardia and bradyphrenic thinking. Subsequently, the seizure was indicated as a severe illicit GHB withdrawal symptom. Thereafter, treatment had to be decided on in the absence of evidence-based and practiced-based guidelines and treatment options for this specific patient population. Initially diazepam was started, which was later on substituted by sodium oxybate. Despite the critical professional situation the patient gave birth to a healthy daughter after 37 weeks of pregnancy.
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Affiliation(s)
- J C van Mechelen
- Department of Psychiatry and Medical Psychology, OLVG Location West, Amsterdam, North Holland, the Netherlands
| | - Bag Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Radboud University, Nijmegen, Gelderland, the Netherlands.,Research and development, Novadic-Kentron Addiction Care, Vught, Noord-Brabant, the Netherlands
| | - Acm Vergouwen
- Department of Psychiatry and Medical Psychology, OLVG Location West, Amsterdam, North Holland, the Netherlands
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15
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Predictors of Leaving an Inpatient Medical Withdrawal Service Against Medical Advice: A Retrospective Analysis. J Addict Med 2019; 12:453-458. [PMID: 29939875 DOI: 10.1097/adm.0000000000000431] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the frequency and predictors of patients leaving an inpatient medical withdrawal unit against medical advice (AMA). METHODS This study used a case-control design to compare patients who were discharged AMA (n = 164) with those who completed treatment (n = 678). Logistic regression analysis was used to determine which variables were independent predictors of patients leaving AMA. RESULTS We found that being admitted through the emergency department (odds ratio [OR] 3.17, confidence interval [CI] 1.66-6.08), having gamma-hydroxybutyrate (OR 7.61, CI 1.81-32.09) as a primary substance of concern compared to alcohol, and having multiple axis I psychiatric diagnoses (OR 2.20, CI 1.16-4.18) or depression (OR 2.86, CI 1.32-6.17) compared with no psychiatric diagnosis increased the odds of leaving inpatient medical withdrawal AMA. By contrast, not being dependent on nicotine (OR 0.45, CI 0.23-0.88) and increasing time since admission (OR 0.42, CI 0.36-0.48) reduced the odds of leaving AMA. CONCLUSIONS The findings of this study reveal novel information about patients who leave inpatient medical withdrawal AMA and can inform targeted interventions to prevent vulnerable patients from terminating treatment early and improve healthcare service utilization.
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16
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Bühler T, Schmid Y, Liechti ME. [Knockout Drugs: Diagnostics in the Emergency Unit and Clinical Practice]. PRAXIS 2019; 108:869-876. [PMID: 31571536 DOI: 10.1024/1661-8157/a003306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Knockout Drugs: Diagnostics in the Emergency Unit and Clinical Practice Abstract. Every now and then, physicians are challenged with date rape drugs. If there is a suspicion of substance administration, the question of involving forensic medicine is commonly raised. In obscure situations or questionable offences, however, patients may wish for an initial diagnosis in the emergency department or the private practice. The physicians are often greatly challenged by the variety of substances, the limited analytical methods and difficulties with the interpretion of results. The major goal of this article is to present diagnostic options including their limitations. An overview of frequently involved substances is provided. Particular focus will be placed on practical aspects, including questions regarding pre-analytics and health insurance coverage.
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Affiliation(s)
- Tim Bühler
- Abteilung für Klinische Pharmakologie & Toxikologie, Universitätsspital Basel
| | - Yasmin Schmid
- Abteilung für Klinische Pharmakologie & Toxikologie, Universitätsspital Basel
| | - Matthias E Liechti
- Abteilung für Klinische Pharmakologie & Toxikologie, Universitätsspital Basel
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17
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Abstract
Novel drugs of abuse are synthetic illicit drugs, or analogues of known illicit drugs, that can be more potent. Novel drugs of abuse are often labeled as designer drugs, research chemicals, legal highs, or psychoactive substances. They are often sold as designated legal or nondrug products, such as incense, plant food, or bath salts, with labeling such as "Not for Human Consumption" or "For Use in Research Only." The prevalence of use of novel drugs of abuse is difficult to determine because specific drugs, compounds, and availability of these drugs are constantly evolving. Changes in chemical structures lead to heterogeneity in physiologic response and clinical symptoms, even within the same category of drug. Pediatricians and emergency medicine physicians should be knowledgeable about novel drugs of abuse and their resulting symptoms for prevention and identification of their use.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
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18
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Raposo Pereira F, McMaster MT, de Vries YD, Polderman N, van den Brink W, van Wingen GA. Influence of Gamma-Hydroxybutyric Acid-Use and Gamma-Hydroxybutyric Acid-Induced Coma on Affect and the Affective Network. Eur Addict Res 2019; 25:173-181. [PMID: 30999293 PMCID: PMC7050670 DOI: 10.1159/000497381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/30/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gamma-hydroxybutyric acid (GHB) is a drug of abuse associated with increased emergency room attendances, due to GHB-induced comas. Withdrawal from GHB often increases social anxiety and is linked to alterations in emotion processing. However, little is known about the effects of GHB-use and GHB-induced comas on affect regulation in humans. OBJECTIVES We aimed to assess the effect of GHB-use and GHB-induced comas on the affective network. METHOD We recruited 27 GHB users with ≥4 GHB-induced comas (GHB-Coma), 27 GHB users without a GHB-induced coma (GHB-NoComa), and 27 polydrug users who never used GHB (No-GHB). Participants completed self-report questionnaires assessing negative affect (depression, anxiety and stress) and performed an emotional face matching task during functional magnetic resonance imaging to probe activity of the amygdala and the hippocampus. RESULTS The GHB-Coma group reported higher levels of depression, anxiety, and stress; showed decreased activity of the hippocampus; and increased functional connectivity of the left hippocampus with the left fusiform gyrus and a cluster on the left temporal-parietal-occipital junction, when compared with the 2 other groups. The GHB-NoComa group showed decreased functional connectivity of the left hippocampus with the amygdala in comparison with the No-GHB group. CONCLUSIONS GHB-use but in particular GHB-induced comas, are associated with altered emotion identification and hippocampal functioning. Awareness campaigns are required to raise consciousness about the adverse effects of GHB-induced comas on affect regulation, despite the absence of subjective side effects.
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Affiliation(s)
- Filipa Raposo Pereira
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,Amsterdam Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands,*Filipa Raposo Pereira, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, AMC (PA.3-220), Meibergdreef 9, 1105 AZ Amsterdam (The Netherlands), E-Mail
| | - Minni T.B. McMaster
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,Amsterdam Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvon D.A.T. de Vries
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nikki Polderman
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,Amsterdam Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands
| | - Guido A. van Wingen
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,Amsterdam Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands
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Beurmanjer H, Kamal RM, de Jong CAJ, Dijkstra BAG, Schellekens AFA. Baclofen to Prevent Relapse in Gamma-Hydroxybutyrate (GHB)-Dependent Patients: A Multicentre, Open-Label, Non-Randomized, Controlled Trial. CNS Drugs 2018; 32:437-442. [PMID: 29651711 PMCID: PMC5976688 DOI: 10.1007/s40263-018-0516-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gamma-hydroxybutyrate (GHB) dependence is associated with a severe, potentially lethal, withdrawal syndrome and relapse rates as high as 60% within 3 months of detoxification. Baclofen has been shown to decrease self-administration of GHB in mice and reduce relapse in a case series of GHB-dependent patients. Controlled studies on the effectiveness of baclofen to prevent relapse in GHB-dependent patients are lacking. AIM The aim of this study was to assess effectiveness of baclofen in preventing relapse in GHB-dependent patients. METHODS This was an out-patient, multicentre, open-label, non-randomized, controlled trial in GHB-dependent patients (n = 107) in the Netherlands. Treatment as usual (TAU, n = 70) was compared with TAU plus baclofen 45-60 mg/day for 3 months (n = 37). Outcome measures were rates of lapse (any use) and relapse (using GHB on average once a week or more), based on self-report. Side effects were monitored with a baclofen side-effects questionnaire. Treatment groups were compared using Chi square analyses, with both per-protocol (PP) and intention-to-treat (ITT) analyses. RESULTS GHB-dependent patients treated with baclofen after detoxification showed no reduced lapse rates, but reduced relapse and dropout rates, compared with patients receiving TAU only (24 vs 50%). While both ITT and PP analyses revealed similar results, the effectiveness of baclofen prescribed PP was slightly higher than in ITT analysis. Patients reported overall limited side effects, with the most frequently reported being feeling tired (28%), sleepiness (14%) and feeling depressed (14%). No serious adverse events were reported. CONCLUSIONS This study showed potential effectiveness of baclofen in preventing relapse in patients with GHB dependence after detoxification. Though promising, future studies with longer follow-up and a randomized double-blind design should confirm these findings before recommendations for clinical practice can be made. CLINICAL TRIAL REGISTRATION Netherlands Trial Register with number NTR4528.
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Affiliation(s)
- Harmen Beurmanjer
- Novadic-Kentron, Vught, The Netherlands.
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands.
| | | | - Cor A J de Jong
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - Boukje A G Dijkstra
- Novadic-Kentron, Vught, The Netherlands
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands
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20
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Treatment consumption and treatment re-enrollment in GHB-dependent patients in The Netherlands. Drug Alcohol Depend 2017; 176:96-101. [PMID: 28531770 DOI: 10.1016/j.drugalcdep.2017.02.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/16/2017] [Accepted: 02/28/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to assess treatment consumption and re-enrollment in treatment in patients with gamma-hydroxybutyrate (GHB)-dependence in Dutch Addiction Treatment Centers (ATCs) in comparison with other addictions. METHODS A cohort-study using nationwide administrative data from regular Dutch ATCs associated with the Dutch National Alcohol and Drugs Information System (LADIS), covering an estimated 95% of ATCs. We selected in- and out-patients with alcohol, drug and/or behavioral addictions with a first treatment episode in 2008-2011 and consecutive treatments until 2013 (n=71,679). Patients still in treatment at that date (n=3686; 5.1%), forensic patients (n=1949; 2.7%) and deceased patients (n=570; 0.8%) were excluded, leaving 65,474 patients (91.3%). Of those, 596 (0.9%) patients had GHB dependence. We analyzed number of treatment contacts, treatment duration, admissions and admission duration of the first treatment episode, and re-enrollment (defined as having started a second treatment episode in the study period). RESULTS GHB-dependent patients showed the highest number of treatment contacts, duration of treatment and chance of being admitted. Re-enrollment rates were 2-5 times higher in GHB-dependent patients than other patients with adjusted HR of other addictions ranging from 0.18 (95% confidence interval [CI]: 0.15-0.21) to 0.53 (95% CI: 0.47-0.61). CONCLUSIONS This study demonstrates high levels of treatment consumption and high rates of treatment re-enrollment in GHB-dependent patients. These findings highlight the urgency of developing effective relapse prevention interventions for GHB-dependent patients.
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