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Harris O, Siefried KJ, Chiew A, Jamshidi N, Chung DT, Moore N, Nic Ionmhain U, Roberts DM, Ezard N, Brett J. Trends in reported GHB-related presentations to Sydney emergency departments between 2012 and 2021. Emerg Med Australas 2024. [PMID: 38558322 DOI: 10.1111/1742-6723.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES In overdose, gamma-hydroxybutyrate (GHB) and its precursors can cause decreased levels of consciousness, coma and death. Here, we aim to describe reported exposure to GHB at four EDs in Sydney, New South Wales (NSW), Australia. METHODS We searched the ED databases of four Sydney metropolitan hospitals for presentations relating to GHB exposure between 2012 and 2021. We calculated annual number of presentations stratified by hospital, age, sex, mode of arrival and triage category. RESULTS A total of 3510 GHB-related presentations to ED were recorded across the four hospitals. Data for all hospitals were only available from 2015 onwards and between 2015 and 2021; there was a 114% increase in annual presentations (from 228 to 487). Males represented 68.7% of all presentations and the median age was 31 years (range 16-74 years). There was an increase in the proportion of female presentations between 2012 and 2021 (from 27.9% to 37.9%) along with the severity of presentation over the same period, with the proportion of presentations with a triage category 1 increasing from 19.7% to 34.5%. CONCLUSIONS Increases in recorded absolute number and severity of GHB-related presentations to Sydney EDs are a major public health concern. There may also be shifts in the demographics of those with GHB-related presentations. Renewed efforts are required to understand the drivers of these increases to optimally target harm reduction approaches.
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Affiliation(s)
- Oliver Harris
- St Vincent's Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Krista J Siefried
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- The National Centre for Clinical Research on Emerging Drugs of Concern (NCCRED), c/o The University of New South Wales, Sydney, New South Wales, Australia
- The National Drug and Alcohol Research Centre (NDARC), The University of New South Wales, Sydney, New South Wales, Australia
| | - Angela Chiew
- Toxicology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Nazila Jamshidi
- Drug Health Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Clinical Pharmacology and Drug Health Services, Sydney Local Health Districy, Sydney, New South Wales, Australia
| | - Daniel T Chung
- Toxicology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Nicholas Moore
- Clinical Toxicology & Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Una Nic Ionmhain
- Clinical Toxicology & Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Darren M Roberts
- Drug Health Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- New South Wales Poison's Information Centre, Sydney Children's Hospital Weastmead, Sydney, New South Wales, Australia
| | - Nadine Ezard
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- The National Centre for Clinical Research on Emerging Drugs of Concern (NCCRED), c/o The University of New South Wales, Sydney, New South Wales, Australia
- The National Drug and Alcohol Research Centre (NDARC), The University of New South Wales, Sydney, New South Wales, Australia
- Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
| | - Jonathan Brett
- St Vincent's Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
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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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Ito M, Walzer M, Blauwet MB, Spence A, Heo N, Kelsh D, Blahunka P, Erdman J, Alsharif MN, Marek GJ. A phase 1 randomized, placebo-controlled study to investigate potential interactions between ASP8062, a positive allosteric modulator of the GABA B receptor, and morphine in recreational opioid users. J Psychopharmacol 2023; 37:449-461. [PMID: 37125424 DOI: 10.1177/02698811231167852] [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: 05/02/2023]
Abstract
BACKGROUND Recent increases in opioid use and subsequent opioid use disorder are a major public health crisis in the United States. AIMS This phase 1 randomized, placebo-controlled study investigated the safety, tolerability, and pharmacokinetics (PKs) of ASP8062, a γ-aminobutyric acid B receptor-positive allosteric modulator, with and without administration of morphine in participants who used opioids recreationally. METHODS Participants were randomly assigned (2:1) to daily dosing with ASP8062 25 mg or placebo on days 1-10. On day 10, all participants received morphine as a single oral dose of 45 mg; assessments were performed on days 11-16. The primary end point was safety, evaluated as the nature, frequency, and severity of adverse events, and end-tidal CO2 levels. PK end points were a secondary outcome measure. RESULTS A total of 24 participants (aged 21-54 years) received ASP8062 (n = 16) or placebo (n = 8). There were no deaths or serious adverse events leading to treatment discontinuation during the study. Most adverse events were mild, with numerically lower absolute number of adverse events reported with ASP8062 plus morphine versus placebo plus morphine. ASP8062 plus morphine did not increase respiratory depression, potential drug abuse- or withdrawal-related adverse events. There were no significant PK interactions. CONCLUSIONS In this phase 1 study, we did not observe any unexpected safety signals or notable PK interactions with concomitant morphine administration. These data suggest a potentially low risk for an increase in drug abuse- or withdrawal-related adverse events or respiratory distress in participants exposed to ASP8062 and morphine.
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Affiliation(s)
- Mototsugu Ito
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mark Walzer
- Clinical Pharmacology & Exploratory Development, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mary Beth Blauwet
- Biostatistics Department, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Anna Spence
- Biostatistics Department, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Nakyo Heo
- Clinical Pharmacology & Exploratory Development, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Debra Kelsh
- Altasciences, Clinical Kansas, Inc., Overland Park, KS, USA
| | - Paul Blahunka
- Employee of Astellas, Northbrook, IL, USA, at the time of the study
| | - Jay Erdman
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mohamad Nour Alsharif
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Gerard J Marek
- Employee of Astellas, Northbrook, IL, USA, at the time of the study
- Gilgamesh Pharmaceuticals Inc., New York, NY, USA
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Stockham P, Partridge E, Alfred S, Boyle L, Camilleri A, Green H, Haustead D, Humphries M, Kostakis C, Mallon J. Characteristics of analytically confirmed gamma-hydroxybutyrate (GHB) positive patients in the emergency department: presentation, poly-drug use, disposition and impact on intensive care resource utilisation. Clin Toxicol (Phila) 2023; 61:241-247. [PMID: 37129222 DOI: 10.1080/15563650.2023.2178933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Gamma-hydroxybutyrate is a potent central nervous system depressant with a narrow recreational dose window and analytical detection time. We describe data relating to intoxicated patients presenting to emergency departments across metropolitan Adelaide who tested positive for gamma-hydroxybutyrate. This work was part of the Emergency Department Admission Blood Psychoactive Testing study. METHODS Over a 15-month period, patients presenting to four metropolitan emergency departments with symptoms of drug intoxication were enrolled in the study. The methodology involved the collection of demographic and clinical data and a de-identified blood sample which underwent comprehensive toxicological analysis. Gamma-hydroxybutyrate was determined using an acid-catalysed cyclisation followed by liquid-liquid extraction and gas chromatography-mass spectrometry. Data relating to samples positive for gamma-hydroxybutyrate were examined. RESULTS AND DISCUSSION A total of 1120 patients were enrolled between March 2019 and May 2020, 309 of whom were positive for gamma-hydroxybutyrate (27.6%). Of these, 256 (83%) were also positive for metamfetamine (methamphetamine). The most common clinical observation in gamma-hydroxybutyrate-positive patients was central nervous system depression (89%). There was a significant relationship between gamma-hydroxybutyrate status and sex; although males outnumbered females in absolute terms, a higher proportion of females (32%) tested positive for gamma-hydroxybutyrate than males (25%, P = 0.0155). Blood gamma-hydroxybutyrate concentrations ranged from 10 to 651 mg/L (0.096-6.2 mmol/L) and increasing gamma-hydroxybutyrate concentration correlated with severe toxicity. The presence of gamma-hydroxybutyrate had a significant impact on the patient discharge destination: the majority (69.2%) of gamma-hydroxybutyrate-positive patients were managed and discharged from the emergency department or their attached short stay wards. A significantly higher proportion of gamma-hydroxybutyrate-positive patients were admitted to the intensive care unit (28.2%) compared with gamma-hydroxybutyrate-negative patients (12.7%, chi-squared = 36.85, P <0 .001). Gamma-hydroxybutyrate positive cases accounted for 45.8% of all study-related intensive care unit admissions. CONCLUSIONS Gamma-hydroxybutyrate is commonly detected in illicit drug-related emergency department presentations and is detected disproportionately in the patient cohort who require intensive care unit level care.
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Affiliation(s)
- Peter Stockham
- Forensic Science SA (Toxicology), Adelaide, Australia
- College of Science and Engineering, Flinders University, Bedford Park, Australia
| | - Emma Partridge
- Forensic Science SA (Toxicology), Adelaide, Australia
- College of Science and Engineering, Flinders University, Bedford Park, Australia
| | - Sam Alfred
- Emergency Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Laura Boyle
- Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
- School of Mathematical Sciences, The University of Adelaide, Adelaide, Australia
| | | | - Hannah Green
- Emergency Department, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, Australia
- Emergency Department, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Melissa Humphries
- School of Mathematical Sciences, The University of Adelaide, Adelaide, Australia
| | | | - Jake Mallon
- Emergency Department, Flinders Medical Centre, Bedford Park, Australia
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5
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Muacevic A, Adler JR. Withdrawal of Gamma-Hydroxybutyrate in a Saudi Male Patient: A Case Report. Cureus 2022; 14:e32298. [PMID: 36505956 PMCID: PMC9729041 DOI: 10.7759/cureus.32298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/12/2022] Open
Abstract
Gamma-hydroxybutyrate (GHB) is a central nervous system (CNS) depressant with limited clinical use but has been misused in the last few decades. During intoxication, the patient may develop CNS depression and may have agitation, while during withdrawal, the patient can present with severe agitation or delirium. Here, we report the case of a 30-year-old Saudi male patient who was brought by his brother to the emergency department (ED) with agitation and delirium. The patient's friend stated the patient had been misusing GHB mixed with alcohol for the last seven months, with the last use occurring 24 hours before the ED presentation. The patient was put on a five-point restraint for safety concerns and received supportive therapy. After two days of admission, the patient completely recovered. As the patient provided a limited history of his GHB misuse, the clinician lacked sufficient information to determine whether the patient was intoxicated or withdrawing. Clinicians in Saudi Arabia need to be highly suspicious of GHB misuse when treating patients with drug intoxication or withdrawal.
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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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Ahmad A, Zhao C, Ali G, Zhou K, Iqbal J. The role of unsustainable HR practices as illegitimate tasks in escalating the sense of workplace ostracism. Front Psychol 2022; 13:904726. [PMID: 36211853 PMCID: PMC9537574 DOI: 10.3389/fpsyg.2022.904726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Unsustainable HR practices impose illegitimate tasks on employees due to a shortage of resources. These illegitimate tasks bring counterproductive work behavior in terms of workplace incivility that creates a sense of ostracism in employees. To address these issues, the study examined the relationship among unsustainable HR practices in terms of illegitimate tasks and workplace ostracism. Whereas workplace incivility is defined as an underlying reason through which this association exists. Adopting a theoretical framework from earlier research, the study used cross-sectional data and subsequently a method of quantitative research, and the sample comprised permanent faculty members of private universities in Pakistan working in different departments with different role titles. Smart PLS was applied to run multiple statistics analyzed on the obtained data. The results from the study supported the hypothesis by depicting a positive and significant association between illegitimate tasks and workplace ostracism. Further, workplace incivility was playing the mediating role between illegitimate tasks and workplace ostracism. The results from the study carry significant implications for managers and researchers. Recommendations and future research directions are also discussed in the paper.
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Affiliation(s)
- Afaq Ahmad
- Institute of Business, Management and Administrative Sciences, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Chenhui Zhao
- School of Business, Wuchang University of Technology, Wuhan, China
| | - Ghazanfar Ali
- Institute of Business, Management and Administrative Sciences, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Kunshun Zhou
- School of Business Administration, Zhongnan University of Economics and Law, Wuhan, China
- School of Economics and Management, Guangxi Science and Technology Normal University, Liuzhou, China
| | - Jawad Iqbal
- Institute of Business, Management and Administrative Sciences, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
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Schulz K, Helms H, Janich A. Full evaporation headspace technique with gas chromatography as a microchemical method for the rapid determination of gamma-hydroxybutyric acid (GHB) in serum samples. Microchem J 2022. [DOI: 10.1016/j.microc.2022.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Palamar JJ. Prevalence and Correlates of GHB Use among Adults in the United States. J Psychoactive Drugs 2022:1-6. [PMID: 35616605 PMCID: PMC9699895 DOI: 10.1080/02791072.2022.2081948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Gamma-hydroxybutyrate (GHB) was a somewhat prevalent club drug two decades ago, but research has been lacking regarding the current epidemiology of use. In this study, prevalence and correlates of past-year GHB use were estimated based on noninstitutionalized US adults participating in the 2015-2020 National Survey of Drug Use and Health (N= 241,675). An estimated 0.05% (95% CI: 0.04-0.07) of adults in the US have used GHB in the past year. Compared to those age 18-25, those age 35-49 were at increased odds for use (aOR = 2.28, 95% CI: 1.02-5.10), and compared to heterosexual men, gay men in particular were at high odds for use (aOR = 27.82, 95% CI: 11.09-69.80). Those identifying as bisexual men (aOR = 3.39, 95% CI: 1.17-9.82) and lesbian/bisexual women (aOR = 3.37, 95% CI: 1.44-7.90) were also at high odds for use. Despite all drugs examined being significant correlates of use in bivariable models (ps < .001), only past-year use of methamphetamine (aOR = 15.68, 95% CI: 7.40-33.25), ketamine (aOR = 8.52, 95% CI: 2.67-27.20), and ecstasy (aOR = 4.41, 95% CI: 1.80-10.75) was associated with increased odds of use in the multivariable model. Results suggest that GHB use is currently rare, but gay men and people who use other party drugs are at particularly high risk for use.
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Affiliation(s)
- Joseph J Palamar
- New York University Grossman School of Medicine, Department of Population Health, New York, NY USA
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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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Azevedo K, Johnson M, Wassermann M, Evans-Wall J. Drugs of Abuse-Opioids, Sedatives, Hypnotics. Crit Care Clin 2021; 37:501-516. [PMID: 34053703 DOI: 10.1016/j.ccc.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Over the last 2 decades, prescription and nonprescription substance use has significantly increased. In this article, 3 particular drug classes-opioids, sedatives, and hypnotics-are discussed. For each class, a brief history of the agent, a description of relevant pharmacology, the clinical presentation of overdose, the management of specific drug overdoses, and a summary of salient points are presented. The intent is to provide a clinically relevant and comprehensive approach to understanding these potential substance exposures in order to provide a framework for management of opioid, sedative, and hypnotic overdoses.
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Affiliation(s)
- Keith Azevedo
- Departments of Emergency and Internal Medicine, University of New Mexico Hospital, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Molly Johnson
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Michael Wassermann
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Jessica Evans-Wall
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131, USA
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Doyno CR, White CM. Sedative-Hypnotic Agents That Impact Gamma-Aminobutyric Acid Receptors: Focus on Flunitrazepam, Gamma-Hydroxybutyric Acid, Phenibut, and Selank. J Clin Pharmacol 2021; 61 Suppl 2:S114-S128. [PMID: 34396551 DOI: 10.1002/jcph.1922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/03/2021] [Indexed: 12/29/2022]
Abstract
There are many nonopioid central nervous system depressant substances that share a gamma-aminobutyric acid (GABA) receptor-related mechanism of action. These sedatives-hypnotics can be indicated to treat anxiety, seizures, depression, and insomnia but are also used as substances of abuse and used to facilitate sexual assault. Barbiturates, methaqualone, and glutethimide were among the first type A GABA receptor-mediated sedative-hypnotics. Their clinical use was limited for most indications by serious adverse events and strong abuse potential but continue to be used illicitly around the world. The benzodiazepines supplanted barbiturates for most indications because they were less likely to cause severe adverse events in monotherapy. Flunitrazepam is a newer benzodiazepine that is preferentially used recreationally and to facilitate sexual assault. Flunitrazepam has greater potency and higher affinity for the type A GABA receptor than most benzodiazepines. Gamma-hydroxybutyric acid is sought illicitly for its hypnotic, euphoric and anabolic effects as well as to facilitate sexual assault. When any of these GABAergic drugs are used in high doses or with other sedative hypnotic agents, respiratory depression, coma, and death have occurred. Chronic use of these GABAergic drugs can lead to significant withdrawal syndromes. Phenibut and selank are poorly studied Russian drugs with GABAergic mechanisms that are inexplicably sold to US consumers as dietary supplements. Poison control center calls regarding phenibut have increased substantially over the past 5 years. Desired euphoriant effects account for the recreational and illicit use of many GABA-modulating agents. However, illicit use can lead to significant toxicities related to abuse, dependence, and subsequent withdrawal syndromes. Significant evaluation of developing agents with GABA properties should be conducted to determine abuse potential before public access ensues.
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Affiliation(s)
- Cassandra R Doyno
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA.,John Dempsey Hospital, University of Connecticut, Farmington, Connecticut, USA
| | - C Michael White
- Department of Research Administration, Hartford Hospital, Hartford, Connecticut, USA
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13
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Arfè R, Bilel S, Tirri M, Frisoni P, Serpelloni G, Neri M, Boccuto F, Bernardi T, Foti F, De-Giorgio F, Marti M. Comparison of N-methyl-2-pyrrolidone (NMP) and the "date rape" drug GHB: behavioral toxicology in the mouse model. Psychopharmacology (Berl) 2021; 238:2275-2295. [PMID: 33881584 DOI: 10.1007/s00213-021-05852-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/12/2021] [Indexed: 01/07/2023]
Abstract
N-methyl-2-pyrrolidone (NMP) and γ-hydroxybutyrate acid (GHB) are synthetic solvents detected in the recreational drug market. GHB has sedative/hypnotic properties and is used for criminal purposes to compromise reaction ability and commit drug-facilitated sexual assaults and other crimes. NMP is a strong solubilizing solvent that has been used alone or mixed with GHB in case of abuse and robberies. The aim of this experimental study is to compare the acute pharmaco-toxicological effects of NMP and GHB on neurological signs (myoclonia, convulsions), sensorimotor (visual, acoustic, and overall tactile) responses, righting reflex, thermoregulation, and motor activity (bar, drag, and accelerod test) in CD-1 male mice. Moreover, since cardiorespiratory depression is one of the main adverse effects related to GHB intake, we investigated the effect of NMP and GHB on cardiorespiratory changes (heart rate, breath rate, oxygen saturation, and pulse distension) in mice. The present study demonstrates that NMP inhibited sensorimotor and motor responses and induced cardiorespiratory depression, with a lower potency and efficacy compared to GHB. These results suggest that NMP can hardly be used alone as a substance to perpetrate sexual assault or robberies.
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Affiliation(s)
- Raffaella Arfè
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy.,Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Sabrine Bilel
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Micaela Tirri
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Paolo Frisoni
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Giovanni Serpelloni
- Department of Psychiatry in the College of Medicine, Drug Policy Institute, University of Florida, Gainesville, FL, USA
| | - Margherita Neri
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Federica Boccuto
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Tatiana Bernardi
- Department of Chemistry and Pharmaceutical Sciences, University of Ferrara, Ferrara, Italy
| | - Federica Foti
- Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Roma, Italia.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168, Roma, Italia
| | - Fabio De-Giorgio
- Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Roma, Italia. .,Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168, Roma, Italia.
| | - Matteo Marti
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy. .,Collaborative Center for the Italian National Early Warning System, Department of Anti-Drug Policies, Presidency of the Council of Ministers, Rome, Italy.
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Safety of withholding intubation in gamma-hydroxybutyrate- and gamma-butyrolactone-intoxicated coma patients in the emergency department. Eur J Emerg Med 2021; 27:223-227. [PMID: 31815871 DOI: 10.1097/mej.0000000000000649] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to determine if supportive care without endotracheal intubation in the emergency department (ED) was safe in the absence of complications in gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL) intoxicated patients with a decreased Glasgow Coma Scale (GCS) score. METHODS This was a retrospective chart review of patients presenting to a Dutch tertiary urban ED with a reduced level of consciousness related to alleged GHB/GBL intoxication between April 2011-December 2014. Primary endpoint was major adverse events, defined by: upper airway obstruction not resolved with mayo tube or nasopharyngeal airway, hypoxia not resolved with 15 l of oxygen delivered via non-rebreathing mask, bradypnea not resolved after stimulation, intubation, bradycardia not resolved after intravenous atropine bolus, hypotension for which inotropes were started. RESULTS Data of 209 patients were retrieved. Major adverse events were reported in five patients (2.4%; 95% CI: 0.8-5.5). Intubation with subsequent ICU admission was required for 1.4% of patients (95% CI: 0.3-4.1). The most frequently seen minor adverse events (N = 209) were: airway obstruction (22%), hypothermia (14.8%), hypoxia (12.9%), bradycardia (8.1%), hypotension (6.7%), bradypnea (5.7%), vomiting (5.3%). There were no deaths. None of the patients had signs of aspiration pneumonia or returned to our ED due to complications. CONCLUSION Our study suggests that conservative airway management for patients with a decreased GCS due to suspected GHB intoxication may be safe. Major adverse events were present in 2.4% of patients, only 1.4% of patients required intubation. All minor adverse events were managed effectively with conservative treatment.
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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: 18] [Impact Index Per Article: 6.0] [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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A randomized phase 1 single-dose polysomnography study of ASP8062, a GABA B receptor positive allosteric modulator. Psychopharmacology (Berl) 2021; 238:867-876. [PMID: 33433644 PMCID: PMC7914186 DOI: 10.1007/s00213-020-05738-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/01/2020] [Indexed: 12/29/2022]
Abstract
RATIONALE Previous research suggests that sleep polysomnography and EEG endpoints can be used to assess GABAergic activity; however, the impact of GABAB receptor positive allosteric modulators on sleep endpoints remains unclear. OBJECTIVES This phase 1 study compared a single dose of ASP8062 (35 mg or 70 mg), a GABAB receptor positive allosteric modulator, with placebo and paroxetine (40 mg). METHODS Healthy adult volunteers were randomized to four treatments (35 mg ASP8062, 70 mg ASP8062, paroxetine 40 mg, or matching placebo), each separated by a 14-day washout. Primary endpoints obtained by polysomnography were time in stage N3 or SWS and time in rapid eye movement (REM) sleep. Secondary endpoints included impact on sleep stages and electroencephalography parameters, pharmacokinetics, nighttime growth hormone (GH), and safety/tolerability. RESULTS In 20 randomized volunteers, ASP8062 led to a significant and seemingly dose-dependent increase in SWS over the entire night; this increase was mainly observed during the first third of the night. ASP8062 did not impact time in REM sleep. Paroxetine had no effect on SWS but produced a significant reduction in time spent in REM sleep. A dose-dependent trend in increased GH release was also observed with ASP8062. Headache and nausea were the most commonly reported treatment-emergent adverse events (TEAEs) for ASP8062; most TEAEs were mild in severity. CONCLUSIONS Single-dose ASP8062 (35 and 70 mg) appeared to result in CNS penetration and enhanced GABAergic activity as measured by increases in slow-wave sleep and growth hormone release.
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Marinelli E, Beck R, Malvasi A, Faro AFL, Zaami S. Gamma-hydroxybutyrate abuse: pharmacology and poisoning and withdrawal management. Arh Hig Rada Toksikol 2020; 71:19-26. [PMID: 32597141 PMCID: PMC7837237 DOI: 10.2478/aiht-2020-71-3314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/01/2019] [Accepted: 03/01/2020] [Indexed: 12/19/2022] Open
Abstract
Gamma-hydroxybutyrate (GHB) is a central nervous system depressant primarily used as a recreational drug of abuse, but also for the treatment of narcolepsy with cataplexy in adult patients and as an adjuvant for control of alcohol withdrawal syndrome. The main aim of this review is to summarise updated knowledge about GHB pharmacokinetics and pharmacodynamics, acute poisoning, and clinical features of GHB withdrawal syndrome, its diagnosis and medical treatment. The most common clinical signs and symptoms of acute poisoning include sleepiness to deep coma, bradycardia, hypotension, and respiratory failure. Therapy is essentially supportive and based on continuous monitoring of vital signs. GHB withdrawal syndrome shares patterns with other withdrawal syndromes such as alcohol withdrawal and is sometimes difficult to distinguish, especially if toxicological tests are GHB-negative or cannot be performed. There are no official detoxification protocols for GHB withdrawal syndrome, but its therapy is based on benzodiazepine. When benzodiazepine alone is not effective, it can be combined with barbiturates or antipsychotics. Information about abuse and distribution of GHB and its precursors/analogues among the general population is still limited. Their prompt identification is therefore crucial in conventional and non-conventional biological matrices, the latter in particular, to clarify all the issues around this complex molecule.
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Affiliation(s)
- Enrico Marinelli
- Department of Anatomical, Histological, Forensic, and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Renata Beck
- Department of Anaesthesia, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Antonio Malvasi
- Department of Obstetrics and Gynaecology, Santa Maria Hospital, Bari, Italy
| | - Alfredo Fabrizio Lo Faro
- Section of Legal Medicine, Department of Excellence SBSP, University “Politecnica delle Marche” of Ancona, Ancona, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic, and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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Elliott L, Haddock CK, Campos S, Benoit E. Polysubstance use patterns and novel synthetics: A cluster analysis from three U.S. cities. PLoS One 2019; 14:e0225273. [PMID: 31794586 PMCID: PMC6890248 DOI: 10.1371/journal.pone.0225273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/31/2019] [Indexed: 02/04/2023] Open
Abstract
The rapid emergence of novel psychoactive substances within the past decade has raised new concerns about the harms associated with unregulated drug use. Synthetic analogues-chemically related to established psychoactive substances like cannabis sativa and catha edulis-in particular have proliferated rapidly, allowing little opportunity for scientific research or the establishment of informal guidelines for safe use among consumers. To explore how synthetic substance use relates to other forms of use, this paper presents an analysis of polysubstance use among a sample of 676 people who use illicit substances in the United States. Participants were sampled from three greater metropolitan areas (Houston/Galveston, Texas; New York City; and New Orleans, Louisiana). Study researchers used cluster-type analyses to develop dendrogram visualizations of the interrelationships between substance types. Results suggest a considerable variation in substance and polysubstance use patterns across states in the U.S. Polysubstance use clustered around well-observed combinations like MDMA/cannabis and cocaine/heroin. Synthetic cannabinoids and cathinones showed no strong clustering with other substances. High rates of binge drinking among users of other substances further support the importance of interventions sensitive to the clinical challenges of polysubstance use.
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Affiliation(s)
- Luther Elliott
- New York University, College of Global Public Health, Center for Drug Use and HIV/HCV Research, New York, New York, United States of America
- * E-mail:
| | | | - Stephanie Campos
- New York State Psychiatric Institute, Columbia University, New York, New York, United States of America
| | - Ellen Benoit
- North Jersey Community Research Initiative, Research Division, Newark, New Jersey, United States of America
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Murai N, Kondo Y, Akuzawa S, Mihara T, Shiraishi N, Kakimoto S, Matsumoto M. A novel GABAB receptor positive allosteric modulator, ASP8062, exerts analgesic effects in a rat model of fibromyalgia. Eur J Pharmacol 2019; 865:172750. [DOI: 10.1016/j.ejphar.2019.172750] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 11/24/2022]
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Prospective Investigation of the Performance of 2 Gamma-Hydroxybutyric Acid Tests: DrugCheck GHB Single Test and Viva-E GHB Immunoassay. Ther Drug Monit 2019; 42:139-145. [PMID: 31318841 DOI: 10.1097/ftd.0000000000000677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gamma-hydroxybutyric acid (GHB) is a recreational drug with central nervous system depressing effects that is often abused. A urine GHB point-of-care test can be of great diagnostic value. The objective of this prospective study was to determine the performance of the new DrugCheck GHB Single Test and the Viva-E GHB immunoassay for urine samples in emergency department patients. METHODS Patients presented to the emergency department of the OLVG hospital in Amsterdam with a Glasgow Coma Scale score <15 and potential drug of abuse intoxication were included in the study. Between June 2016 and October 2017, 375 patients were included. Using the DrugCheck GHB Single Test (Express Diagnostics Int'l, Blue Earth, MN) and the Viva-E GHB immunoassay (Siemens Healthineers, The Hague, the Netherlands), patients' urine samples were tested for GHB (cutoff for a positive result, 10 or 50 mcg/mL GHB). To ensure quality, the results obtained were compared with those generated using a validated gas chromatography method. The tests were considered reliable if specificity and sensitivity were both >90%. Possible cross-reactivity with ethanol was investigated by analyzing ethanol concentrations in patients' samples. RESULTS Seventy percentage of the included patients was men, and the median age was 34 years old. The DrugCheck GHB Single Test's specificity and sensitivity were 90.0% and 72.9%, respectively, and using 50 mcg/mL as a cutoff value, its specificity and sensitivity improved to 96.7% and 75.0%, respectively. Serum and urine ethanol levels in the false-positive group were significantly higher compared with those in the true-negative group. The specificity and sensitivity of the Viva-E GHB immunoassay (cutoff value of 50 mcg/mL and excluding samples with ethanol levels ≥2.0 g/L) were 99.4% and 93.5%, respectively. CONCLUSIONS The DrugCheck GHB Single Test's specificity was sufficient, whereas its sensitivity was poor, making it unsuitable for use at point-of-care. Contrarily, using 50 mcg/mL as the cutoff value and excluding samples with ethanol levels ≥2.0 g/L, the Viva-E GHB immunoassay showed acceptable results to detect clinically relevant GHB intoxications.
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Galicia M, Dargan PI, Dines AM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, Wood DM, Miró Ò. Clinical relevance of ethanol coingestion in patients with GHB/GBL intoxication. Toxicol Lett 2019; 314:37-42. [PMID: 31301370 DOI: 10.1016/j.toxlet.2019.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/16/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Ethanol intake can increase the sedative effects of gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), although the real clinical impact is unknown. We studied the clinical impact of the co-ingestion of ethanol in patients presenting to the Emergency Department (ED) with acute toxicity related to GHB/GBL use. METHOD We performed a secondary analysis of the Euro-DEN Plus Registry (14 countries, 22 EDs) which includes 17,371 consecutive patients presenting to the ED with acute recreational drug toxicity over 39 consecutive months (October 2013 - December 2016). We compared the epidemiological and clinical characteristics and ED management of patients identified as presenting with acute toxicity related to lone GHB/GBL (Group A) or GHB/GBL combined with ethanol (Group B) without other concomitant drugs. RESULTS A total of 609 patients were included (age 32 (8) years; 116 women (19%); Group A: 183 patients and Group B: 426). The most common features were reduction in consciousness (defined as Glasgow Coma Score <13 points: 56.1%) and agitation/aggressiveness (33.6%). Those with ethanol co-ingestion were younger patients (Group A/B: 31.5/33.1 years, p = 0.029) and ethanol co-ingestion was associated with a lower frequency of bradycardia (23.5%/15.7%, p = 0.027) and more frequent arrival at the ED by ambulance (68.3/86.6%; p < 0.001), reduction in consciousness (58.9%/49.1%; p = 0.031), need for treatment in the ED (49.2%/60.4%; p = 0.011), use of sedatives (20.1%/12.8%; p = 0.034), admission to critical care units (22.4%/55.3%; p < 0.001), and longer hospital stay (stay longer than 6 h: 16.9%/28.4%; p = 0.003). CONCLUSIONS Co-ingestion of ethanol increases the adverse effects of patients intoxicated by GHB/GBL, leading to greater depression of consciousness, need for treatment, admission to the ICU and longer hospital stay.
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Affiliation(s)
- Miguel Galicia
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, Barcelona, Spain.
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom; Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom
| | - Christopher Yates
- Servicio de Urgencias, Hospital Son Espases, Palma de Mallorca, Spain
| | - Fridtjof Heyerdahl
- The National CBRNe Centre of Medicine, Department of Acute Medicine, Medical Division, Oslo University Hospital, Oslo, Norway
| | - Knut Erik Hovda
- The National CBRNe Centre of Medicine, Department of Acute Medicine, Medical Division, Oslo University Hospital, Oslo, Norway
| | - Isabella Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | | | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom; Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, Barcelona, Spain; Medical School, University of Barcelona, Spain
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Soichot M, Leclercq M, Allard M, Mihoubi A, Gourlain H, Bourgogne E, Megarbane B, Labat L. Intérêt d’une méthode enzymatique pour le diagnostic des intoxications par GHB/GBL. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2019. [DOI: 10.1016/j.toxac.2019.03.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Substance abuse is a common presentation to Emergency Departments (ED). A case of gamma-hydroxybutyrate (GHB) presented to our ED is reported, its clinical history and findings, biochemical and toxicity is discussed. This drug affects the neurological, muscular, biochemical and sexual function.
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Affiliation(s)
- Ys Sia
- Tang Shiu Kin Hospital, Accident and Emergency Department, Hong Kong
| | - Yt Wong
- Ruttonjee Hospital & Tang Shiu Kin Hospital, Accident and Emergency Department
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Kapitány-Fövény M, Zacher G, Posta J, Demetrovics Z. GHB-involved crimes among intoxicated patients. Forensic Sci Int 2017; 275:23-29. [PMID: 28288338 DOI: 10.1016/j.forsciint.2017.02.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 02/02/2017] [Accepted: 02/23/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In recent years, the involvement of GHB in drug facilitated sexual assaults has been one of the most frequently studied aspects of GHB in both clinical and non-clinical settings. GHB-involved acquisitory crimes, however, can be mentioned as understudied research topics, as well as the poisoning severity properties of GHB. MEASURES The medical reports of Péterfy Sándor Street Hospital Clinic and Casualty Centre's 408 GHB-intoxication cases (352 patients) were reviewed and registered. Analyzed data consisted of epicrisis, serum and urine concentration of various substances (including GHB), scores of Glasgow Coma Scale and Poisoning Severity Score. RESULTS Majority of the patients were males, in their twenties. GHB was detected in 34.1% and it was solely consumed in 27.7% of all the cases. Ethanol was found to be the most frequently co-ingested substance. A higher rate of severe poisonings was observed among males. We found significant difference in the frequency of enduring sexual assaults and acquisitory crimes between intentional and unintentional GHB intake cases. Among unintentional GHB intake cases, 6.5% endured GHB-involved sexual assaults, whereas 21.7% endured an acquisitory crime. Among recurrent GHB intoxication cases generated by the same patients, voluntary and sole GHB consumptions were more frequently observed, however, enduring any crime was less characteristic. DISCUSSION Our results regarding demographic and substance use characteristics and the frequency of GHB-facilitated sexual assaults are in line with former findings. Enduring acquisitory crimes due to unintentional GHB intake was found to be more inherent than enduring sexual assaults. Authors emphasise that the victims of these acquisitory crimes were typically males. CONCLUSION GHB's role in drug facilitated acquisitory crimes seems to be significant, although the decrease in GHB's popularity is observed among intoxicated patients as well. The need for further research on GHB's impact on cognitive impairment and on sexual correlates of intentional GHB use is addressed by the authors.
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Affiliation(s)
- Máté Kapitány-Fövény
- Institute of Psychology, Eötvös Loránd University, Budapest, Hungary; Faculty of Health Sciences, Semmelweis University, Budapest, Hungary; Nyírő Gyula Hospital National Institute of Psychiatry and Addictology, Drug Outpatient and Prevention Centre, Budapest, Hungary.
| | - Gábor Zacher
- Military Hospital State Health Centre, Emergency Ward, Budapest, Hungary
| | - János Posta
- Institute of Forensic Medicine, University of Debrecen, Hungary
| | - Zsolt Demetrovics
- Institute of Psychology, Eötvös Loránd University, Budapest, Hungary
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Presentations to an urban emergency department in Switzerland due to acute γ-hydroxybutyrate toxicity. Scand J Trauma Resusc Emerg Med 2016; 24:107. [PMID: 27581664 PMCID: PMC5007834 DOI: 10.1186/s13049-016-0299-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/24/2016] [Indexed: 12/02/2022] Open
Abstract
Background γ-Hydroxybutyrate (GHB) is a drug of abuse with dose-dependent sedative effects. Systematic data on the acute toxicity of GHB from emergency department (ED) presentations over a long period of time are currently missing from the literature. The present study described the clinical features of GHB toxicity. Methods Retrospective case series of GHB intoxications seen in an urban ED. Results From January 2002 to September 2015, 78 GHB-related intoxication cases were recorded (71 % male patients). The mean ± SD age was 29 ± 8 years. The co-use of alcohol and/or other illicit drugs was reported in 65 % of the cases. Neurological symptoms other than central nervous system depression included agitation (40 %) and clonus (21 %). The most frequent reasons for admission were coma (64 %) and agitation (23 %). The median time to regain consciousness was 90 min (range, 3–400 min). Sudden recovery was reported in 25 cases (32 %). Coma was not significantly associated with polyintoxication. Coma occurred in 77 % of the alcohol co-users and in 62 % ofthe non-alcohol users (p=0.052). The mean recovery time in comatose patients was 142 min in patients with co-use of alcohol compared with 89 min in patients without alcohol co-use (p=0.07). Alcohol co-use was not significantly associated with nausea/vomiting (p=0.07). The co-use of stimulants was not significantly associated with non-responsive coma (Glasgow Coma Scale = 3) or mean recovery time. Analytical confirmation of GHB was available in 37 cases (47 %), with additional quantitative analysis in 20 cases. The median GHB concentration was 240 mg/L (range, 8.3–373 mg/L). Intoxication was severe in 72 % of the cases. No fatalities occurred, and 72 % of the patients were discharged directly home from the ED. Discussion There were trend associations between alcohol co-use and frequency and length of coma and nausea/vomiting which did not reach the significance level (all p=0.05-0.07) but may nevertheless be clinically relevant. As the exact time of use is not always known, and co-use of other substances can affect the severity of poisoning, no definitive conclusions can be drawn regarding the association between GHB concentration and severity. Conclusion Impaired consciousness and agitation were typical findings of GHB intoxication. The co-use of alcohol and/or other illicit substances is common but was not significantly associated with the severity of the intoxications in our study.
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Knegt VE, Breindahl T, Harboe KM, Møller GL, Børresen ML. Gamma‐hydroxybutyrate and cocaine intoxication in a Danish child. Clin Case Rep 2016; 4:228-31. [PMID: 27014439 PMCID: PMC4771861 DOI: 10.1002/ccr3.492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 11/25/2015] [Accepted: 12/12/2015] [Indexed: 11/29/2022] Open
Abstract
GHB intoxication must be considered in children with coma and a suspicion of drug intoxication. Furthermore, mixed intoxication with several substances and the possibility of unpredictable symptom profiles should be anticipated to ensure optimal symptomatic treatment of patients.
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Affiliation(s)
| | - Torben Breindahl
- Department of Clinical Biochemistry Vendsyssel Hospital Aalborg University Aalborg Denmark
| | - Kirstine Moll Harboe
- Department of Clinical Pharmacology and Danish Poison Information Center Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Gitte Leth Møller
- Department of Pediatrics Hvidovre University Hospital Hvidovre Denmark
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Liechti ME, Quednow BB, Liakoni E, Dornbierer D, von Rotz R, Gachet MS, Gertsch J, Seifritz E, Bosch OG. Pharmacokinetics and pharmacodynamics of γ-hydroxybutyrate in healthy subjects. Br J Clin Pharmacol 2016; 81:980-8. [PMID: 26659543 DOI: 10.1111/bcp.12863] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/25/2015] [Accepted: 12/08/2015] [Indexed: 01/26/2023] Open
Abstract
AIMS γ-Hydroxybutyrate (GHB) is used as a treatment for narcolepsy and alcohol withdrawal and as a recreational substance. Nevertheless, there are limited data on the pharmacokinetics and pharmacokinetic-pharmacodynamic relationships of GHB in humans. We characterized the pharmacokinetic profile and exposure-psychotropic effect relationship of GHB in humans. METHODS Two oral doses of GHB (25 and 35 mg kg(-1) ) were administered to 32 healthy male subjects (16 for each dose) using a randomized, placebo-controlled, cross-over design. RESULTS Maximal concentrations of GHB were (geometric mean and 95% CI): 218 (176-270) nmol ml(-1) and 453 (374-549) nmol ml(-1) for the 25 and 35 mg kg(-1) GHB doses, respectively. The elimination half-lives (mean ± SD) were 36 ± 9 and 39 ± 7 min and the AUC∞ values (geometric mean and 95% CI) were 15 747 (12 854-19 290) and 40 113 (33 093-48 622) nmol∙min ml(-1) for the 20 and 35 mg kg(-1) GHB doses, respectively. Thus, plasma GHB exposure (AUC0-∞ ) rose disproportionally (+40%) with the higher dose. γ-Hydroxybutyrate produced mixed stimulant-sedative effects, with a dose-dependent increase in sedation and dizziness. It did not alter heart rate or blood pressure. A close relationship between plasma GHB exposure and its psychotropic effects was found, with higher GHB concentrations associated with higher subjective stimulation, sedation, and dizziness. No clockwise hysteresis was observed in the GHB concentration effect plot over time (i.e., no acute pharmacological tolerance). CONCLUSION Evidence was found of a nonlinear dose-exposure relationship (i.e., no dose proportionality) at moderate doses of GHB. The effects of GHB on consciousness were closely linked to its plasma exposure and exhibited no acute tolerance.
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Affiliation(s)
- Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, Βasel, CH-4031, Switzerland
| | - Boris B Quednow
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, Zurich, CH-8032, Switzerland
| | - Evangelia Liakoni
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, Βasel, CH-4031, Switzerland
| | - Dario Dornbierer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, Zurich, CH-8032, Switzerland
| | - Robin von Rotz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, Zurich, CH-8032, Switzerland
| | - Maria Salomé Gachet
- Institute of Biochemistry and Molecular Medicine, University of Bern, Bühlstrasse 28, Bern, CH-3012, Switzerland
| | - Jürg Gertsch
- Institute of Biochemistry and Molecular Medicine, University of Bern, Bühlstrasse 28, Bern, CH-3012, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, Zurich, CH-8032, Switzerland
| | - Oliver G Bosch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, Zurich, CH-8032, Switzerland
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Bosch OG, Seifritz E. The behavioural profile of gamma-hydroxybutyrate, gamma-butyrolactone and 1,4-butanediol in humans. Brain Res Bull 2016; 126:47-60. [PMID: 26855327 DOI: 10.1016/j.brainresbull.2016.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 01/28/2016] [Accepted: 02/02/2016] [Indexed: 01/24/2023]
Abstract
Gamma-hydroxybutyrate (GHB) is a putative neurotransmitter, a drug of abuse, and a medical treatment for narcolepsy and other neuropsychiatric disorders. Its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD) are endogenously converted to GHB and thereby exert their psychobehavioural effects. In humans, GHB has a wide spectrum of properties ranging from stimulation and euphoria in lower doses, to sedation, deep sleep, and coma after ingestion of high doses. However, behavioural studies in healthy volunteers remain scarce and are usually limited to psychomotor performance testing. Most available data arise from either qualitative studies with illicit users or clinical trials examining therapeutic properties of GHB (then usually termed sodium oxybate). Here, we present an overview of the behavioural effects of GHB, GBL, and 1,4-BD in these three populations. GHB and its precursors strongly influence behaviours related to core human autonomic functions such as control of food intake, sexual behaviour, and sleep-wake regulation. These effects are instrumentalised by illicit users and clinically utilised in neuropsychiatric disorders such as narcolepsy, fibromyalgia, and binge-eating syndrome. Considering the industry withdrawal from psychopharmacology development, repurposing of drugs according to their behavioural and clinical profiles has gained increasing relevance. As such, GHB seems to be an attractive candidate as an experimental therapeutic in depression.
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Affiliation(s)
- Oliver G Bosch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Zurich University Hospital for Psychiatry, Lenggstrasse 31, 8032 Zurich, Switzerland.
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Zurich University Hospital for Psychiatry, Lenggstrasse 31, 8032 Zurich, Switzerland
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Shuaib W, Acevedo JN, Khan MS, Santiago LJ, Gaeta TJ. The top 100 cited articles published in emergency medicine journals. Am J Emerg Med 2015; 33:1066-71. [PMID: 25979301 DOI: 10.1016/j.ajem.2015.04.047] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/23/2015] [Accepted: 04/24/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Our objective was to identify trends and examine the characteristics of the top 100 cited articles in emergency medicine (EM) journals. METHODS Scopus Library database was queried to determine the citations of the top 100 EM articles. A second database (Google Scholar) was used to gather the following information: number of authors, publication year, journal name, impact factor, country of origin, and article type (original article, review article, conference paper, or editorial). The top 100 cited articles were selected and analyzed by 2 independent investigators. RESULTS We identified 100 top-cited articles published in 6 EM journals, led by Annals of Emergency Medicine (65) and American Journal of Emergency Medicine (15). All top-cited articles were published between 1980 and 2009. The common areas of study were categorized as cardiovascular medicine, emergency department administration, toxicology, pain medicine, pediatrics, traumatology, and resuscitation. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles (P < .005). CONCLUSION The top-cited articles published in EM journals help us recognize the quality of the works, discoveries, and trends steering EM. Our analysis provides an insight to the prevalent areas of study being cited within our field of practice.
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Affiliation(s)
- Waqas Shuaib
- Division of Emergency Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA; Department of Emergency Medicine, Hospital General de la Plaza de Salud, Santo Domingo, Dominican Republic.
| | - Javier N Acevedo
- Department of Clinical Epidemiology and Public Health, Universidad Autónoma de Santo Domingo, Santo Domingo, Dominican Republic
| | | | - Luis J Santiago
- Department of Emergency Medicine, Hospital General de la Plaza de Salud, Santo Domingo, Dominican Republic
| | - Theodore J Gaeta
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY
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van der Heide A, Donjacour CEHM, Pijl H, Reijntjes RHAM, Overeem S, Lammers GJ, Van Someren EJW, Fronczek R. The effects of sodium oxybate on core body and skin temperature regulation in narcolepsy. J Sleep Res 2015; 24:566-75. [PMID: 25913575 DOI: 10.1111/jsr.12303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/24/2015] [Indexed: 01/08/2023]
Abstract
Patients suffering from narcolepsy type 1 show altered skin temperatures, resembling the profile that is related to sleep onset in healthy controls. The aim of the present study is to investigate the effects of sodium oxybate, a widely used drug to treat narcolepsy, on the 24-h profiles of temperature and sleep-wakefulness in patients with narcolepsy and controls. Eight hypocretin-deficient male narcolepsy type 1 patients and eight healthy matched controls underwent temperature measurement of core body and proximal and distal skin twice, and the sleep-wake state for 24 h. After the baseline assessment, 2 × 3 g of sodium oxybate was administered for 5 nights, immediately followed by the second assessment. At baseline, daytime core body temperature and proximal skin temperature were significantly lower in patients with narcolepsy (core: 36.8 ± 0.05 °C versus 37.0 ± 0.05 °C, F = 8.31, P = 0.01; proximal: 33.4 ± 0.26 °C versus 34.3 ± 0.26 °C, F = 5.66, P = 0.03). In patients, sodium oxybate administration increased proximal skin temperature during the day (F = 6.46, P = 0.04) to a level similar as in controls, but did not affect core body temperature, distal temperature or distal-proximal temperature gradient. Sodium oxybate administration normalised the predictive value of distal skin temperature and distal-proximal temperature gradient for the onset of daytime naps (P < 0.01). In conclusion, sodium oxybate administration resulted in a partial normalisation of the skin temperature profile, by increasing daytime proximal skin temperature, and by strengthening the known relationship between skin temperature and daytime sleep propensity. These changes seem to be related to the clinical improvement induced by sodium oxybate treatment. A causal relationship is not proven.
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Affiliation(s)
| | - Claire E H M Donjacour
- Leiden University Medical Centre, Leiden, the Netherlands.,SleepWake Centre SEIN, Zwolle, the Netherlands
| | - Hanno Pijl
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Sebastiaan Overeem
- Sleep Medicine Centre 'Kempenhaeghe', Heeze, the Netherlands.,Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Gert J Lammers
- Leiden University Medical Centre, Leiden, the Netherlands.,SleepWake Centre SEIN, Heemstede, the Netherlands
| | - Eus J W Van Someren
- Department of Sleep & Cognition, Netherlands Institute for Neuroscience, Amsterdam, the Netherlands.,Departments of Integrative Neurophysiology and Medical Psychology, Centre for Neurogenomics and Cognitive Research (CNCR), Neuroscience Campus Amsterdam, VU University and Medical Centre, Amsterdam, the Netherlands
| | - Rolf Fronczek
- Leiden University Medical Centre, Leiden, the Netherlands
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Port A, Olszewski H, Walther U, Büttner A, Rentsch D. Nachweis von γ-Hydroxybuttersäure bei γ-Butyrolacton-Abhängigkeit. Rechtsmedizin (Berl) 2014. [DOI: 10.1007/s00194-014-0966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Heytens L, Neels H, Van Regenmortel N, van den Brink W, Henckes M, Schouwers S, Dockx G, Crunelle CL. Near-fatal persistent anion- and osmolal-gap acidosis due to massive gamma-butyrolactone/ethanol intoxication. Ann Clin Biochem 2014; 52:283-7. [PMID: 25205856 DOI: 10.1177/0004563214553278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case of an ethanol and massive gamma-butyrolactone (GBL) intoxication, the precursor of the recreational drug gamma-hydroxybutyric acid (GHB), resulting in life-threatening metabolic acidosis (pH 6.5) with a highly increased anion- and osmolal gap. Rapid analysis using gas chromatography revealed a GHB plasma concentration of 4400 mg/L, far above the upper limit concentration of 1000 mg/L found in adult fatalities attributed to GBL. Full recovery was established following supportive treatment including haemodialysis. This is the first report of a combined ethanol/GBL intoxication as a cause of high serum anion- and osmolal-gap metabolic acidosis.
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Affiliation(s)
- Luc Heytens
- Department of Intensive Care, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Hugo Neels
- Toxicological Center, University of Antwerp, Antwerp, Belgium Laboratory for Clinical Chemistry and Toxicology, ZNA Stuivenberg, Antwerp, Belgium
| | | | - Wim van den Brink
- Amsterdam Institute for Addiction Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Manu Henckes
- Department of Nephrology, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Sofie Schouwers
- Clinical Laboratory, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Greet Dockx
- Laboratory for Clinical Chemistry and Toxicology, ZNA Stuivenberg, Antwerp, Belgium
| | - Cleo L Crunelle
- Toxicological Center, University of Antwerp, Antwerp, Belgium
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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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Morse BL, Morris ME. Toxicokinetics/Toxicodynamics of γ-hydroxybutyrate-ethanol intoxication: evaluation of potential treatment strategies. J Pharmacol Exp Ther 2013; 346:504-13. [PMID: 23814094 DOI: 10.1124/jpet.113.206250] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
γ-Hydroxybutyrate (GHB), a common drug of abuse, is often coingested with ethanol. Increasing renal clearance via monocarboxylate transporter (MCT) inhibition represents a potential therapeutic strategy in GHB overdose, as does inhibition of GABAB receptors. In this study, we investigate toxicokinetic/toxicodynamic interactions between GHB-ethanol and efficacy of treatment options for GHB-ethanol intoxication in rats. Sedation was assessed using the endpoint of return-to-righting reflex. Respiration was assessed using plethysmography. Coadministration of 2.0 g/kg ethanol i.v. with 600 mg/kg GHB i.v. increased sleep time compared with GHB alone. Administration of ethanol to steady-state concentrations of 0.1-0.2% and 0.3-0.4% (w/v) did not affect toxicokinetics of 600 mg/kg GHB i.v., or respiratory rate, but did result in significantly lower peak tidal volumes compared with GHB alone. Oral administration of 2.5 g/kg ethanol had no significant effect on toxicokinetics of 1500 mg/kg orally administered GHB. Pretreatment with specific receptor inhibitors indicated no effect of GABAA receptor inhibition on sleep time or respiratory depression in GHB-ethanol intoxication. GABAB receptor inhibition partially prevented sedation and completely prevented respiratory depression. Ethanol increased fatality when administered at 0.1-0.2% (4 of 10) and 0.3-0.4% (9 of 10) versus 1500 mg/kg GHB i.v. alone (0 of 10). Treatment with the MCT inhibitor, l-lactate, significantly decreased sleep time after GHB-ethanol and decreased fatality at 0.1-0.2% (0 of 10) and 0.3-0.4% ethanol (5 of 10). Treatment with a GABAB receptor antagonist completely prevented fatality at 0.3-0.4% (0 of 10). These data indicate that ethanol potentiates the sedative and respiratory depressant effects of GHB, increasing the risk of fatality. MCT and GABAB receptor inhibition represent potentially effective treatments in GHB-ethanol intoxication.
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Affiliation(s)
- Bridget L Morse
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York 14214, USA
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Schröck A, Hari Y, König S, Auwärter V, Schürch S, Weinmann W. Pharmacokinetics of GHB and detection window in serum and urine after single uptake of a low dose of GBL - an experiment with two volunteers. Drug Test Anal 2013; 6:363-6. [DOI: 10.1002/dta.1498] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/17/2013] [Accepted: 04/21/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Alexandra Schröck
- Institute of Forensic Medicine, Forensic Toxicology and Chemistry; University of Bern; Switzerland
| | - Yvonne Hari
- Institute of Forensic Medicine, Forensic Toxicology and Chemistry; University of Bern; Switzerland
| | - Stefan König
- Institute of Forensic Medicine, Forensic Toxicology and Chemistry; University of Bern; Switzerland
| | - Volker Auwärter
- Institute of Forensic Medicine; University Medical Center; Freiburg Germany
| | - Stefan Schürch
- Department of Chemistry and Biochemistry; University of Bern; Switzerland
| | - Wolfgang Weinmann
- Institute of Forensic Medicine, Forensic Toxicology and Chemistry; University of Bern; Switzerland
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Neijzen R, Ardenne PV, Sikma M, Egas A, Ververs T, Maarseveen EV. Activated charcoal for GHB intoxication: An in vitro study. Eur J Pharm Sci 2012; 47:801-3. [DOI: 10.1016/j.ejps.2012.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/19/2012] [Accepted: 09/02/2012] [Indexed: 11/25/2022]
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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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Hospital in the Field: Prehospital Management of GHB Intoxication by Medical Assistance Teams. Prehosp Disaster Med 2012; 27:463-7. [DOI: 10.1017/s1049023x12000994] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroductionRecreational use of gamma-hydroxybutyrate (GHB) is increasingly common at mass-gathering dance events in Australia. Overdose often occurs in clusters, and places a significant burden on the surrounding health care infrastructure.ObjectiveTo describe the clinical presentation, required interventions and disposition of patrons with GHB intoxication at dance events, when managed by dedicated medical assistance teams.MethodsRetrospective analysis of all patrons attending St. John Ambulance medical assistance teams at dance events in the state of Victoria (Australia), from January 2010 through May 2011.Main outcome measuresClinical presentation, medical interventions and discharge destination.ResultsSixty-one patients with GHB intoxication attended medical teams during the study period. The median age was 22 years, and 64% were male. Altered conscious state was present in 89% of attendances, and a GCS <9 in 44%. Hypotension, bradycardia and hypothermia were commonly encountered. Endotracheal intubation was required in three percent of patrons. Median length of stay onsite was 90 minutes. Ambulance transport to hospital was avoided in 65% of presentations.ConclusionsThe deployment of medical teams at dance events and music festivals successfully managed the majority of GHB intoxications onsite and avoided acute care ambulance transfer and emergency department attendance.DutchMJ,AustinKB.Hospital in the field: prehospital management of GHB intoxication by medical assistance teams.Prehosp Disaster Med.2012;27(4):1-5.
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Abstract
Adolescents are experimenting with recreational drugs on a regular basis, particularly at social gatherings such as parties, raves and mass events. A combination of reduced fluid intake, physical activity and drug-induced hyperthermia leads to complications such as heat stroke, delirium and potentially death. The clinician needs to be aware of the variety of pharmacologically active substances available in the recreational marketplace in order to diagnose and manage these patients. Recreational misadventure, because of incorrect dosage or mixing multiple substances, is a common reason for teenagers presenting to hospital with toxidromes. Death from club drug overdose is more likely to be associated with suicidal intent, related risky behaviour and trauma, as well as the inherent toxicity of the drug itself. Although many teenagers are concerned about 'drink spiking' with club drugs, the most common agent causing drink spiking incidents is ethanol.
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Affiliation(s)
- Naren Gunja
- The Children's Hospital at Westmead, Westmead, Australia.
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van Amsterdam JG, van Laar M, Brunt TM, van den Brink W. Risk assessment of gamma-hydroxybutyric acid (GHB) in the Netherlands. Regul Toxicol Pharmacol 2012; 63:55-63. [DOI: 10.1016/j.yrtph.2012.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/22/2012] [Accepted: 03/07/2012] [Indexed: 11/26/2022]
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Hensley LG. Drug-Facilitated Sexual Assault on Campus: Challenges and Interventions. JOURNAL OF COLLEGE COUNSELING 2011. [DOI: 10.1002/j.2161-1882.2002.tb00219.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bramness JG, Haugland S. [Abuse of γ-hydroxybutyrate]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:2122-5. [PMID: 22048208 DOI: 10.4045/tidsskr.10.1454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Gamma-hydroxybutyrate (GHB) is naturally present in the human body, but may also be used as an intoxicating drug. Information from several sources has suggested its increased availability and use in Norway. There have also been reports of an increasing use of the chemical precursor gamma-butyrolactone (GBL).There is currently a need for knowledge on symptoms, addictiveness and overdoses, as well as targeted preventive measures. MATERIAL AND METHODS The article is based on a discretionary selection of articles resulting from a literature search in PubMed, as well as reports from Norwegian and European authorities and research institutions. RESULTS An intake of small amounts of GHB produces an intoxicating effect, whereas higher doses can result in poisoning. Deaths have been reported. The effect may be variable, due to a steep dose-response curve and interaction with alcohol and other intoxicants. Treatment of poisoning is symptomatic and supportive. Treatment of abstinence is also supportive, while delirium may be treated as delirium tremens. INTERPRETATION Preventive measures should be tailored specifically to potential user-groups.
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Affiliation(s)
- Jørgen G Bramness
- Senter for rus og avhengighetsforskning, Universitetet i Oslo, Norway.
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Michaeli B, Vallotton L, Yersin B, Carron PN. Fibrillation auriculaire paroxystique sur overdose de gamma-hydroxybutyrate (GHB). ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0123-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Wood DM, Brailsford AD, Dargan PI. Acute toxicity and withdrawal syndromes related to γ-hydroxybutyrate (GHB) and its analogues γ-butyrolactone (GBL) and 1,4-butanediol (1,4-BD). Drug Test Anal 2011; 3:417-25. [PMID: 21548140 DOI: 10.1002/dta.292] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 03/21/2011] [Accepted: 03/22/2011] [Indexed: 02/05/2023]
Abstract
Gamma-hydroxybutyrate (GHB) has been used as a recreational drug since the 1990s and over the last few years there has been increasing use of its analogues gamma-butyrolactone (GBL) and to a lesser extent 1,4-butanediol (1,4BD). This review will summarize the literature on the pharmacology of these compounds; the patterns and management of acute toxicity associated with their use; and the clinical patterns of presentation and management of chronic dependency associated with GHB and its analogues.
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Affiliation(s)
- David M Wood
- Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Determination of gamma-hydroxybutyric acid in dried blood spots using a simple GC-MS method with direct “on spot” derivatization. Anal Bioanal Chem 2010; 398:2173-82. [DOI: 10.1007/s00216-010-4183-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 08/13/2010] [Accepted: 08/30/2010] [Indexed: 01/18/2023]
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Knudsen K, Jonsson U, Abrahamsson J. Twenty-three deaths with gamma-hydroxybutyrate overdose in western Sweden between 2000 and 2007. Acta Anaesthesiol Scand 2010; 54:987-92. [PMID: 20701597 DOI: 10.1111/j.1399-6576.2010.02278.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND gamma-Hydroxybutyrate (GHB) is a drug of abuse with a status as being safe. In spite of a reputation of low toxicity, a huge number of deaths associated with this drug have been recorded during recent years in Sweden. It is unclear whether coingestion with other drugs or ethanol causes death in GHB overdoses or whether GHB itself is the main cause of death. OBJECTIVES The aim of this study was to analyze the cause of death in GHB-related fatalities seen in our region. METHODS All cases of deaths with GHB during the year 2000-2007 in the region of western Sweden were studied retrospectively. The cases were classified as either GHB poisonings without any, with a minor or a major influence of other drugs on the cause of death. RESULTS Twenty-three cases were diagnosed as deaths due to GHB overdose. Ninety-one percent coingested other substances. Ninety-one percent of the decedents were male. Age varied between 16 and 46, with the median age at 25 years. Forty-three percent of the cases were classified as GHB poisonings without any or a minor influence of other drugs on the cause of death. Thirty percent also ingested ethanol. Two patients (9%) were only intoxicated with GHB. CONCLUSIONS Intoxication with GHB carries some mortality. Combining GHB with ethanol does not explain the many deaths in our region, nor do extremely high plasma concentrations of GHB. The intake of opioids increases the toxicity of GHB. The drug itself has such biological activities that an overdose is dangerous and may lead to death.
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Affiliation(s)
- K Knudsen
- Department of Anesthesia and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Kantrowitz JT, Citrome L, Javitt DC. A review of tolerability and abuse liability of gamma-hydroxybutyric acid for insomnia in patients with schizophrenia. Clin Ther 2009; 31 Pt 1:1360-73. [PMID: 19698899 DOI: 10.1016/j.clinthera.2009.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Approved therapeutic uses for gamma-hydroxybutyric acid (GHB) (or sodium oxybate), a gamma-aminobutyric acid type B and GHB receptor agonist, include narcolepsy in the United States and Europe and alcohol abuse treatment in Italy. Possible efficacy of GHB in schizophrenia has also been proposed. A tolerability concern regarding use of GHB is its abuse potential. Given the high comorbidity of substance disorders and schizophrenia, a systematic assessment of the published literature is crucial. OBJECTIVE The aim of this review was to assess the tolerability and abuse liability of GHB in the context of future clinical studies as a potential treatment for insomnia in patients with schizophrenia. METHODS A literature search in English (inception through April 2009, inclusive) was conducted of MEDLINE, EMBASE, and PsycINFO using the search term GHB. All articles whose abstracts mentioned human use of GHB were read in their entirety. The reference sections of identified articles were reviewed for publications that might have been missed by the initial search. RESULTS GHB is abused by a small percentage of people (<1%) as a "club drug" and is commonly associated with enhanced sexual experiences (65%), euphoria (41%), somnolence (71%), and confusion (24%), according to a recent study. A review of all available emergency room case series suggests that while GHB can be associated with serious coma necessitating intubation, the number of reported fatal cases associated with GHB appears limited. Clarity on the lethality of GHB is complicated by instability of GHB in postmortem samples and frequent concomitant ingestions. Furthermore, formal abuse liability studies do not support high abuse propensity for GHB, mainly because oversedation and dizziness may lead most individuals to find GHB unpleasant at high doses. As supported by 2 large studies, there is limited evidence to suggest widespread use as an agent in sexual assault. Years of clinical use in narcolepsy do not support the development of tolerance or withdrawal in those subjects without substance dependence. CONCLUSIONS Tolerability and abuse liability issues, while a concern with GHB given its abuse potential, do not preclude further study of the potential use for insomnia in nondually diagnosed schizophrenia. Full cognizance must be taken of risk/benefit tradeoffs, and to the development of improved formulations with decreased abuse liability.
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Affiliation(s)
- Joshua T Kantrowitz
- Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York 10962, USA.
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Dunn M, Topp L, Degenhardt L. GHB in Sydney, Australia, 2000–2006: A case study of the EDRS as a strategic early warning system. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2009; 20:413-7. [DOI: 10.1016/j.drugpo.2009.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 01/06/2009] [Accepted: 01/12/2009] [Indexed: 10/21/2022]
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