The Effect of Co-occurring Substance Use on Gamma-hydroxybutyric Acid Withdrawal Syndrome

A narrative review of outcome measures used in drug and alcohol inpatient withdrawal treatment research

ISSUES

Assessing drug and alcohol inpatient withdrawal treatment programs is important, as these represent a first step of treatment among people with alcohol and drug problems. However, there are many ways of measuring outcomes making it difficult for service providers to decide which domains and methods to use. This narrative review aims to clarify frequencies of the domains and methods used to assess withdrawal treatment outcomes.

APPROACH

We reviewed published studies that examined outcomes of inpatient drug and alcohol withdrawal treatment. The types of outcome measures used and the frequency of use were summarised.

KEY FINDINGS

The review showed that assessment of withdrawal treatment outcomes goes beyond traditional abstinence measures. Outcomes mainly focus on biological and psychological outcomes, with social outcomes rarely measured. Even within outcome domains (e.g., cravings), there were many assessment methods.

IMPLICATIONS

The review provides service providers with an outline of common outcome domains and measures. Given the importance of social functioning to recovery from alcohol and drug problems, greater emphasis on such measures is desirable. Future research could develop greater consensus on outcome measures for use in withdrawal management services to facilitate clarity around factors associated with treatment success.

CONCLUSION

Outcome assessment in withdrawal treatment goes beyond abstinence to include holistic measurement of biological, psychological and some social outcomes; but more work needs to be done to cohere the different assessment methods and broaden the scope to include social functioning.

Inpatient GHB withdrawal management in an inner-city hospital in Sydney, Australia: a retrospective medical record review

RATIONALE

Regular consumption of gamma-hydroxybutyrate (GHB) may result in a dependence syndrome that can lead to withdrawal symptoms. There are limited data on medications to manage GHB withdrawal.

OBJECTIVES

To examine characteristics associated with delirium and discharge against medical advice (DAMA), in the context of implementing a GHB withdrawal management protocol at an inner-city hospital in 2020.

METHODS

We retrospectively reviewed records (01 January 2017-31 March 2021), and included admissions that were ≥ 18 years of age, admitted for GHB withdrawal, and with documented recent GHB use. Admissions were assessed for demographics, medications administered, features of delirium, ICU admission, and DAMA. Exploratory analyses were conducted to examine factors associated (p < 0.2) with features of delirium and DAMA.

RESULTS

We identified 135 admissions amongst 91 patients. Medications administered included diazepam (133 admissions, 98.5%), antipsychotics (olanzapine [70 admissions, 51.9%]), baclofen (114 admissions, 84%), and phenobarbital (8 admissions, 5.9%). Features of delirium were diagnosed in 21 (16%) admissions. Delirium was associated with higher daily GHB consumption prior to admission, while duration of GHB use, time from presentation to first dose of diazepam, and concomitant methamphetamine use were inversely associated with delirium. DAMA occurred amongst 41 (30%) admissions, and was associated with a longer time from presentation to first dose of baclofen, while being female and receiving a loading dose of diazepam were inversely associated.

CONCLUSIONS

This study adds to the literature in support of the safety and feasibility of diazepam and baclofen for the management of GHB withdrawal. Prospective, randomised trials are required.

Gamma-hydroxybutyric acid-induced organic delirium complicated by polydrug use successfully treated with electroconvulsive therapy: a case report

Background

Patients with gamma-hydroxybutyric acid withdrawal symptoms are at high risk of developing organic delirium, which can be fatal. The recommended first-line treatment is benzodiazepines, but treatment-resistant cases are frequent. Here we describe a case of successful bilateral electroconvulsive therapy in a patient with severe and highly agitated acute organic delirium induced by gamma-hydroxybutyric acid withdrawal and complicated by polydrug use resistant to first-line treatment. To our knowledge, this is the first report on the effect of electroconvulsive therapy on treatment-resistant delirium caused by gamma-hydroxybutyric acid withdrawal.

Case presentation

A 21-year-old Danish man diagnosed with untreated attention deficit hyperactivity disorder developed severely agitated acute organic delirium caused by gamma-hydroxybutyric acid withdrawal in a Danish psychiatric ward. The patient was subjected to physical restraints and transferred to the intensive care unit for treatment. During the next 10 days, the patient showed no clinical improvement despite first-line, high-dose benzodiazepines along with intense supportive treatment with propofol, phenobarbital, and antipsychotics. On day 11, bilateral frontotemporal electroconvulsive therapy treatment was initiated and full clinical recovery was obtained after four sessions.

Discussion

The full clinical remission after four electroconvulsive therapy sessions, strongly supports that electroconvulsive therapy may be an effective treatment when severe delirium induced by gamma-hydroxybutyric acid withdrawal is resistant to conventional first-line treatment with benzodiazepines. Moreover, this case illustrates that clinically effective seizures were achieved despite intensive concurrent exposure to anticonvulsive drugs. Therefore, this case report encourages consideration of electroconvulsive therapy in patients with gamma-hydroxybutyric acid delirium who are resistant to psychopharmacological treatment.

Successful Treatment of Severe Gamma-Hydroxybutyric Acid Withdrawal Syndrome With Dantrolene

The prevalence of gamma-butyrolactone/gamma-hydroxybutyric acid (GBL/GHB) use is increasing. The gravity and number of incidents with this drug are relatively high. A feared complication is addiction and its withdrawal syndrome, which can be life-threatening and is difficult to treat. We present the case of a 31-year-old man, admitted to the ICU because of accidental GBL withdrawal. The patient was tachycardic, sweaty, extremely agitated, and showed signs of psychosis. High doses of benzodiazepines, propofol, sufentanil, and quetiapine could not sedate the patient sufficiently. Dosing with pharmaceutical GHB was challenging due to severe gastric retention. As the patient developed hyperthermia and rhabdomyolysis, signs of a neuroleptic malignant syndrome (NMS), he was treated with dantrolene. After 14 days, the patient was discharged to a psychiatric clinic for further treatment. GHB affects multiple neurotransmitters and chronic use causes the up- or down-regulation of several receptors. During GHB withdrawal, the patient developed a hyperexcitable state, in which there was insufficient gamma-aminobutyric acid (GABA) (the most important inhibiting neurotransmitter) and an abundance of glutamate (the most important excitatory neurotransmitter). High-dose benzodiazepines are often advocated as the first-line treatment, but benzodiazepine resistance has frequently been reported. Therefore, treatment with pharmaceutical GHB is advised. Patients with GHB-withdrawal who have clinical signs of NMS can be treated with dantrolene because it regulates the distorted calcium secretion and affects the serotonin and cholinergic system.

Characterization of the GHB Withdrawal Syndrome

The gamma-hydroxybutyric acid (GHB) withdrawal syndrome can have a fulminant course, complicated by severe complications such as delirium or seizures. Detoxification by tapering with pharmaceutical GHB is a safe way to manage GHB withdrawal. However, a detailed description of the course of the GHB withdrawal syndrome is currently lacking. This study aimed to (1) describe the course of GHB withdrawal symptoms over time, (2) assess the association between vital signs and withdrawal symptoms, and (3) explore sex differences in GHB withdrawal. In this observational multicenter study, patients with GHB use disorder (n = 285) were tapered off with pharmaceutical GHB. The most reported subjective withdrawal symptoms (SWS) were related to cravings, fatigue, insomnia, sweating and feeling gloomy. The most prevalent objective withdrawal symptoms (OWS) were related to cravings, fatigue, tremors, sweating, and sudden cold/warm feelings. No association between vital signs and SWS/OWS was found. Sex differences were observed in the severity and prevalence of specific withdrawal symptoms. Our results suggest that the GHB withdrawal syndrome under pharmaceutical GHB tapering does not strongly differ from withdrawal syndromes of other sedative drugs. The lack of association between vital signs and other withdrawal symptoms, and the relative stability of vitals over time suggest that vitals are not suitable for withdrawal monitoring. The reported sex differences highlight the importance of a personalized approach in GHB detoxification.

Unity in diversity: A systematic review on the GHB using population

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.

Successful treatment of severe, treatment resistant GHB withdrawal through thiopental-coma

BACKGROUND

In patients with gamma-hydroxybutyrate (GHB) use disorder (GUD), withdrawal can have a fulminant course with rapid progression of severe, potentially life-threatening complications. Case: We present a 45-year old man with severe GHB withdrawal, resistant to conventional treatment with pharmaceutical GHB, high doses of benzodiazepines and baclofen. GHB withdrawal finally responded to thiopental-induced coma therapy, with burst suppression pattern on electroencephalography (EEG). The patient fully recovered, without withdrawal or residual neuropsychiatric symptoms. Discussion: To our knowledge, this is the first case report in which barbiturates were used to induce a coma to treat severe, treatment resistant GHB withdrawal. This case suggests barbiturate coma therapy might be considered in severe GHB withdrawal which does not respond to conventional treatment.

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

BACKGROUND

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

CASE

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

CONCLUSION

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

Demographic and Clinical Characteristics of Regular GHB-Users with and without GHB-Induced Comas

Gamma hydroxybutyric acid (GHB) has been used recreationally for nearly three decades and its chronic use is frequently associated with serious adverse events including GHB-intoxication with GHB-induced comas. Moreover, despite its low prevalence, the number of individuals with GHB-use disorders is steadily increasing. However, the risk-factors associated with chronic GHB-use or the development of a GHB-use disorders remain poorly understood. Purpose: This study aims to profile two types of GHB-users, those with and those without GHB-induced comas. Methods: We included 27 GHB users with ≥4 GHB-induced comas (GHB-Coma), 27 GHB users without a coma (GHB-NoComa), and 27 polydrug users who never used GHB (No-GHB). Participants completed self-reported questionnaires in order to assess their demographic and clinical features, and their use profile of GHB and other drugs. Results: The typical GHB user in our sample was young, single, living alone, well-educated, and a student. The GHB-Coma group had lower self-control and reported higher negative affect than the GHB-NoComa group. GHB-Coma participants were heavier GHB users and mostly used GHB alone at home, whereas the GHB-NoComa group mostly used GHB with friends and in nightclubs. Remarkably, the majority of participants were not concerned about potential neurocognitive impairments induced by GHB-intoxication and/or GHB-induced comas. Conclusion: In this assessment, different profiles for recreational users with and without GHB-induced comas were well expressed. Their description contributes to a better understanding of the risk factors associated with recreational GHB-use, GHB-induced coma, and the development of GHB-use disorders.

Inpatient management of gamma-hydroxybutyrate withdrawal

OBJECTIVES

To describe the baseline characteristics, treatment and retention in patients electively admitted for gamma-hydroxybutyrate (GHB) withdrawal management.

METHODS

All patients admitted between July 2010 to June 2016 who used GHB two or more times per week with a minimum duration of 3 months were identified and data extracted by file review.

RESULTS

Twelve cases satisfied the inclusion criteria, of whom 50% were female; 75% were using GHB daily, with an average daily amount of 16 ml. Average duration of use was 60 months. All subjects were using amphetamine type stimulants and nicotine. Psychiatric comorbidity and unintentional overdose were common; 50% completed treatment. Medications used included diazepam and neuroleptic. Two patients completed withdrawal with no medications. No subject using greater than 90 ml GHB in the preceding week completed treatment. Pattern of GHB use did not predict medication requirements during withdrawal management.

CONCLUSIONS

There were low numbers attending for elective treatment for GHB use. Heavier GHB use predicted poor treatment retention. Polysubstance use and psychiatric co-morbidities need consideration in treatment planning.

Inpatient Gamma-Hydroxybutyrate Detoxification: A Case Report Describing Day-to-day Therapeutic Management

BACKGROUND

Gamma-hydroxybutyrate (GHB) is a synthetic drug increasingly used by consumers of psychoactive substances. The sought after psychoactive effects of GHB have resulted in an increase in recreational use in Europe. GHB is considered to have a high dependence potential, and abrupt discontinuation after long-term use can result in a severe withdrawal syndrome. Despite a large number of publications related to GHB withdrawal and detoxification, to date, no evidence-based protocol or consensual international therapeutic guidelines are available (over and above the administration of benzodiazepines). We hereby present a day-to-day description of inpatient GHB detoxification management, from admission to discharge.

CASE SUMMARY

This case report pertains to a 47-year-old patient hospitalized for a severe GHB use disorder. The patient had independently made several unsuccessful attempts to stop GHB use. Following to these failures, the patient was oriented to our addiction department for inpatient detoxification. Withdrawal symptoms appeared 4 hours after the last dose of GHB, and consisted of diaphoresis, coenesthetic hallucinations, tremors, motor instability, tachycardia, and a hypertensive peak. Symptoms were successfully managed with diazepam titration and nonpharmacological treatment. The duration of hospitalization was 13 days. At discharge, detoxification was complete and the patient was engaged in relapse prevention therapy. Three months after discharge, the patient had maintained abstinence.

CONCLUSIONS

GHB withdrawal, which can be severe, is better prevented or attenuated by daily medical monitoring and adjustment of treatment dosage. Failure of outpatient detoxification should be included in the indication criteria in the guidelines for inpatient detoxification.

Pharmacological Treatment in γ-Hydroxybutyrate (GHB) and γ-Butyrolactone (GBL) Dependence: Detoxification and Relapse Prevention

The misuse of γ-hydroxybutyrate (GHB) for recreational purposes has resulted in an increase in GHB-related problems such as intoxications, dependence and withdrawal in several countries in Europe, Australia and the US over the last decade. However, prevalence rates of misuse of GHB and its precursor, γ-butyrolactone (GBL), are still relatively low. In this qualitative review paper, after a short introduction on the pharmacology of GHB/GBL, followed by a summary of the epidemiology of GHB abuse, an overview of GHB dependence syndrome and GHB/GBL withdrawal syndrome is provided. Finally, the existing literature on management of GHB detoxification, both planned and unplanned, as well as the available management of GHB withdrawal syndrome, is summarized. Although no systematic studies on detoxification and management of withdrawal have been performed to date, general recommendations are given on pharmacological treatment and preferred treatment setting.