GHB is a natural endogenous neurotransmitter. It can also be ingested orally and crosses the blood-brain barrier. It is structurally similar to gamma-aminobutyric acid (GABA) and acts on GABA & GHB receptors in brain with effects on the dopaminergic system. It is rapidly eliminated and not detectable after: 4 hours in the blood 12 hours in the urine.



This poster includes: Symptoms of GHB overdose and withdrawal, Management of GHB overdose and withdrawal, Treatment episodes & outcomes in the GHB clinic

Gibbons, Zorina

Keenan, Eamon

McCarron, Peter

Santlal, Kiran

National Documentation Centre on Drug Use

GAMMA	HYDROXYBUTYRATE	&	GAMMA	BUTROLACTONE	(GHB/GBL):		A	CASE	SERIES	OF	INPATIENT	&	OUTPATIENT	DETOXIFICATION	Dr. Kiran Santlal1, Dr. Zorina Gibbons1, Dr. Peter McCarron1, Dr. Eamon Keenan2	1National Drug Treatment Centre, Dublin 	2HSE-National Clinical Lead-Addiction Services	Introduc)on		GHB	 is	 a	 natural	 endogenous	 neurotransmi.er.	 It	 can	 also	 be	ingested	orally	and	crosses	the	blood-brain	barrier.		It	 is	structurally	similar	to	gamma-aminobutyric	acid	(GABA)	and	acts	 on	 GABA	 &	 GHB	 receptors	 in	 brain	 with	 eﬀects	 on	 the	dopaminergic	system.1	It	is	rapidly	eliminated	and	not	detectable	aRer:	4	hours	in	the	blood	12	hours	in	the	urine		The	more	recent	primary	mode	of	GHB	abuse	worldwide	has	been	for	its	subjecUve	eﬀects	on:	Sociability	–	increased	conﬁdence	Sexuality	–	higher	libido	&	disinhibiUon	Sleep	–	chronic	usage	&	higher	doses		GBL	&	GHB	are	iniUally	consumed	during:	Club	&	Circuit	Par)es	–	as	a	precursor	to	aRer-parUes	ACer-par)es	 –	 Drug	 cocktail,	 with	 Ecstasy,	 LSD,	 Alcohol,	Mephedrone,	Cannabis,	Sildenaﬁl	(Viagra),	Cocaine,	Crystal	Meth	Saunas,	 Sex	 clubs	 &	 Chemsex	 par)es	 –	 mulUple	 partners	(average	 of	 5).	 Risk	 of	 unprotected	 consensual	 sex,	 and	unprotected	non-consensual	sex	(1	in	4	GHB	users	pass	out).2	72	 hour	 Chemsex	 binges	 may	 be	 the	 “Perfect	 Storm”	 for	 HIV/HepaUUs	C	transmission.	People	involved	in	these	parUes	may	end	up	 losing	 days/turning	 up	 too	 late	 for	 anU-viral	 drugs	 (PEP)	 or	emergency	contracepUon.			It	is	very	easy	to	overdose	on	G	because3:	-	Strengths	can	vary	from	shipment	to	shipment	-	Doses	involved	measured	in	such	small	quanUUes	-	Narrow	therapeu)c	index										1	milligram	=	Euphoria										1.5	milligrams	=	Sleep	Discussion		Why	Did	They	Relapse?	-	Previously	moved	in	G-using	circles	-	Unable	to	have	sex	without	GBL/GHB	-	Many	liked	person	they	were,	“beher	than	without	it”	-	 Unable	 to	 cope	 with	 withdrawal	 symptoms	 e.g.	 anxiety,	panic	ahacks,	&	insomnia	for	a	several	weeks	-	Relapse	on	either	GHB	or	onto	alcohol		PaUents	 can	 successfully	 detox	 but	 sUll	 be	 unprepared	 for	what	they	might	encounter	on	the	clubbing	scene		-	Culture	that	can	be	defensive	about	right	to	use	drugs		-	Widespread	normalisaUon	and	availability	of	drugs		-	Porn-star	expectaUons		-	Online	rejecUons		-	HIV	sUgma		Highest	risk	of	relapse	was	typically	1	week	post	detoxiﬁcaUon	–	follow	up	must	be	structured	&	frequent	for	at	least	4	weeks	Baclofen	 could	 be	 conUnued	 for	 up	 to	 2	 weeks	 aRer	 the	regimen	has	ceased	as	this	medicaUon	alleviates	some	distress		Harm	ReducUon	InformaUon	Harm	 reducUon	 –	 PaUent	 educaUon:	 Dosing	 of	 G,	 9mings,	potenUally	dangerous	interac9ons	with	other	drugs	or	alcohol,	potenUal	for	sexual	harm,	or	other	health	harms	that	can	arise	from	 prolonged	 use	 or	 overdosing,	 G	 Card,	 G	 Posters	 &	InformaUon	Packet	References:	1Noorden	 M,	 et	 al,	 Gamma-hydroxybutyrate	 Withdrawal	 Syndrome:	 Dangerous	 but	 Not	 Well	 Known.	 General	 Hospital	Psychiatry	209;	31:394	–	396	2O’Donnell	K,	et	al.	MISI	2015,	Findings	From	the	Men	Who	Have	Sex	With	Men	Internet	Survey	3Barker	et	al.	Experiences	of	Gamma	Hydroxybutyrate	(GHB)	IngesIon:	A	Focus	Group	Study,	J	PsychoacIve	Drugs.	2007	Jun;	39	(2):	115	–	129	4Mio2o	K,	et	al.	GHB	Withdrawal	Syndrom,	March	2001;	Texas	Commission	on	Alcohol	and	Drug	Abuse	5Taylor	D,	et	al.	The	Maudsley	Prescribing	Guidelines	in	Psychiatry	12th	EdiIon	6McDonough	M,	 et	 al.	 Clinical	 features	 and	management	 of	Gamma-Hydroxybutyrate	 (GHB)	Withdrawal:	 A	 Review.	Drug	&	Alcohol	Dependence.	2004;	75	(1):	3	–	9	7Decision	 Rules	 for	 GHB	 (Gamma-Hydroxybutyric	 Acid)	 DetoxiﬁcaIon:	 A	 Vigne2e	 Study,	 Drug	 and	 Alcohol	 Dependence	 135	(2014)	146	–	151		Resources	Involved	in	Development	of	GHB	Clinic:	NaUonal	Drug	Treatment	Centre	St.	Michael’s	Ward,	Beaumont	Hospital	Rialto	Community	Drug	Team	General	PracUUoners,	Medical	&	Psychiatric	Teams	in	hospital	GUIDE	Clinics	&	Gay	Men’s	Health	Project	Emergency	Departments	&	Paramedics		Psychologists	&	Counsellors		Chemsex	Working	Group:	NaUonal	Drug	Treatment	Centre	Gay	Men’s	Health	Project	Ana	Liﬀey	Drug	Project	HIV	Ireland	Gay	Health	Network	Onset	&	Dura)on	 Overdose	 Withdrawals	Onset	 Within	a	few	minutes	of	ingesUon	 1	–	2	hours	aRer	last	dose	Progression		Rapidly	progresses	regardless	of	treatment		Rapidly	progresses	if	untreated/inadequate	treatment		DuraUon	 Typically	persists	for	1	–	3	hours	 Can	last	up	to	12	days	Recovery	Rapid	improvement		(4	–	8	hours)	with	supporUve	hospital	care.	Withdrawal	symptoms	can	develop	up	to	48	hours	post	recovery		Usually	complete	recovery	with	medicaUon,	and	input	from	other	members	of	MDT		Severity	 Overdose	 Withdrawals	Mild	Euphoria, nausea, ataxia, hypersalivation, vomiting, diarrhoea, headache, amnesia		Anxiety, tremor, insomnia, nausea & vomiting, hypertension, tachycardia		Moderate	Confusion/psychosis, agitation, drowsiness, tremor, myoclonus, urinary incontinence, 	 hypotonia, hypothermia, hypotension, bradycardia		Severe anxiety, confusion, delirium, formication, visual hallucinations	Severe	Coma, convulsions,, 	ECG abnormalities 	(U waves), 	Cheyne-Stokes respiration & respiratory depression leading to respiratory arrest		Agitation, paranoia & psychosis	Rhabdomyolysis & seizures 	(For transfer to ICU)		Acute	Clinical	Management	 Overdose	 Withdrawals	Assessment		Standard	medical	assessment		Urine	Drug	Screening	–	outrule	other	causes		Current	Substance	(Polysubstance)	Use.	QuanUfy	intake:		“round	the	clock	use”	–	dosing	every	1	–	2	hours		Laboratory	InvesUgaUons		Hypernatraemia,	Hyperglycaemia,	Hypokalaemia,		Metabolic	acidosis		Baseline;	FBC,	U&E,	LFT,	TFT,	CRP	CreaUne	Kinase	–	Rhabdomyolysis	Urine	Drug	Screen,	ECG		Management/	MedicaUon			TOXBASE®	recommends	in	clinical	uncertainty,		consider	a		Naloxone	(opioid	antagonist)	ﬁrst.		Medical	management.		Chlordiazepoxide/Diazepam	Baclofen	Sodium	Valproate	Melatonin		0	2	4	6	8	10	12	31/12/14	 31/12/15	 31/12/16	 26/05/17	Re-referrals	 0	 0	 4	 5	New Referrals	 1	 5	 1	 6	New Referrals & Re-referrals Since Commencement	Heterosexual Female	23%	Homosexual Male	60%	Heterosexual Male	17%	Sexuality & Gender		Maudsley	Guidelines	(Community	Detoxiﬁca)on)5		• Dispose	of	remaining	supply	&	no	GHB	usage	for	2	hours	prior	to	prescribing	Diazepam	20mg	on	1st	day	of	detoxiﬁcaUon	• 	Repeat	aRer	2	hours	&	Administer	Baclofen	10mg	• Dispense	another	40mg	Diazepam	&	30mg	Baclofen		–	Up	to	60	–	80mg	Diazepam/24	hours.			• If	 total	 Diazepam	 >100mg/24	 hours	 not	 controlling	 symptoms,	medical	consultaUon	recommended.		• Adjust	medica9on	daily	–	Seldom	needed	beyond	4	–	6		days	• Advisable	 to	 have	 Flumazenil	 available	 in	 the	 event	 of	 a	Benzodiazepine	overdose		NHS	Lothian	Guidelines	for	GHB	Detoxiﬁca)on6,7	Symptoms of GHB Overdose and Withdrawal3,4	Management	of	GHB	Overdose	and	Withdrawal:		Methods	Criteria	for	inpa)ent	management	“Round	the	clock”	usage	–	every	1	–	2	hours,	throughout	the	day	Previous	unsuccessful	detoxiﬁcaUons	Medically	complicated	picture	–	Epilepsy/BZD	Withdrawal	seizures	Alert	Medical	teams	on	call		Criteria	for	Outpa)ent	Management	of	GHB	Withdrawal:	Solely	G	usage	–	no	regular	usage	of	other	substances	No	medical	history	of	Epilepsy/BZD	withdrawal	seizures	Suppor9ve	 home	 environment	 –	 ahend	 with	 designated	 non-substance	using	friend/family	member	who	will	monitor	overnight	PotenUal	rapid	access	to	inpaUent	care	Early	and	aggressive	management	Close	monitoring	over	2	–	4	weeks	for	tachycardia,	insomnia,	anxiety,	and/or	any	medical	deterioraUon	Results	G Clinic - Inpatient (n=5)	25%	G Clinic - Outpatient (n=12)	44%	Medical Inpatient &	G Clinic Outpatient (n=4) 31%	Treatment Episodes & Outcomes	G Clinic Inpatient	G Clinic Outpatient	Medical Inpt. & G Clinic OPD	Unsuccessful	3	6	1	0	2	5	2	2	Outcomes of G Clinical & Medical Detoxiﬁcation	No Relapse	 Relapse	

Gamma Hydroxybutyrate & Gamma Butrolactone (GHB/GBL): a case series of inpatient & outpatient detoxification.

https://www.drugsandalcohol.ie/29988/1/club-health-conference-ghb-poster.pdf

Gamma Hydroxybutyrate & Gamma Butrolactone (GHB/GBL): a case series of inpatient & outpatient detoxification.

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National Documentation Centre on Drug Use