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Freeman G, Siefried KJ, Roberts DM, Rodgers C, Nic Ionmhain U, Ramanathan J, Ezard N, Brett J. Phenobarbital to manage severe gamma-hydroxybutyrate withdrawal: A case series. Drug Alcohol Rev 2023; 42:27-32. [PMID: 36269081 DOI: 10.1111/dar.13556] [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: 05/18/2022] [Revised: 08/05/2022] [Accepted: 09/13/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Management of a withdrawal syndrome following cessation of regular gamma-hydroxybutyrate (GHB) use, and its precursors, can represent a clinical challenge due to rapid onset delirium and/or seizures. Severe GHB withdrawal can be characterised by persistent or worsening features despite increasing benzodiazepine doses and regular baclofen. Barbiturates, such as phenobarbital, are an appealing option in this context due to their unique GABA-A receptor action. CASE SERIES This series describes the use of phenobarbital in 13 cases, 12 patients, across two hospitals in Sydney, Australia, with persistent or progressive GHB withdrawal despite benzodiazepine-based management. A median cumulative dose of oral diazepam prior to commencing phenobarbital was 120 mg (range 80-255 mg). The median time from the last GHB use to the first dose of phenobarbital was 24 h (range 7-57 h). Eight cases received phenobarbital orally on a general ward and 5 intravenously in intensive care units. An improvement in GHB withdrawal symptoms was observed after phenobarbital in all cases and there were no adverse events related to phenobarbital. DISCUSSION AND CONCLUSION This case series suggests that phenobarbital for the management of benzodiazepine-resistant GHB withdrawal can be safe, even in general inpatient settings, and may avert the progression of delirium. Most data on the management of GHB withdrawal comes from case reports or series, such as this one. This highlights the need for prospective trials to establish an evidence base for therapeutic approaches, including validated measures of withdrawal severity and more information relating to the safe and effective dosing of phenobarbital.
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Affiliation(s)
- Georgia Freeman
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia
| | - Krista J Siefried
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia.,National Centre for Clinical Research on Emerging Drugs of Concern, c/o UNSW, Sydney, Australia.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, UNSW Sydney, Sydney, Australia.,Drug Health, Royal Prince Alfred Hospital, Sydney, Australia
| | - Craig Rodgers
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia
| | - Una Nic Ionmhain
- Liverpool Hospital, Sydney, Australia.,South West Sydney Clinical School, UNSW Sydney, Sydney, Australia
| | | | - Nadine Ezard
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia.,National Centre for Clinical Research on Emerging Drugs of Concern, c/o UNSW, Sydney, Australia.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Jonathan Brett
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, UNSW Sydney, Sydney, Australia
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Tay E, Lo WKW, Murnion B. Current Insights on the Impact of Gamma-Hydroxybutyrate (GHB) Abuse. Subst Abuse Rehabil 2022; 13:13-23. [PMID: 35173515 PMCID: PMC8843350 DOI: 10.2147/sar.s315720] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/05/2022] [Indexed: 01/23/2023] Open
Affiliation(s)
- Emma Tay
- Drug Health Services, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Wing Kwan Winky Lo
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bridin Murnion
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Correspondence: Bridin Murnion, Drug Health Services, Western Sydney Local Health District, 4A Fleet Street, North Parramatta, NSW, 2151, Australia, Tel +61 2 9840 3888, Fax +61 2 9840 3927, Email
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