Nonfatal instances of intoxication with gamma-hydroxybutyrate in the United Kingdom

Complications in post-mortem GHB cut-off values in urine samples: A case report

Gamma-hydroxybutyric acid (GHB) is a drug of abuse, that interplays with a GABAergic system, resulting in an euphoric state and increased mood and impulses. Two cases of fatal mixed intoxications including GHB intake are presented here. In both cases, GHB was used together with multiple other drugs. Interpretation of GHB cut-off values are complicated in post-mortem analysis, because GHB can be post-mortem formed. The post-mortem GHB formation is dependent of the post-mortem interval (PMI) and the storage conditions of the samples. The GHB concentrations in urine are more stable compared to blood samples, when the samples are stored at the correct way at - 20 °C. Therefore, urine is the recommended matrix to analyze in toxicological screenings, since it allows more specific determination of exposure to exogenous GHB. Different cut-off values are used for matrices from living and deceased people. A cut-off value of 30 mg/L is recommended to discriminate between endogenous concentrations and concentrations resulting from exogenous GHB exposure. Moreover, post-mortem GHB formation can take place before sampling. However, when the samples are immediately stored at cooled conditions, no in vitro formation of GHB will take place. Urinary screening of GHB may serve as an initial screening for estimation of exposure of GHB in the body. However, additional quantitative GHB analysis in blood is required to estimate GHB exposure at the time of death. Furthermore, to obtain more reliable results for the ante-mortem GHB exposure, it may be useful to measure other biomarkers, like some GHB metabolites, especially in blood.

Characteristics and dose-effect relationship of clinical gamma-hydroxybutyrate intoxication: A case series

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.

Metabolic Alterations Associated with γ-Hydroxybutyric Acid and the Potential of Metabolites as Biomarkers of Its Exposure

γ-Hydroxybutyric acid (GHB) is an endogenous short chain fatty acid that acts as a neurotransmitter and neuromodulator in the mammalian brain. It has often been illegally abused or misused due to its strong anesthetic effect, particularly in drug-facilitated crimes worldwide. However, proving its ingestion is not straightforward because of the difficulty in distinguishing between endogenous and exogenous GHB, as well as its rapid metabolism. Metabolomics and metabolism studies have recently been used to identify potential biomarkers of GHB exposure. This mini-review provides an overview of GHB-associated metabolic alterations and explores the potential of metabolites for application as biomarkers of GHB exposure. For this, we discuss the biosynthesis and metabolism of GHB, analytical issues of GHB in biological samples, alterations in metabolic pathways, and changes in the levels of GHB conjugates in biological samples from animal and human studies. Metabolic alterations in organic acids, amino acids, and polyamines in urine enable discrimination between GHB-ingested animals or humans and controls. The potential of GHB conjugates has been investigated in a variety of clinical settings. Despite the recent growth in the application of metabolomics and metabolism studies associated with GHB exposure, it remains challenging to distinguish between endogenous and exogenous GHB. This review highlights the significance of further metabolomics and metabolism studies for the discovery of practical peripheral biomarkers of GHB exposure.

Differentiation of endogenous and exogenous γ-Hydroxybutyrate in rat and human urine by GC/C/IRMS

Gamma (γ)-hydroxybutyric acid (GHB) has been reported to be an endogenous compound in the mammalian brain. It used to treat symptoms of alcohol, opioid, and drug withdrawal and cataplexy of narcolepsy. However, it is often used for criminal purposes because it is colorless, tasteless, and has short half-life. For this reason, there is a need for a method of distinguishing between endogenous and exogenous GHB administration. Therefore, urine from rat before administration of GHB and GHB urine after the single intraperitoneal injection of GHB as 30 mg/100 g were collected from Sprague-Dawley rats (7 weeks old, 10 males and females). Negative control urine, urine from individuals suspected of taking GHB, and urine from victims who were GHB-involved crime were collected. In urine samples, GHB was extracted with two-step SPE and collected fraction was derivatized and analyzed by GC/MS and GC/C/IRMS. In GC/MS and GC/C/IRMS analysis of rat urine, there was a statistically significant difference between urine from rat before administration of GHB and GHB rat urine (p < 0.05). In GC/MS analysis of human urine samples, there was no significant difference among human urine groups (negative control, suspects' urine, and victims' urine), but in GC/C/IRMS analysis of human urine samples, there was a statistically significant difference among human urine groups (p = 0.0001). Through these results, GC/C/IRMS can be more effective tool to identify endogenous and exogenous GHB in urine than GC/MS. This study can build a drug management system in forensic investigation agency and offer interpretation method to forensic science and court.

Presentations to an urban emergency department in Switzerland due to acute γ-hydroxybutyrate toxicity

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.

GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome

The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent central nervous system depressant and is often encountered during forensic investigations of living and deceased persons. The sodium salt of GHB is registered as a therapeutic agent (Xyrem®), approved in some countries for the treatment of narcolepsy-associated cataplexy and (Alcover®) is an adjuvant medication for detoxification and withdrawal in alcoholics. Trace amounts of GHB are produced endogenously (0.5-1.0 mg/L) in various tissues, including the brain, where it functions as both a precursor and a metabolite of the major inhibitory neurotransmitter γ-aminobutyric acid (GABA). Available information indicates that GHB serves as a neurotransmitter or neuromodulator in the GABAergic system, especially via binding to the GABA-B receptor subtype. Although GHB is listed as a controlled substance in many countries abuse still continues, owing to the availability of precursor drugs, γ-butyrolactone (GBL) and 1,4-butanediol (BD), which are not regulated. After ingestion both GBL and BD are rapidly converted into GHB (t½ ~1 min). The Cmax occurs after 20-40 min and GHB is then eliminated from plasma with a half-life of 30-50 min. Only about 1-5% of the dose of GHB is recoverable in urine and the window of detection is relatively short (3-10 h). This calls for expeditious sampling when evidence of drug use and/or abuse is required in forensic casework. The recreational dose of GHB is not easy to estimate and a concentration in plasma of ~100 mg/L produces euphoria and disinhibition, whereas 500 mg/L might cause death from cardiorespiratory depression. Effective antidotes to reverse the sedative and intoxicating effects of GHB do not exist. The poisoned patients require supportive care, vital signs should be monitored and the airways kept clear in case of emesis. After prolonged regular use of GHB tolerance and dependence develop and abrupt cessation of drug use leads to unpleasant withdrawal symptoms. There is no evidence-based protocol available to deal with GHB withdrawal, apart from administering benzodiazepines.

Screening and confirmation methods for GHB determination in biological fluids

The purpose of this review is to provide a comprehensive overview of reported methods for screening and confirmation of the low-molecular-weight compound and drug of abuse gamma-hydroxybutyric acid (GHB) in biological fluids. The polarity of the compound, its endogenous presence, its rapid metabolism after ingestion, and its instability during storage (de novo formation and interconversion between GHB and its lactone form gamma-butyrolactone) are challenges for the analyst and for interpretation of a positive result. First, possible screening procedures for GHB are discussed, including colorimetric, enzymatic, and chromatography-based procedures. Confirmation methods for clinical and forensic cases mostly involve gas chromatography (coupled to mass spectrometry), although liquid chromatography and capillary zone electrophoresis have also been used. Before injection, sample-preparation techniques include (a combination of) liquid-liquid, solid-phase, or headspace extraction, and chemical modification of the polar compound. Also simple "dilute-and-shoot" may be sufficient for urine or serum. Advantages, limitations, and trends are discussed.

Sociodemographic and substance use characteristics of γ hydroxybutyrate (GHB) dependent inpatients and associations with dependence severity

BACKGROUND

The number of admissions to addiction treatment centers in the Netherlands for gamma hydroxybutyrate (GHB) dependence is rapidly growing. Until now, treatment seeking GHB users have hardly been studied. This study characterizes inpatients in treatment for GHB dependence in terms of sociodemographics, motives for substance use and reasons for seeking treatment. In addition, variables associated with dependence severity are identified.

METHODS

Patients were recruited by their therapists at 4 different addiction treatment centers dispersed throughout the Netherlands. They were asked to fill out the questionnaire, including sociodemographic and clinical characteristics, GHB and other drug use, and a modified version of the Drug Use Disorders Identification Test (DUDIT) to screen for GHB dependence. The associations of relevant variables with dependence severity were determined using multiple regression analysis.

RESULTS

A total of 75 inpatients (response rate 90.4%) participated in the study. Most patients were young (mean 26.8 ± 9.1) males (73%) with low education (78%) and not employed (48%). Most of them (75%) had started using GHB the year before treatment admission, 42 (56%) frequently combined GHB with sedatives and 26 (35%) frequently combined GHB with stimulants. Dependence severity was strongly associated with sleep problems and the combined use of GHB and stimulants.

CONCLUSION

This study shows that sociodemographic characteristics of GHB inpatients are similar to those of problematic users of other club drugs. Sleep problems and combined use of GHB and stimulants were strongly associated with GHB dependence. Together, these factors might help to better identify people at risk for GHB dependence.

The clinical toxicology of γ-hydroxybutyrate, γ-butyrolactone and 1,4-butanediol

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.

Dried blood spot punches for confirmation of suspected γ-hydroxybutyric acid intoxications: validation of an optimized GC–MS procedure

Background: γ-hydroxybutyric acid ( GHB ), notorious as a club- and date-rape drug, was quantified in dried blood spots (DBS) by punching out a disc, followed by ‘on-spot’ derivatization and analysis by GC–MS. Results: A homogenous distribution in DBS was demonstrated and accurate results were obtained when analyzing a disc punched out from a 20–35 µl spot, regardless the hematocrit of the blood sample. Validation based on US FDA and European Medicines Agency guidelines was performed, with a calibration range covering 2–100 µg/ml. Conclusion: A sensitive GC–MS method for GHB analysis in DBS was successfully optimized and validated. The successful analysis of DBS collected from GHB abusers suggests the routine applicability of the DBS sampling technique for GHB analysis in toxicological cases.

Acute toxicity and withdrawal syndromes related to γ-hydroxybutyrate (GHB) and its analogues γ-butyrolactone (GBL) and 1,4-butanediol (1,4-BD)

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.

γ Hydroxybutyrate use: exploring the influence of outcome expectancies through memory modeling

Gamma hydroxybutyrate (GHB) has been linked to overdose, criminal surreptitious administration, the need for emergency medical care, and fatalities worldwide. To begin to identify and understand the motivational factors that lead to the use of GHB, the present investigation utilized methods that have been successful in identifying potential expectancy targets and have been incorporated into prevention and intervention strategies successful in reducing high-risk alcohol use. In the present investigation, GHB expectancies were elicited from 926 voluntary participants aged 18-60 at a university in the southeastern United States to develop the GHB Expectancy Questionnaire (GHBEQ). The GHBEQ was subsequently administered to a different sample of 1,373 participants aged 18-55 in order to empirically derive the possible organization of GHB expectancies in memory, including likely paths of GHB expectancy activation. Findings suggest differences in GHB expectancies based on use history and sex. These results can be used to understand differences in GHB use for men and women, and to develop expectancy-based prevention and intervention programming to prevent and reduce its use in high-risk populations. 

Twenty-three deaths with gamma-hydroxybutyrate overdose in western Sweden between 2000 and 2007

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.

Forensic toxicology findings in deaths involving gamma-hydroxybutyrate

Concentrations of the illicit drug gamma-hydroxybutyrate (GHB) were determined in femoral venous blood and urine obtained at autopsy in a series of GHB-related deaths (N = 49). The analysis of GHB was done by gas chromatography after conversion to gamma-butyrolactone and quantitation of the latter with a flame ionization detector. The cutoff concentration of GHB in femoral blood or urine for reporting positive results was 30 mg/L. The deceased were mainly young men (86%) aged 26.5 +/- 7.2 years (mean +/- SD), and the women (14%) were about 5 years younger at 21.4 +/- 5.0 years. The mean, median, and highest concentrations of GHB in femoral blood (N = 37) were 294, 190, and 2,200 mg/L, respectively. The mean urine-to-blood ratio of GHB was 8.8, and the median was 5.2 (N = 28). In 12 cases, the concentrations of GHB in blood were negative (<30 mg/L) when the urine contained 350 mg/L on average (range 31-1,100 mg/L). Considerable poly-drug use was evident in these GHB-related deaths: ethanol (18 cases), amphetamine (12 cases), and various prescription medications (benzodizepines, opiates, and antidepressants) in other cases. Interpreting the concentrations of GHB in postmortem blood is complicated because of concomitant use of other psychoactive substances, variable degree of tolerance to centrally acting drugs, and the lack of reliable information about survival time after use of the drug.

Abrupt awakening phenomenon associated with gamma-hydroxybutyrate use: A case series

Case reports mention a sudden awakening from GHB-associated coma but do not specify its time course. The aim of the present case series was to investigate the time course of the awakening from GHB intoxication and the relationship to plasma concentrations of GHB and the presence of other drugs. Unconscious (GCS <or=8) participants at six large rave parties who were treated at medical stations were included. Serial blood samples were taken every 10 to 30 minutes for toxicological analysis. At the same time-points, the depth of coma was scored with the Glasgow Coma Score (GCS). Fifteen out of 21 unconscious patients proved to be positive for GHB. Fourteen of these had ingested one or more other drugs. The median GHB plasma concentration upon arrival in the medical station was 212 microg/ml (range 112 to 430 microg/ml). In 10 patients the GCS was scored more than twice, allowing study of the time course. The GCS of these patients remained <or=8 for a median time of 90 minutes (range 30 to 105 minutes). The duration of the transition between GCS of <or=8 and >or=12 was 30 minutes (range 10 to 50 minutes). A subgroup of five patients had a GCS of 3 upon arrival and remained at 3 for a median time of 60 minutes (range 30 to 110 minutes), while the median time for the transition between the last point with GCS 3 and the first with GCS 15 was 30 minutes (range 20 to 60 minutes). This case series illustrates that patients with GHB intoxications remain in a deep coma for a relatively long period of time, after which they awaken over about 30 minutes. This awakening is accompanied by a small change in GHB concentrations. A confounding factor in these observations is co-ingested illicit drugs.

Gamma-hydroxybutyric acid (GHB) measurement by GC-MS in blood, urine and gastric contents, following an acute intoxication in Belgium

Gamma-hydroxybutyrate (GHB, sodium oxybate) is a compound related to neuromodulator gamma-aminobutyric acid (GABA), emerging as a recreational drug of abuse and as a rape drug. GHB-related emergencies have dramatically increased in the 1990s, but a decrease is observed since 2000. We describe the case of an acute GHB intoxication in a 28-year-old male who fell unconscious after ingestion of a mouthful of an unknown beverage, and required medical support for 2 days. A cocaine abuse was also detected by preliminary toxicological screening, but the clinical presentation was not typical of cocaine intoxication. A simple liquid-liquid extraction was used for quantitation of GHB, followed by disilyl-derivatization and analysis in selective ion monitoring (SIM) mode by gas chromatography-mass spectrometry (GC-MS), using GHB-d6 as internal standard. High concentrations of GHB were detected in urine (3020 mg/L) and gastric contents (71487 mg/L) at admission. After a 6-hours delay, GHB was still present in urine at 2324 mg/L and in blood at 43 mg/L. The clinical symptoms of cocaine intoxication were diminished by GHB consumption, and the cerebral scan was modified. Attention must thus be paid to acute intoxications with surprising clinical symptoms, and GHB has probably to be added to the preliminary toxicological screening. Data available regarding GHB are briefly reviewed, and our results are compared with previously published reports of non-fatal GHB intoxication.

Physostigmine for gamma-hydroxybutyrate coma: inefficacy, adverse events, and review

Physostigmine has been proposed as an antidote for gamma hydroxybutyrate (GHB) intoxication, based on associated awakenings in 1) patients anesthetized with GHB and 2) five of six patients administered physostigmine for GHB intoxication. However, there are neither well-supported mechanisms for physostigmine reversal of GHB effects, supportive animal studies, nor randomized, placebo-controlled trials demonstrating safety, efficacy, or improved outcomes. We sought to determine the outcomes of patients with GHB-induced coma after a physostigmine treatment protocol was instituted in an urban Emergency Department and ambulance service. Our search of medical records located five cases of GHB toxicity, all with co-intoxicants, who received physostigmine. None demonstrated response and, further, there were associated adverse events, including atrial fibrillation (2), pulmonary infiltrates (1) and significant bradycardia (1), and hypotension (1). We also reviewed 18 published GHB toxicity case series for incidence of adverse effects, stimulant co-intoxicants (which may heighten risk of physostigmine), complications, and outcomes of supportive care for GHB toxicity. We conclude that physostigmine is not indicated for reversal of GHB-induced alteration of consciousness; it is not efficacious, it may be unsafe, particularly in the setting of recreational polydrug use; and supportive care results in universally good outcomes.

A study of patients presenting to an emergency department having had a "spiked drink"

OBJECTIVES

To assess the scale of drink spiking in our area and identify which drugs are being used to spike drinks and also to assess whether there is a problem with drink spiking in any particular establishment.

METHODS

A prospective study of all patients presenting to an emergency department with alleged drink spiking over a 12-month period. Samples were analysed for levels of alcohol and drugs of misuse. Information was collected as to where the alleged spiking took place and the involvement of the police.

RESULTS

75 patients attended with alleged drink spiking over the period of 12 months. 42 samples were analysed and tested positive for drugs of misuse in 8 (19%) cases. 65% of those tested had alcohol concentrations >160 mg%. The alleged spiking took place in 23 different locations, with 2 locations accounting for 31% of responses. Only 14% of those questioned had informed the police.

CONCLUSIONS

Most patients allegedly having had a spiked drink test negative for drugs of misuse. The symptoms are more likely to be a result of excess alcohol.

Clinical urinalysis of drugs and alcohol in instances of suspected surreptitious administration ("spiked drinks")

Many suspected victims of surreptitious drug and/or alcohol administration may present to hospitals or healthcare centres and never come to the attention of forensic or law enforcement professionals. Therefore, it is necessary to include clinical toxicological findings in order to assess the growing perception that instances have become more widespread within society. Between July 2002 and June 2004, 180 requests were received for toxicological analysis of individuals presenting to their GP or hospital following self-reported or suspected surreptitious drug administration (e.g. "spiked drink"). There was a rise of 77% in the number of requests from 2002-2003 to 2003-2004 which peaked in December of each year (most likely due to the increased socialization of people during the festive season). Between 2002 and 2004, 34% of patients were male and 66% were female with an overall average age of 25 (range 11-73). Following urinary analysis using immunoassay and gas chromatography (mass spectrometry, flame-ionisation detection and nitrogen-phosphorus detection), 59% of cases were negative for drugs and alcohol in 2002-2003 and 51% in 2003-2004. Drugs or alcohol were detected in 32% of cases in 2002-2003 and in 45% in 2003-2004. Out of the 169 cases analysed, ethanol (alcohol) was the most commonly detected compound (24% of cases), followed by amphetamines (amphetamine, MDMA, MDA, MDEA--11% of cases), cannabinoids (9% of cases), benzodiazepines (temazepam, nordiazepam, oxazepam--9% of cases), cocaine (4% of cases), opiates (dihydrocodeine, codeine--2% of cases), chlorpheniramine (0.6% of cases), ephedrine 0.6% of cases), fluoxetine (0.6% of cases), tramadol (0.6% of cases) and zopiclone (0.6% of cases). No gamma-hydroxybutyrate (GHB), gamma-butyrolactone (GBL) or flunitrazepam was detected in the cases analysed.

Lung injury from "liquid ecstasy": a role for coagulation activation?

We describe our second clinical observation of pulmonary injury after a "liquid ecstasy" ingestion/inhalation by a 3-year-old girl. Apart from the deep coma state, a markedly asymmetric pulmonary compromise was recorded. A transient coagulation activation was detected, possibly triggered off by the toxic effect on the lung alveolar-capillary membrane.

The presence of gamma-hydroxybutyric acid (GHB) and gamma-butyrolactone (GBL) in alcoholic and non-alcoholic beverages

Gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL) are regularly implicated in instances of surreptitious drug administration, particularly in beverages (so-called "spiked drinks"). In order to assist in the interpretation of cases where analysis of the actual beverage is required, over 50 beverages purchased in the UK were analysed for the presence of GHB and GBL. It was found that naturally occurring GHB and GBL were detected in those beverages involving the fermentation of white and particularly red grapes. No GHB or GBL was detected in other drinks such as beer, juice, spirits or liqueurs. GHB/GBL was detected in red wine vermouth (8.2 mg/L), sherry (9.7 mg/L), port (GBL), red wine (4.1-21.4 mg/L) and white wine (<3-9.6 mg/L). The presence of GHB/GBL did not appear to be influenced by the alcohol content or the pH of the beverage. In addition, the concentration in wines did not appear to be related to the geographical origin of the grape type. This is believed to be the first published data concerning the endogenous presence of GHB and GBL in the beverages described.

Survival of massive γ-hydroxybutyrate/ 1,4-butanediol overdose

Gamma-hydroxybutyrate and its metabolic precursors gamma butyrolactone and 1,4-butanediol are widely used recreational drugs known to cause short periods of deep sedation with rapid recovery. We present a case of survival with good neurological outcome following massive ingestion in which the patient remained sedated for 14 h.