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Darke S, Duflou J, Chrzanowska A, Farrell M, Lappin J, Peacock A. Changes in the rates and characteristics of gamma hydroxybutyrate (GHB)-related death in Australia, 2001-2023. Drug Alcohol Rev 2024. [PMID: 39238184 DOI: 10.1111/dar.13940] [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: 05/20/2024] [Revised: 08/14/2024] [Accepted: 08/19/2024] [Indexed: 09/07/2024]
Abstract
INTRODUCTION In recent years gamma hydroxybutyrate (GHB) use appears to have increased. This study aimed to determine: (i) population rates of GHB-related death in Australia, 2001-2021; and (ii) whether there have been changes in the characteristics of GHB-related death in Australia over the period 2001-2023. METHODS Retrospective study of all Australian cases in which GHB was a mechanism contributory to death retrieved from the National Coronial Information System (n = 217). Joinpoint regression models were used to analyse trends in overall rates. RESULTS Death rates were stable between 2001 and 2015 ('stable period') (annual percent change [APC] = 3.7) but showed marked acceleration between 2016 and 2021 ('accelerated period') (APC = 44.4). Circumstances of death were: unintentional toxicity (81.6%), intentional toxicity (5.1%), self-harm (6.0%), traumatic injury (7.4%). Compared to the stable period, later cases were slightly older (34.2 vs. 30.7 years, p < 0.05), less likely to be employed (odds ratio [OR] 0.4), but more likely to have substance use problems (OR 3.9), a history of injecting drug use (OR 3.5), mental health problems (OR 3.6), and to have present in their blood at toxicological screening opioids (OR 3.2) and hypnosedatives (OR 3.7). The median blood GHB concentration was 170 mg/L, (range 0-3210), which did not change significantly. There were no differences in major organ pathology, but the proportion with aspiration pneumonia declined (OR 0.4). DISCUSSION AND CONCLUSIONS GHB-related death rates increased from 2016, accompanied by changes in case characteristics. In recent years GHB use appears to have extended to a population more likely to have substance use problems and use other respiratory depressants.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Agata Chrzanowska
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Julia Lappin
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- Discipline of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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Kim M, Oh S, Kim S, Ji M, Choi B, Bae JW, Lee YS, Paik MJ, Lee S. Alcohol perturbed locomotor behavior, metabolism, and pharmacokinetics of gamma-hydroxybutyric acid in rats. Biomed Pharmacother 2023; 164:114992. [PMID: 37301134 DOI: 10.1016/j.biopha.2023.114992] [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: 03/25/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
Gamma-hydroxybutyric acid (GHB), both a metabolic precursor and product of gamma-aminobutyric acid (GABA), is a central nervous system depressant used for the treatment of narcolepsy-associated cataplexy and alcohol withdrawal. However, administration of GHB with alcohol (ethanol) is a major cause of hospitalizations related to GHB intoxication. In this study, we investigated locomotor behavior as well as metabolic and pharmacokinetic interactions following co-administration of GHB and ethanol in rats. The locomotor behavior of rats was evaluated following the intraperitoneal administration of GHB (sodium salt, 500 mg/kg) and/or ethanol (2 g/kg). Further, time-course urinary metabolic profiling of GHB and its biomarker metabolites glutamic acid, GABA, succinic acid, 2,4-dihydroxybutyric acid (OH-BA), 3,4-OH-BA, and glycolic acid as well as pharmacokinetic analysis were performed. GHB/ethanol co-administration significantly reduced locomotor activity, compared to the individual administration of GHB or ethanol. The urinary and plasma concentrations of GHB and other target compounds, except for 2,4-OH-BA, were significantly higher in the GHB/ethanol co-administration group than the group administered only GHB. The pharmacokinetic analysis results showed that the co-administration of GHB and ethanol significantly increased the half-life of GHB while the total clearance decreased. Moreover, a comparison of the metabolite-to-parent drug area under the curve ratios demonstrated that the metabolic pathways of GHB, such α- and β-oxidation, were inhibited by ethanol. Consequently, the co-administration of GHB and ethanol aggravated the metabolism and elimination of GHB and enhanced its sedative effect. These findings will contribute to clinical interpretation of GHB intoxication.
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Affiliation(s)
- Mingyu Kim
- College of Pharmacy, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, the Republic of Korea
| | - Songjin Oh
- College of Pharmacy, Sunchon National University, 25 Jungang-ro, Suncheon 57922, the Republic of Korea
| | - Suji Kim
- College of Pharmacy, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, the Republic of Korea
| | - Moongi Ji
- College of Pharmacy, Sunchon National University, 25 Jungang-ro, Suncheon 57922, the Republic of Korea
| | - Byeongchan Choi
- College of Pharmacy, Sunchon National University, 25 Jungang-ro, Suncheon 57922, the Republic of Korea
| | - Jung-Woo Bae
- College of Pharmacy, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, the Republic of Korea
| | - Yong Sup Lee
- College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, the Republic of Korea
| | - Man-Jeong Paik
- College of Pharmacy, Sunchon National University, 25 Jungang-ro, Suncheon 57922, the Republic of Korea.
| | - Sooyeun Lee
- College of Pharmacy, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, the Republic of Korea.
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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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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: 19] [Impact Index Per Article: 6.3] [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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Luethi D, Liechti ME. Designer drugs: mechanism of action and adverse effects. Arch Toxicol 2020; 94:1085-1133. [PMID: 32249347 PMCID: PMC7225206 DOI: 10.1007/s00204-020-02693-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 12/18/2022]
Abstract
Psychoactive substances with chemical structures or pharmacological profiles that are similar to traditional drugs of abuse continue to emerge on the recreational drug market. Internet vendors may at least temporarily sell these so-called designer drugs without adhering to legal statutes or facing legal consequences. Overall, the mechanism of action and adverse effects of designer drugs are similar to traditional drugs of abuse. Stimulants, such as amphetamines and cathinones, primarily interact with monoamine transporters and mostly induce sympathomimetic adverse effects. Agonism at μ-opioid receptors and γ-aminobutyric acid-A (GABAA) or GABAB receptors mediates the pharmacological effects of sedatives, which may induce cardiorespiratory depression. Dissociative designer drugs primarily act as N-methyl-D-aspartate receptor antagonists and pose similar health risks as the medically approved dissociative anesthetic ketamine. The cannabinoid type 1 (CB1) receptor is thought to drive the psychoactive effects of synthetic cannabinoids, which are associated with a less desirable effect profile and more severe adverse effects compared with cannabis. Serotonergic 5-hydroxytryptamine-2A (5-HT2A) receptors mediate alterations of perception and cognition that are induced by serotonergic psychedelics. Because of their novelty, designer drugs may remain undetected by routine drug screening, thus hampering evaluations of adverse effects. Intoxication reports suggest that several designer drugs are used concurrently, posing a high risk for severe adverse effects and even death.
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Affiliation(s)
- Dino Luethi
- Center for Physiology and Pharmacology, Institute of Pharmacology, Medical University of Vienna, Währinger Strasse 13a, 1090, Vienna, Austria.
- Institute of Applied Physics, Vienna University of Technology, Getreidemarkt 9, 1060, Vienna, Austria.
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
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Darke S, Peacock A, Duflou J, Farrell M, Lappin J. Characteristics and circumstances of death related to gamma hydroxybutyrate (GHB). Clin Toxicol (Phila) 2020; 58:1028-1033. [PMID: 32068430 DOI: 10.1080/15563650.2020.1726378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Gamma hydroxybutyrate (GHB) has gained substantial popularity as an illicit recreational drug. The current study aimed to: (1) determine the characteristics and circumstances of death of all recorded cases of GHB-related death in Australia, 2001-2019; (2) determine the toxicology of cases; and (3) determine major organ pathology.Methods: Retrospective study of all Australian cases in which GHB was a mechanism contributory to death retrieved from the National Coronial Information System (n = 74). Information was collected on cause of death, demographics, circumstances of death, toxicology and major organ pathology.Results: The mean age was 31.5 years and 70.3% were male. The predominant circumstance of death was accidental drug toxicity (79.7%), including five cases attributed to a combination of toxicity and natural disease. Other deaths were due to trauma (12.2%) and suicide (8.2%). The fatal incident overwhelmingly occurred in a home environment (82.4%). In all cases, GHB was consumed orally. The median GHB blood concentration was 210 mg/L (range 13-1350 mg/L), and was significantly higher in toxicity cases than others (258 vs. 98 mg/L, p < .01). Other substances were present in 92.2%, most commonly psychostimulants (64.1%), hypnosedatives (28.2%) and alcohol (20.3%). Resuscitation was attempted in 20.3% of cases. Acute pneumonia (36.7%) and aspiration of vomitus (30.6%) were common.Conclusions: The typical case was a young male, who swallowed GHB and used it with other substances, most commonly at home. While acute drug toxicity was the most common cause of death, there was a substantial minority due to trauma or suicide.
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Affiliation(s)
- Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, Kensington, Australia
| | - Amy Peacock
- National Drug & Alcohol Research Centre, University of New South Wales, Kensington, Australia
| | - Johan Duflou
- National Drug & Alcohol Research Centre, University of New South Wales, Kensington, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, Kensington, Australia
| | - Julia Lappin
- National Drug & Alcohol Research Centre, University of New South Wales, Kensington, Australia.,School of Psychiatry, University of New South Wales, Kensington, Australia
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Kietzerow J, Otto B, Wilke N, Rohde H, Iwersen-Bergmann S, Andresen-Streichert H. The challenge of post-mortem GHB analysis: storage conditions and specimen types are both important. Int J Legal Med 2019; 134:205-215. [PMID: 31598775 DOI: 10.1007/s00414-019-02150-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND For the interpretation of concentrations of gamma-hydroxybutyrate (GHB) in post-mortem specimens, a possible increase due to post-mortem generation in the body and in vitro has to be considered. The influence of different storage conditions and the specimen type was investigated. METHOD AND MATERIAL Post-mortem GHB concentrations in femoral venous blood (VB), heart blood (HB), serum (S) from VB, urine (U), cerebrospinal fluid (CSF) and vitreous humour (VH) were determined by gas chromatography-mass spectrometry after derivatisation. Various storage conditions, that is 4 °C or room temperature (RT) and the addition of sodium fluoride (NaF), were compared during storage up to 30 days. Additionally, bacterial colonisation was determined by mass spectrometry fingerprinting. RESULTS Twenty-six cases without involvement of exogenous GHB were examined. GHB concentrations (by specimen) at day 0 were 3.9-22.1 mg/L (VB), 6.6-33.3 mg/L (HB), < 0.5-18.1 mg/L (U), 1.1-10.4 mg/L (CSF) and 1.7-22.0 mg/L (VH). At 4 °C, concentrations increased at day 30 to 5.6-74.5 mg/L (VB), 4.6-76.5 mg/L (HB) and < 0.5-21.3 mg/L (U). At RT, concentrations rose to < 0.5-38.5 mg/L (VB), 1.2-94.6 mg/L (HB) and < 0.5-37.5 mg/L (U) at day 30. In CSF, at RT, an increase up to < 0.5-21.2 mg/L was measured, and at 4 °C, a decrease occurred (< 0.5-6.5 mg/L). GHB concentrations in VH remained stable at both temperatures (1.2-20.9 mg/L and < 0.5-26.2 mg/L). The increase of GHB in HB samples with NaF was significantly lower than that without preservation. No correlation was found between the bacterial colonisation and extent of GHB concentration changes. CONCLUSION GHB concentrations can significantly increase in post-mortem HB, VB and U samples, depending on storage time, temperature and inter-individual differences. Results in CSF, VH, S and/or specimens with NaF are less affected.
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Affiliation(s)
- J Kietzerow
- Institute of Legal Medicine, Department of Forensic Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute of Legal Medicine, Department of Forensic Toxicology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - B Otto
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N Wilke
- Institute of Forensic Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - H Rohde
- Department of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Iwersen-Bergmann
- Institute of Legal Medicine, Department of Forensic Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Andresen-Streichert
- Institute of Legal Medicine, Department of Forensic Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Institute of Legal Medicine, Department of Forensic Toxicology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany.
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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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Case report: Another death associated to γ-hydroxybutyric acid intoxication. Forensic Sci Int 2019; 299:34-40. [DOI: 10.1016/j.forsciint.2019.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/05/2019] [Accepted: 03/15/2019] [Indexed: 11/21/2022]
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Madah-Amiri D, Myrmel L, Brattebø G. Intoxication with GHB/GBL: characteristics and trends from ambulance-attended overdoses. Scand J Trauma Resusc Emerg Med 2017; 25:98. [PMID: 28938889 PMCID: PMC5610436 DOI: 10.1186/s13049-017-0441-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 09/13/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Overdoses from so-called "club drugs" (GHB/GBL) have become a more frequent cause of overdoses attended by ambulance services. Given its availability, affordability, and lack of awareness of risks, there is a common misconception among users that the drug is relatively safe. METHODS This study reviewed ambulance records in Bergen, Norway between 2009 and 2015 for cases of acute poisonings, particularly from suspected GHB/GBL intoxication. RESULTS In total, 1112 cases of GHB and GBL poisoning were identified. GHB was suspected for 995 (89%) of the patients. Men made up the majority of the cases (n = 752, 67.6%) with a median age of 27 years old. Temporal trends for GHB/GBL overdoses displayed a late-night, weekend pattern. The most frequent initial symptoms reported were unconsciousness, or reduced consciousness. Most of the patients required further treatment and transport. During the period from 2009 to 2015, there was a nearly 50% decrease in GHB/GBL overdoses from 2013 to 2014. DISCUSSION The characteristics of GHB/GBL overdose victims shed light on this patient group. The decrease in incidence over the years may be partly due to a legal ban on GBL in Norway, declared in 2010. It may also be due to an increase in the use of MDMA/ecstasy. CONCLUSION The review of ambulance records on the prehospital treatment of overdoses can be beneficial in monitoring, preparing, and prevention efforts aimed to benefit this vulnerable group.
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Affiliation(s)
- Desiree Madah-Amiri
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway
| | - Lars Myrmel
- Bergen Emergency Medical Services, Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Morse BL, Chadha GS, Felmlee MA, Follman KE, Morris ME. Effect of chronic γ-hydroxybutyrate (GHB) administration on GHB toxicokinetics and GHB-induced respiratory depression. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 43:686-693. [PMID: 28662343 DOI: 10.1080/00952990.2017.1339055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND γ-hydroxybutyrate (GHB) has a high potential for illicit use; overdose of this compound results in sedation, respiratory depression and death. Tolerance to the hypnotic/sedative and electroencephalogram effects of GHB occurs with chronic GHB administration; however, tolerance to respiratory depression has not been evaluated. GHB toxicodynamic effects are mediated predominantly by GABAB receptors. Chronic treatment may affect monocarboxylate transporters (MCTs) and alter the absorption, renal clearance and brain uptake of GHB. OBJECTIVES To determine effects of chronic GHB dosing on GHB toxicokinetics, GHB-induced respiratory depression, and MCT expression. METHODS Rats were administered GHB 600 mg/kg intravenously daily for 5 days. Plasma, urine and tissue samples and respiratory measurements were obtained on days 1 and 5. Plasma and urine were analyzed for GHB by LC/MS/MS and tissue samples for expression of MCT1, 2 and 4 and their accessory proteins by QRT-PCR. RESULTS No differences in GHB pharmacokinetics or respiratory depression were observed between days 1 and 5. Opposing changes in MCT1 and MCT4 mRNA expression were observed in kidney samples on day 5 compared to GHB-naïve animals, and MCT4 expression was increased in the intestine. CONCLUSIONS The lack of tolerance observed with GHB-induced respiratory depression, in contrast to the tolerance reported for the sedative/hypnotic and electroencephalogram effects, suggests that different GABAB receptor subtypes may be involved in different GABAB-mediated toxicodynamic effects of GHB. Chronic or binge users of GHB may be at no less risk for fatality from respiratory arrest with a GHB overdose than with a single dose of GHB.
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Affiliation(s)
- Bridget L Morse
- a Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,b Investigative Drug Disposition, Transporters & Pharmacogenomics , Eli Lilly and Company , Indianapolis , IN , USA
| | - Gurkishan S Chadha
- a Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,c School of Pharmacy , University of New England , Biddeford , ME , USA
| | - Melanie A Felmlee
- a Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,d Department of Pharmaceutics & Medicinal Chemistry, Thomas J. Long School of Pharmacy & Health Sciences , University of the Pacific , Stockton , CA , USA
| | - Kristin E Follman
- a Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Marilyn E Morris
- a Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
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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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Jamey C, Kintz P, Martrille L, Raul JS. Fatal Combination with 3-Methylmethcathinone (3-MMC) and Gamma-Hydroxybutyric Acid (GHB). J Anal Toxicol 2016; 40:546-52. [DOI: 10.1093/jat/bkw058] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 04/16/2016] [Indexed: 11/14/2022] Open
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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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Busardò FP, Jones AW. GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome. Curr Neuropharmacol 2016; 13:47-70. [PMID: 26074743 PMCID: PMC4462042 DOI: 10.2174/1570159x13666141210215423] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/01/2014] [Accepted: 10/25/2014] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Francesco P Busardò
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Alan W Jones
- Department of Clinical Pharmacology, University of Linköping, Linköping, Sweden
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Gamma hydroxybutyrate (GHB), gamma butyrolactone (GBL) and 1,4-butanediol (1,4-BD; BDO): A literature review with a focus on UK fatalities related to non-medical use. Neurosci Biobehav Rev 2015; 53:52-78. [PMID: 25843781 DOI: 10.1016/j.neubiorev.2015.03.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 03/08/2015] [Accepted: 03/25/2015] [Indexed: 11/22/2022]
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Heyerdahl F, Hovda KE, Giraudon I, Yates C, Dines AM, Sedefov R, Wood DM, Dargan PI. Current European data collection on emergency department presentations with acute recreational drug toxicity: Gaps and national variations. Clin Toxicol (Phila) 2014; 52:1005-12. [DOI: 10.3109/15563650.2014.976792] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Andresen-Streichert H, Jensen P, Kietzerow J, Schrot M, Wilke N, Vettorazzi E, Mueller A, Iwersen-Bergmann S. Endogenous gamma-hydroxybutyric acid (GHB) concentrations in post-mortem specimens and further recommendation for interpretative cut-offs. Int J Legal Med 2014; 129:57-68. [DOI: 10.1007/s00414-014-1051-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/14/2014] [Indexed: 10/25/2022]
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Symptoms and signs in interpreting gamma-hydroxybutyrate (GHB) intoxication - an explorative study. Scand J Trauma Resusc Emerg Med 2014; 22:27. [PMID: 24758357 PMCID: PMC4012517 DOI: 10.1186/1757-7241-22-27] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/07/2014] [Indexed: 11/25/2022] Open
Abstract
Background Acute poisoning with gamma-hydroxybutyrate (GHB) has been a serious medical and social problem in different parts of the world including Sweden. GHB is a drug of abuse which acts primarily as central nervous system (CNS) depressants. GHB has serious toxicity, although many young users do not recognise GHB as a dangerous drug. The aim of this pilot study was to explore how symptoms with risk of failure in vital functions would be valued among professionals that encounter GHB intoxication in the emergency phase. Methods A web-based survey focusing on the assessment of vital clinical signs for possible GHB intoxication using a numeric scale was carried out during April and May 2011. The participants, n 105, are all professionals who encounter GHB intoxicated in the emergency phase, but have different levels of training in GHB intoxication, mainly Registered Nurses (RNs) in southwest Sweden, employed in pre-hospital or emergency departments at somatic and most psychiatric health care facilities, as well as police officers who in their work come into contact with drug users. Responses in the survey were scored according to risk of GHB intoxication with serious failure of vital functions. The score value was then referred to a so-called evidence based priority (EBP) scale and analysed using descriptive statistics and Fisher's exact test. Results Cardiac arrest, coma, hypoxia, general convulsions, slow respiratory and heart rate and pale skin are symptoms with the highest risk of serious failure in vital physical functions and were predominantly recognised as such. Conclusion Despite the professionals' different levels of training in GHB intoxication, all of them were relatively well aware of and in accordance regarding the most risky symptoms. The interpretation score for the less risky symptoms and signs of GHB intoxication varied depending on their degree of training. The results should be viewed cautiously, as the size of the professional groups and their general knowledge of critical symptoms of GHB poisoning varied.
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Korf DJ, Nabben T, Benschop A, Ribbink K, van Amsterdam JGC. Risk factors of γ-hydroxybutyrate overdosing. Eur Addict Res 2014; 20:66-74. [PMID: 24080792 DOI: 10.1159/000353237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/17/2013] [Indexed: 12/14/2022]
Abstract
The aim of this study was to identify in recreational drug users the factors which increase the risk of overdosing (OD) with γ-hydroxybutyrate (GHB). A purposive sample of 45 experienced GHB users was interviewed, equally divided into three groups (never OD, occasional OD, and repeat OD). The repeat OD group scored highest on many risk factors regarding GHB use, the occasional OD group scored intermediate, and the never OD group scored lowest. Participants, whether or not they had overdosed on GHB, most often perceived GHB use (e.g. using more GHB than usual, using GHB doses too closely together) as the main reason for GHB OD, and many participants who had overdosed on GHB reported that they had taken more GHB than usual at their most recent occasion of GHB OD. No significant differences in co-use of GHB with other substances were found between the three groups. Our findings indicate that using GHB in the company of groups of friends probably reduces, but does not eliminate, the risk of OD.
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Affiliation(s)
- Dirk J Korf
- Bonger Institute of Criminology, University of Amsterdam, Amsterdam, The Netherlands
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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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Aromatario M, Bottoni E, Santoni M, Ciallella C. New “Lethal highs”: A case of a deadly cocktail of GHB and Mephedrone. Forensic Sci Int 2012; 223:e38-41. [DOI: 10.1016/j.forsciint.2012.09.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/19/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
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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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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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Fjeld B, Burns ML, Karinen R, Larssen B, Smith-Kielland A, Vindenes V. Long-term stability of GHB in post-mortem samples and samples from living persons, stored at -20°C, using fluoride preservatives. Forensic Sci Int 2012; 222:47-51. [PMID: 22648054 DOI: 10.1016/j.forsciint.2012.04.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 04/26/2012] [Accepted: 04/30/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Reanalyses are frequently requested in forensic toxicology, and knowledge of the stability of drugs in biological samples is of major importance for the interpretation of the toxicological findings. Currently, the literature on stability of gammahydroxybutyrate (GHB) in blood samples from living subjects and in post-mortem blood is limited. The purpose of this study was to evaluate the long-term stability of GHB in both blood samples from persons suspected of drug use and post-mortem blood samples. METHODS A total of 59 reanalyses were performed in whole blood samples, 27 samples from living subjects and 32 samples taken at autopsies. The samples were stored in the freezer between 0.4 and 7.2 years at -20°C in vials containing preservatives. Analyses were performed by GC-FID, and cut-off level was 10.3 mg/L. The concentrations in 22 of the samples were below cut-off. RESULTS The mean change in concentration between initial analysis and reanalysis was -0.8% for the positive samples from living persons and -7.1% for the positive post-mortem samples. Changes ranged from -32.4% to 21.0% for samples from living and from -30.4% to 34.4% for post-mortem samples. All negative samples were still negative at the time of reanalysis. CONCLUSION Reanalysis of these forensic whole blood samples stored several years at -20°C with fluoride preservation did not exhibit changes in GHB concentrations of practical significance for the interpretation of toxicological findings.
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Affiliation(s)
- Bente Fjeld
- Norwegian Institute of Public Health, Division of Forensic Medicine and Drug Abuse Research, PO Box 4404, Nydalen, N-0403 Oslo, Norway.
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Bosch OG, Quednow BB, Seifritz E, Wetter TC. Reconsidering GHB: orphan drug or new model antidepressant? J Psychopharmacol 2012; 26:618-28. [PMID: 21926421 DOI: 10.1177/0269881111421975] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
For six decades, the principal mode of action of antidepressant drugs is the inhibition of monoamine re-uptake from the synaptic cleft. Tricyclic antidepressants, selective serotonin re-uptake inhibitors (SSRIs) and the new generation of dual antidepressants all exert their antidepressant effects by this mechanism. In the early days of the monoaminergic era, other efforts have been made to ameliorate the symptoms of depression by pharmacological means. The gamma-aminobutyric acid (GABA) system was and possibly still is one of the main alternative drug targets. Gammahydroxybutyrate (GHB) was developed as an orally active GABA analogue. It was tested in animal models of depression and human studies. The effects on sleep, agitation, anhedonia and depression were promising. However, the rise of benzodiazepines and tricyclic antidepressants brought GHB out of the scope of possible treatment alternatives. GHB is a GABA(B) and GHB receptor agonist with a unique spectrum of behavioural, neuroendocrine and sleep effects, and improves daytime sleepiness in various disorders such as narcolepsy, Parkinson's disease and fibromyalgia. Although it was banned from the US market at the end of the 1990s because of its abuse and overdose potential, it later was approved for the treatment of narcolepsy. New research methods and an extended view on other neurotransmitter systems as possible treatment targets of antidepressant treatment brought GHB back to the scene. This article discusses the unique neurobiological effects of GHB, its misuse potential and possible role as a model substance for the development of novel pharmacological treatment strategies in depressive disorders.
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Affiliation(s)
- Oliver G Bosch
- Clinic of Affective Disorders and General Psychiatry, University Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
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Abstract
BACKGROUND Gamma-hydroxybutyric acid (GHB) has become one of the most dangerous illicit drugs of abuse today. It is used as a recreational and date rape drug because of its depressant effect on the central nervous system, which may cause euphoria, amnesia, respiratory arrest, and coma. There is an urgent need for a simple, easy-to-use assay for GHB determination in urine and blood. In this article, a rapid enzymatic assay adapted to clinical chemistry analyzers for the detection of GHB is presented. METHODS The described GHB enzymatic assay is based on a recombinant GHB dehydrogenase. The full validation of the assay was performed on a Konelab 30 analyzer (Thermo Fisher Scientific). RESULTS The analytical sensitivity was <1.5 mg/L, whereas the functional sensitivity was 4.5 mg/L in serum and 2.8 mg/L in urine. The total imprecision coefficient of variation (CV) was <9.8% in serum and <7.9% in urine. The within-run imprecision showed a CV of <3.8% in serum and <4.6% in urine. The assay was linear within the range 5-250 mg/L. Mean recoveries were 109% in serum and 105% in urine. No cross-reactivity was observed for tested GHB analogues and precursors. Comparison of GHB-positive samples showed an excellent correlation with ion chromatography, gas chromatography-mass spectrometry, and liquid chromatography associated to tandem mass spectrometry. Except for ethanol, no substantial interference from serum constituents and some drugs was observed. CONCLUSIONS This automated GHB assay is fully quantitative and allows the accurate measurement of GHB in serum and urine. It can be used as a rapid screening assay for the determination of GHB in intoxicated or overdosed patients.
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van Amsterdam JGC, Brunt TM, McMaster MTB, Niesink RJM. Possible long-term effects of γ-hydroxybutyric acid (GHB) due to neurotoxicity and overdose. Neurosci Biobehav Rev 2012; 36:1217-27. [PMID: 22342779 DOI: 10.1016/j.neubiorev.2012.02.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 01/24/2012] [Accepted: 02/02/2012] [Indexed: 11/17/2022]
Abstract
In several countries, including the Netherlands, the use of GHB seems to be rising. GHB is regarded by recreational users as an innocent drug without any side effects. Recently, the number of patients in treatment due to GHB addiction sharply increased. In addition, various studies report incidents following risky GHB use or GHB overdosing. Other sedative drugs, like ketamine and alcohol have been shown to result in unintended neurotoxic harm at the level of memory and cognitive function. As outlined in the present review, GHB and ketamine have a common mode of action, which suggests that GHB may also lead to similar neurotoxicity as ketamine. GHB overdosing, as well as binge drinking (and high ketamine doses), induce profound coma which is probably neurotoxic for the brain especially in the maturing brain of young adults. It is therefore advocated to investigate possible long-term neurotoxic effects in recreational GHB users e.g. by studying the residual effects on cognition and memory.
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Affiliation(s)
- Jan G C van Amsterdam
- National Institute of Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands.
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Dahl SR, Olsen KM, Strand DH. Determination of γ-hydroxybutyrate (GHB), β-hydroxybutyrate (BHB), pregabalin, 1,4-butane-diol (1,4BD) and γ-butyrolactone (GBL) in whole blood and urine samples by UPLC-MSMS. J Chromatogr B Analyt Technol Biomed Life Sci 2011; 885-886:37-42. [PMID: 22226469 DOI: 10.1016/j.jchromb.2011.12.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 12/06/2011] [Accepted: 12/08/2011] [Indexed: 11/27/2022]
Abstract
The demand of high throughput methods for the determination of gamma-hydroxybutyrate (GHB) and its precursors gamma-butyrolactone (GBL) and 1,4-butane-diol (1,4BD) as well as for pregabalin is increasing. Here we present two analytical methods using ultra-high pressure liquid chromatography (UPLC) and tandem mass spectrometric (MS/MS) detection for the determination of GHB, beta-hydroxybutyrate (BHB), pregabalin, 1,4BD and GBL in whole blood and urine. Using the 96-well formate, the whole blood method is a simple high-throughput method suitable for screening of large sample amounts. With an easy sample preparation for urine including only dilution and filtration of the sample, the method is suitable for fast screening of urine samples. Both methods showed acceptable linearity, acceptable limits of detection, and limits of quantification. The within-day and between-day precisions of all analytes were lower than 10% RSD. The analytes were extracted from matrices with recoveries near 100%, and no major matrix effects were observed. Both methods have been used as routine screening analyses of whole blood and urine samples since January 2010.
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Affiliation(s)
- Sandra Rinne Dahl
- Norwegian Institute of Public Health, Division of Forensic Medicine and Drug Abuse Research, P.O. Box 4404, Nydalen, 0403 Oslo, Norway.
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Roiko SA, Felmlee MA, Morris ME. Brain uptake of the drug of abuse γ-hydroxybutyric acid in rats. Drug Metab Dispos 2011; 40:212-8. [PMID: 22019629 DOI: 10.1124/dmd.111.041749] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
γ-Hydroxybutyric acid (GHB) is an endogenous compound and a substrate for the ubiquitous monocarboxylate transporter (MCT) family. GHB is also a drug of abuse due to its sedative/hypnotic and euphoric effects, with overdoses resulting in toxicity and death. The goal of this study was to characterize the distribution of GHB into the brain using in vivo microdialysis and in vitro uptake studies and to determine concentration-effect relationships for GHB in a rat animal model. GHB was administered to rats (400, 600, and 800 mg/kg i.v.), and blood, dialysate, and urine were collected for 6 h post-GHB administration. The GHB plasma and extracellular fluid (ECF) concentration-time profiles revealed that GHB concentrations in ECF closely followed plasma GHB concentrations. Sleep time increased in a dose-dependent manner (91 ± 18, 134 ± 11, and 168 ± 13 min, for GHB 400, 600, and 800 mg/kg, respectively). GHB partitioning into brain ECF was not significantly different at 400, 600, and 800 mg/kg. GHB uptake in rat and human brain endothelial cells exhibited concentration dependence. The concentration-dependent uptake of GHB at pH 7.4 was best-fit to a single-transporter model [K(m) = 18.1 mM (human), 23.3 mM (rat), V(max) = 248 and 258 pmol · mg(-1) · min(-1) for human and rat, respectively]. These findings indicate that although GHB distribution into the brain is mediated via MCT transporters, it is not capacity-limited over the range of doses studied in this investigation.
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Affiliation(s)
- Samuel A Roiko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 527 Hochstetter Hall, Buffalo, NY 14260, USA
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Marclay F, Saudan C, Vienne J, Tafti M, Saugy M. Source inference of exogenous gamma-hydroxybutyric acid (GHB) administered to humans by means of carbon isotopic ratio analysis: novel perspectives regarding forensic investigation and intelligence issues. Anal Bioanal Chem 2011; 400:1105-12. [DOI: 10.1007/s00216-011-4891-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 03/08/2011] [Accepted: 03/09/2011] [Indexed: 11/29/2022]
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Andresen H, Aydin BE, Mueller A, Iwersen-Bergmann S. An overview of gamma-hydroxybutyric acid: pharmacodynamics, pharmacokinetics, toxic effects, addiction, analytical methods, and interpretation of results. Drug Test Anal 2011; 3:560-8. [DOI: 10.1002/dta.254] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 12/05/2010] [Accepted: 12/06/2010] [Indexed: 11/11/2022]
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