Gamma hydroxybutyrate (GHB) withdrawal and dependence
- Deborah L Zvosec, PhD
Deborah L Zvosec, PhD
- Research Associate, Department of Emergency Medicine
- Hennepin County Medical Center
- Stephen W Smith, MD
Stephen W Smith, MD
- Department of Emergency Medicine, Hennepin County Medical Center
- Associate Professor of Emergency Medicine
- University of Minnesota School of Medicine
- Section Editors
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The clinical features and management of GHB withdrawal are reviewed here. Acute intoxication with GHB and its management are discussed separately, as is the general management of the poisoned patient. (See "Gamma hydroxybutyrate (GHB) intoxication" and "General approach to drug poisoning in adults".)
Throughout this review we use the term "GHB" to refer to GHB and its analogs, GBL and BD, unless specifically noted. The pharmacology of GHB and its analogs are discussed separately. (See "Gamma hydroxybutyrate (GHB) intoxication", section on 'Pharmacology and cellular toxicology'.)
Due to the absence of surveillance and systematic reporting mechanisms, little is known of the prevalence of chronic GHB abuse or dependence. Cases of GHB dependence and withdrawal have been reported in the United States (US), Canada, Europe, and Australia [1-15].
The Texas Department of State Health Services has reported a steady increase in the number of patients admitted for treatment of GHB dependence, from 2 in 1998 to a peak of 113 in 2008 and 91 in 2009 . According to this report, GHB dependent users were slightly older than other users of club drugs (average age 29 to 32 years), often had a history of injection drug use, and frequently had primary dependency problems with amphetamines or methamphetamines. Users also reported using GHB’s sedative effects to counteract the stimulant effects of methamphetamine, and vice versa. Combined data from Texas and the California Poison Control System (CPCS) suggest that GHB dependence is more common among men and occurs in a wide age range (17 to 60 years) [16,17]. According to CPCS data, common reasons for starting to use GHB are bodybuilding and treatment of insomnia.
Although total exposures declined over the course of the CPCS study, the proportion of patients with severe outcomes from GHB withdrawal increased from 10 of 130 cases in 1999 to 2001 to 10 of 37 cases in 2002 to 2003 . Of 167 total cases, 80 (48 percent) were admitted to a hospital for treatment of withdrawal. The median hospital stay was three days, with 27 of 80 (34 percent) admitted for five or more days. A review of 38 cases of withdrawal from GHB reported a mean duration of nine days (range 3 to 15) .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- ILLICIT AND THERAPEUTIC USE
- PHARMACOLOGY, CELLULAR TOXICOLOGY, AND PATHOPHYSIOLOGY
- RISK FACTORS FOR GHB DEPENDENCE
- DOSING PATTERNS ASSOCIATED WITH DEPENDENCE
- CLINICAL FEATURES OF WITHDRAWAL
- Common symptoms, onset, and course
- Specific signs and symptoms
- DIFFERENTIAL DIAGNOSIS
- LABORATORY EVALUATION
- Specific testing for GHB
- General evaluation
- General approach
- Mild to moderate withdrawal, without delirium
- Severe withdrawal, with delirium
- - Medications used for sedation
- - Management of seizures
- - IV fluids and vitamin repletion
- - Restraints
- - Unproven and possibly harmful treatments
- Antihypertensive medications
- Antipsychotic medications
- Outpatient detoxification
- Persistent symptoms post-detoxification
- CHEMICAL DEPENDENCY TREATMENT AND RELAPSE PREVENTION
- PITFALLS IN MANAGEMENT
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS