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Gamma hydroxybutyrate (GHB) abuse

INTRODUCTION

Gamma hydroxybutyrate (GHB) is a central nervous system (CNS) depressant first synthesized in France as an analog of gamma aminobutyric acid (GABA) and capable of crossing the blood brain barrier [1]. Initially used as an anesthetic in Europe, GHB's inadequate analgesic effects and side effects, including myoclonus and emergence delirium, prevented approval in the United States (US) [2].

In the 1980s GHB was marketed as a bodybuilding and weight loss drug and sold in health food stores. Subsequently use became more widespread as GHB was abused for euphoric, sexual, stimulant, and relaxant effects. Internet websites, chat rooms, and forums have figured prominently in the dissemination of information and misinformation regarding GHB sources and supplies, use and effects, and legal status around the world [3,4].

GHB is used as a therapeutic agent in the United States (US) and several countries in Europe. In the US, GHB has a bifurcated Drug Enforcement Administration scheduling status, passed in March 2000. GHB used for illicit purposes is a US Food and Drug Administration (FDA) Schedule I Controlled Substance, while pharmaceutical GHB (Xyrem® in the US, also called "sodium oxybate"), which was initially approved to treat cataplexy in patients with narcolepsy, is a Schedule III drug. Although Xyrem® is distributed through one central pharmacy and the manufacturer maintains a risk management program, the absence of restrictions on off-label use, abuse during various clinical trials despite supervision, and ongoing demand make it susceptible to abuse [5-8].

While "supplements" containing GHB (or the congeners gamma butyrolactone [GBL] and butanediol [BD]) have largely disappeared from the internet, industrial GBL and BD are used worldwide and remain readily available. Sales have gradually switched to GBL and BD, sold spuriously as non-toxic and organic solvents, cleaning products, and chemical samples to avoid detection and prosecution [9]. GHB is also synthesized in home kitchens using GBL, with recipes readily available through the internet.

The toxicology and management of acute GHB intoxication are reviewed here. GHB withdrawal, the toxicology of other specific agents that may be coingested, and general management of the poisoned patient are discussed elsewhere. (See "Gamma hydroxybutyrate (GHB) dependence and withdrawal" and "MDMA (ecstasy) intoxication" and "Cocaine: Acute intoxication" and "General approach to drug poisoning in adults".)
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