Gamma hydroxybutyrate (GHB) dependence and withdrawal
- 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
Gamma hydroxybutyrate (GHB) is a drug of abuse that is used for its euphoric, stimulant, sedative, and sexual effects. Gamma butyrolactone (GBL) and 1,4 butanediol (BD) are analogs or precursors of GHB which, when ingested, are rapidly metabolized to GHB, with the same clinical effects. All three compounds, GHB, GBL and BD, are used as dietary “supplements” for purported health benefits, including bodybuilding and treatment of insomnia, anxiety, and alcohol dependence. Tolerance, psychological and physical dependence, and withdrawal have been reported among individuals using GHB, GBL, and BD for both recreational purposes and purported health benefits. [1-9].
GHB is also used as a therapeutic agent in the United States and Europe. In the US, GHB is available as Xyrem® (sodium oxybate), which has been approved by the Food and Drug Administration (FDA) for treatment of narcolepsy with cataplexy and/or excessive daytime sleepiness. In Europe, GHB is available as Xyrem®, as Alcover®, which has been studied for treatment of alcohol and drug dependence, and as Somsanit®, which has been approved as an anaesthetic. Craving, abuse, dependence, and withdrawal have been reported in therapeutic trials in which GHB/Alcover® was administered under close supervision [10-12], as well as among patients treated with Xyrem® [13,14].
The clinical features and management of GHB withdrawal are reviewed here. Acute intoxication with GHB and its management are discussed elsewhere, 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 [1-8,15-21].
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- PHARMACOLOGY, CELLULAR TOXICOLOGY, AND PATHOPHYSIOLOGY
- CLINICAL FEATURES OF WITHDRAWAL
- Risk factors for development of GHB dependence
- Dosing patterns
- Common symptoms, onset, and course
- Specific signs and symptoms
- DIFFERENTIAL DIAGNOSIS
- LABORATORY EVALUATION
- Specific testing
- General testing
- General approach
- - Mild to moderate withdrawal, without delirium
- - Severe withdrawal, with delirium
- - Benzodiazepines
- - Barbiturates
- - Propofol
- - Anticonvulsants
- - Baclofen
- - Antihypertensives
- - Antipsychotics
- Vitamins and fluids
- Outpatient detoxification
- Persistent symptoms post-detoxification
- CHEMICAL DEPENDENCY TREATMENT AND RELAPSE PREVENTION
- PITFALLS IN MANAGEMENT
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS