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PRACTICE GUIDELINES
OFFICE-BASED TREATMENT GUIDELINE FOR GHB (gamma-hydroxubutyrate) WITHDRAWAL
The TSPP Executive Council approved the Guideline on April 17,
2005 upon recommendation of the Professional Practices Committee.
Introduction: GHB is a metabolite of GABA, the inhibitory
neurotransmitter and binds to GHB-receptors found mainly in the pons and
hippocampus. GHB is highly soluble, has a salty taste and is therefore difficult
to disguise. Doses of 20-30 mg/kg of GHB induce sleep, and 50 mg/kg produces an
anesthetic effect. The duration of GHB’s effect is approximately 4 hours.
GHB was used in the 1960s-1970s as a general anesthetic, but discontinued due to
dosing problems and adverse effects. In the1980s, GHB was used by body builders,
and as a sleep aid and dietary supplement. GHB was banned in 1990 by the FDA due
to GHB-induced coma and seizures, and GHB was labeled as Schedule I in 2000.
Following rescheduling of GHB, use of the more toxic 1,4-butanediol, an
industrial solvent, and gamma-butryolactone (GHL), has increased. These are
“pro-drugs” that when ingested are converted to GHB. Use of GHB and the related
pro-drugs has markedly increased since 1999.
“Pro-drugs” are known by the following names:
Grievous Bodily Harm
Rest-Eze
Easy Lay
Firewater
G
Zen
Blue Nitro
Miracle Cleaning Products
Liquid Ecstasy
Serenity
BlueRaine
Georgia Home Boy
Scoop
Thunder
Clinical effects of GHB include:
• Euphoria
• Disinhibition
• Relaxation
• Increased feelings of sexuality
• Aggression
Physical effects include:
• Ataxia
• Nystagmus
The subjective and physical effects of GHB are similar to those of alcohol and
overdose can induce a comatose state. Overdose typically occurs in the presence
of other drugs, particularly alcohol, sedatives, and opioids. The major cause of
death from overdose is respiratory depression. GHB-induced bradycardia responds
well to atropine administration.
Withdrawal Symptoms
Withdrawal symptoms occur in subjects taking 100 gms of GHB daily. Both the
symptoms of GHB withdrawal and the treatment of withdrawal are based on
anecdotal reports only. The symptoms of withdrawal and the treatment of
withdrawal are similar to those of alcohol.
Early Symptoms of Withdrawal:
Anxiety
Insomnia
Tremor
Confusion
Nausea and Vomiting
Late symptoms of withdrawal (2-3 days after last use):
Autonomic instability
Increased blood pressure
Diaphoresis
Hallucinations
Anxiety
Disorientation and Delirium
Acute symptoms may last for up to two weeks.
Protracted Withdrawal-May persist for up to 3-6 months after last use of GHB
Dysphoria
Anxiety
Memory problems
Insomnia
High risk of relapse to GHB, alcohol, or other sedative-hypnotics
Treatment
• Supportive Care.
• Benzodiazepines should be used to treat symptoms as they occur. The use of
several different types of benzodiazepines have been reported, and it is
unlikely that any specific BZ has an advantage over the other. As with alcohol,
longer half-life BZs (i.e. diazepam, chlordiazepoxide) require less frequent
dosing and decrease the likelihood of breakthrough symptoms. For example,
Clordiazapoxide may be initiated on day one at 50 mg po q 6 hours with a
decrease to 25 mg po q 6 hours for the next several days with adjustments made
according to symptom severeity. A supplement of 25 mg q 1-2 hours could be added
if withdrawal symptoms are not abating with the above schedule. Similarly,
Lorazepam could be initiated on day one at a level of 2 mg po tid with a
decrease to 1 mg po tid on days two and three with subsequent dosing determined
by the presence of continuing symptoms. A supplement of 1.5 –1 mg every hour if
withdrawal symptoms are not abating could be provided on a prn basis.
Barbituates have also been reported in the treatment of GHB withdrawal, though
it is unlikely that these drugs confer any advantage over BZs and have increased
toxicity.
• Antipsychotics can be used for delirium.
• The physician will need to asses environmental, behavioral, and/or medical
factors that support or mitigate against outpatient treatment. If insufficient
capacity to comply or concomitant medical or psychiatric factors are
co-occurring and/or environmental support seems minimal inpatient treatment may
be preferred.
References:
Bowles TM, Sommi RW, Amiri M.
Successful management of prolonged gamma-hydroxybutyrate and alcohol withdrawal.
Pharmacotherapy. 2001 Feb;21(2):254-7.
Craig K, Gomez HF, McManus JL, Bania TC.
Severe gamma-hydroxybutyrate withdrawal: a case report and literature review.
J Emerg Med. 2000 Jan;18(1):65-70.
Miotto K, Darakjian J, Basch J, Murray S, Zogg J, Rawson R.
Gamma-hydroxybutyric acid: patterns of use, effects and withdrawal.
Am J Addict. 2001 Summer;10(3):232-41
Schneir AB, Ly BT, Clark RF.
A case of withdrawal from the GHB precursors gamma-butyrolactone and
1,4-butanediol.
J Emerg Med. 2001 Jul;21(1):31-3.
Zvosec DL, Smith SW, McCutcheon JR, Spillane J, Hall BJ, Peacock EA.
Adverse events, including death, associated with the use of 1,4-butanediol.
N Engl J Med. 2001 Jan 11;344(2):87-94. |
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