Gamma-Hydroxybutyrate (GHB) With-Drawal

Case A 35-year-old man with no significant medical history presented to a university ED complaining of anxiety. tremors and insomnia. The patient denied use of common street drugs or tobacco. He admitted to social weekend alcohol consumption, but had not been drinking during the preceding 2 weeks. His vital signs were: temperature 37.2OC, pi~lse 105/min. respirations 161 min. blood pressure 148188 mmHg. Physical examination revealed a muscular young man with a resting tremor and obvious anxiety. but was otherwise unremarkable. The patient's girlfriend took the physician aside and revealed the actual reason for seeking ED treatment was that he was trying to quit using GHB. She also confirmed he had nor been drinking alcohol and was not a habitual alcohol user. The patient subsequently admitted to using increasing amounts of GHB for the previous 2.5 years, and was consuming 1 to 2 "capfuls" of liquid GHB 4 to 6 times daily (exact dose unknown). His last dose was 20 hours prior to presentation. The patient first started using GHB at the urging of weight-lifting friends. He had attempted to quit multiple times without success. A presumptive diagnosis of GHB withdrawal was made. The patient was treated with 20 mg of oral diazepam in the ED, which relieved the tremors. After a 3-hour observation period. he was discharged with a 3-day prescription for lorazepam. referred to a local primary care clinic and given substance abuse counseling information. Although laboratory confirmation of GHB use was not obtained. this case illustrates the features of GHB withdrawel that will be discussed in this article: the clinical manifestations of the GHB withdrawal syndrome, the similarities to withdrawal from other sedative-hypnotic agents. and the treatment options. Recognizing and treating GHB withdrawal will be of increasing importance to emergency physicians as its popularity continues to grow. Clirlical Marl(festc~tions GHB is a naturally occurring substance. found in highest concentrations in the basal ganglia and hypothalamus of brain tissue.' Although commercial sale of GHB is illegal in the United States. it is still easy to obtain, as evidenced by its abundance at rave parties. GHB recipes and various precursor formulations containing gamma-butyrolactone, 1.4-butanediol, dihydro-2(3H)-furanone and 4-butanolide are also available via the internet.? The precursors are converted in vivo to GHB after ingestion. GHB is popular among rave crowds and bodybuilders. and has been implicated as a "date-rape" drug. Investigational narcolepsy treatment is the only FDA approved use for GHB …