Transcript GBL

GBL Dependence and
withdrawal
James Bell
January 2014
GHB/GBL
Mr JL, 25
Presented February 2010, seeking to withdraw from GBL
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First used GHB 6 years ago - “best thing I’d ever taken”.
Euphoric, confident, and wanted more
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Dependent use 2 years –2mL every1-2 hours
Three previous detoxifications
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March 2009 – presented ED psychotic on day 3, treated by
AMH. Remained abstinent one month, very depressed, lost
his job. Resumed GBL use, rapidly became dependent
again.
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Nov 2009 Detoxed in hospital following presentation with
overdose – rapid relapse
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Nov 2009 Then referred for ambulatory detox, did not
begin
Mr JL – Medical events 2006-2009
① Oct. 2006 BIBA from club agitated and uncooperative
having used GHB, ecstasy, cocaine and alcohol. Selfdischarged
② May 2007 BIBA from club with GHB, cocaine and
ketamine intoxication. 3 tonic-clonic seizures prior to
hospital. Required lorazepam and discharged home
③ Feb. 2009 Presented to ED, Self-discharged before seen
④ April 2009 BIBA following GHB and methamphetamine
use. Agitated and hyperventilating, given IV diazepam
and self-discharged
⑤ May 2009 Admitted in coma (GCS 3). Crash intubation,
ventilated on ITU and self-discharged from step-down
⑥ May 2009 Admitted with agitation and suicidal intent
during GBL withdrawal.
Mr JL Drug Use History

Alcohol age 13, cannabis age 14-17, dance drugs
age 19+ “cocktails”. Never injected.
 Alcohol use has increased when stopping GBL
(max 3/4 bottle of vodka)
Recent drug use
 Cigarettes 10/day
 Alcohol- 20 units weekly
 MDMA, occasional ketamine, cocaine <2-3g once
to twice a week
 Methamphetamine (0.5g fri/sat)
Mr JL – social Hx
 Gay man, lives with partner, also GBL
dependent
 Unemployed. Lost 3 jobs since becoming
dependent on GBL
 Used to party, since becoming dependent
increasingly withdrawn
 Could spend £200/week on drugs (GBL
£60 for 1litre). All friends use/have tried.
 Parents pay for food and rent
JL - Progress
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Day 1 diazepam 110mg, baclofen 30mg
Days 2-4 Diazepam 20mg/day, baclofen
30mg/day
Day 4,8 – slept well, feels comfortable, no GBL
use
Days 10– remained abstinent from GBL. 4 days
after ceasing diazepam, began feeling increasing
anxiety – not sleeping, depressed, unmotivated.
Commenced mirtazapine 15mg nocte
Progress II
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Day 15 – still difficulty sleeping, but more
motivated, seeking work
Day 21 DNA for appointment
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2 months later – brief lapse(3 days) to
GBL use.
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3 months – GBL free, well, still uses other
party drugs
GBL
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“Legal High” – cleaning fluid, now a Class
C drug, possession restricted to people
having business registration after 21/12/09
Precursor of GHB
Produces confidence, charm, relaxation
(“charisma”), sexual disinhibition
In higher doses produces prompt sleep
Usage mainly in gay males
GBL destined for industrial use
Why do people use GBL?
1. Sociability
2. Sexuality
3. Sleep
GBL - toxicity
Narrow therapeutic window – small margin
between dose and overdose
(sold with pipettes for accurate measurement)
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About 3 presentations/ week to GSST
with OD (GBL, GHB)
Rare deaths
GBL - dependence
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Uncommon
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Involves dosing every 1-2 hours
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Can develop rapidly (eg after a “long
weekend” of partying)
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Often occurs when drug is used to facilitate
sleep
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Associated with social withdrawal,
emotional blunting, and compromised
social role
GBL Withdrawal
Withdrawal onset is rapid – 3-4 hours
Can be severe (delirium, agitated psychosis,
anxiety and insomnia; may require ICU
management and /or very high dose BZD)
Risk of rhabdomyolysis and ARF
Relapse not rare
Features of withdrawal
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Tachycardia
Anxiety and insomnia ++
Formication, visual disturbances
Tremor
Sweaty palms
Delirium (psychotic features)
Rationale for treatment
1. Ambulatory withdrawal is the default option
2. Initiate treatment before withdrawal established
3. Use high dose diazepam (rapid oral absorption,
long half-life) 70-100mg in first 24/24
4. Add baclofen (GABAb agonist) 10-20mg q8h
Managing GBL withdrawal
Withdrawal can be managed on an ambulatory
basis, but needs:
• Supportive home environment
• Potential rapid access to in-patient care
• early and aggressive management
• close monitoring
• ongoing monitoring over weeks
Maudsley experience
>50 patients completed withdrawal
1. Patients NOT socially excluded - mostly
employed, educated, and with no other drug
dependence
2. Erratically compliance - people don’t answer
calls, cancel appointments, and appear to think
that they are managing their own lives
3. Many relapsed, weeks to months after
detoxification
Why did people relapse?
1. Move in GBL using circles?
2. Unable to have sex without GBL
3. Many “liked the person they were on GBL
better than the person I am without it”
Why did people relapse?
1. Move in GBL using circles
2. Unable to have sex without GBL
3. Many “liked the person they were on GBL
better than the person I am without it”
4. Relapse after detox is typical of all drugs
(especially nicotine, opioids, and GBL)
Party Drugs (legal highs, NPS, etc)
Bewildering array, commonly:
- stimulants (amphetamine type stimulants,
cathinones)
- Prescription medications (ketamine, gaba
agonists, opioids)
Used by
1. Gay club scene (GBL, mephedrone, viagra)
2. Internet “geeks”
3. Students
Further reading
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Bell J & Collins R (2011) Gamma-butyrolactone
(GBL) dependence and withdrawal Addiction
106(2); 442-447
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McDonough M, Kennedy N, Glasper A, Bearn J
(2004) Clinical features and management of
gamma-hydroxybutyrate (GHB) withdrawal: a
review Drug and Alcohol Dependence 75; 3–9
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Le Tourneau J, Hagg D, Smith S (2008) Baclofen
and gamma-hydroxybutyrate withdrawal
Neurocritical Care 8(3):430-3