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THE EDUCATOR - Fall 2002
Gamma Hydroxy
Butrate (GHB) Fact Sheet
By Trinka Porrata
WHAT
IS GHB?
Gamma
hydroxybutyrate (GHB) is an illicit chemical that has become a major cause
of drug-related comas in the US and other countries. In fact, the number
of GHB overdoses in the United States has now out-paced overdoses from
MDMA (Ecstasy). GHB was rejected by the American medical community in
the 1960s, but has become popular among many people for its ability to
cross the blood-brain barrier freely and depress consciousness, resulting
in euphoria and intoxication. It is also touted on the Internet as a sleep
aid, an anti-depressant and weight loss product, although these uses are
not substantiated by reality and may carry a potentially deadly twist.
Starting first as an alternative to steroids in the late 1980s, when steroids
were being controlled, GHB has grown into a multi-headed medical nightmare,
draining emergency room services, shattering the lives of those who have
lost loved ones to it, and terrifying families/friends of those addicted
to it. Yet it is still a mystery to most law enforcement
officers, medical/coroner personnel, and parents.
HISTORY
GHB was first synthesized in France more than 40 years ago as
a possible anesthetic, but because of its undesirable side effects was
rejected by the American medical community. Its legal use anywhere is
dwindling as countries are beginning to recognize the problems. GHB resurfaced
in 1987 as an orphan drug being researched to treat the combination of
sleep disorders known as narcolepsy/cataplexy. At about the same time,
steroid users were told that it might enhance the body’s production of
growth hormone (in deep sleep state). However, due to growing numbers
of overdoses, it was ordered off the shelves of stores in November 1990.
Unfortunately, it has gained status as a recreational drug and as a rape
drug, and has become dangerously common. As a result of increased restrictions
on GHB itself, its “analogs,” or chemical cousins that turn into GHB in
the body, have become increasingly prevalent.
USERS
*Attendees at dance clubs or “rave” parties are perhaps the
most prominent users of GHB to alter mood.
*Sexual predators of all ages are attracted by the disinhibiting and euphoric
effects of GHB, for they know a user may be easily taken advantage of
in an assault. Some exotic dancers and strippers self-dose with GHB, seeking
a “sexier” performance.
*Bodybuilders and other athletes, including professional athletes, are
the least recognized users. In fact, this group, often using it on a daily
basis, are the ones most likely to become addicted.
*Business professionals who travel frequently and think GHB is a safe
sleep aid (comparable to melatonin, for example) are another unrecognized
group, also subject to addiction and withdrawal.
*The elderly are also potential victims, being told that GHB is an anti-aging
compound.
*Gay and lesbian populations also use GHB as a recreational drug. In some
cases, it is also used in this community for rape or robbery purposes..
*People subject to drug testing programs use GHB as an alcohol substitute
and to bypass drug testing.
NOTE: Identification of GHB is complicated by the short duration of time
that it persists in body fluids and by the absence of GHB testing from
the normal testing procedures of most agencies. This will change, as risks
of GHB are more widely recognized.
ANALOGS
OF GHB
Over the past several years, a variety of states, beginning
with Rhode Island and Georgia, have added GHB to their lists of controlled
substances, thus making it possible for criminal penalties to be administered
for use of the drug. This forced gamma butyrolactone (GBL) and 1,4-butanediol
(BD), to step into the spotlight. GBL is both a precursor (a primary ingredient
in making GHB) and an active analog (a substance that converts to GHB
in the human body, with the same physical effect as GHB). BD is an active
analog, also converting rapidly to GHB in the body. Another analog that
has surfaced, gamma hydroxyvalerate (GHV), is on its way to becoming as
universal as GBL and BD. Both GBL and BD achieve this conversion inside
of the body, and GBL can transform into GHB both inside and outside of
the body. GHB remains accessible to abusers through this simple conversion,
though all are illegal for human consumption since March 2000, when GHB
was federally scheduled. What is unsettling, though, is how easy it is
to get a hold of these precursors. GBL and BD and valeric acid substances
are available at gyms, chemical supply stores, the Internet, and through
mail order. They are sold as powders, capsules, gels or liquids and can
be found in a variety of concentrations, colors, and flavors. There are
more than 80 street and trade names for GHB and its analogs.
EFFECTS
OF GHB
GHB’s depressant effects on the brain in low doses produce a
high or euphoric feeling as inhibitions are depressed. When the dose is
increased, profound coma results. The heart rate may also be depressed
or slowed. Effects on the nervous system may result in a spasm of muscle
contractions called myoclonus, producing seizure-like movements. Other
effects such as confusion, amnesia, vomiting and irregular breathing are
dangerous when combined with the major depressant effects of GHB. Other
drugs in combination with GHB, especially other depressants such as alcohol,
may worsen the depressive effects and increase the possibility of a fatal
outcome. The “desired” effects for GHB in low doses may sound inviting,
but the consequence of the wrong dose may be death. The dosage response
of GHB is quite steep, meaning that a tiny increase in dose may cause
a dramatic increase in symptoms and, thus, in risk. Variable effects mean
that a teaspoon might be perfect one time, but may become an overdose
the next time! It is also important to be aware of the consequences that
occur when GHB is mixed with other chemicals. For instance, mixing GHB
with alcohol or other depressants is even more likely to result in death.
The effects last about four hours and can resolve quite suddenly.
CONSEQUENCES
TO PROVIDERS
Selling, administering, or otherwise providing GHB to another
person, whether they take it willfully or not, can result in a variety
of criminal charges ranging from possession, possession for sale, sale,
or poisoning to even manslaughter and homicide. Administering GHB to an
individual for purposes of sex (whether concealed or disguised as a “tonic”
or health drink) or having sex with a person unconscious or impaired by
GHB (or other drugs) can also result in a variety of criminal charges.
Civil charges may also be brought against the person (or business) who
sells, supplies or administers GHB in some circumstances. These consequences
will vary from state to state or country to country.
GHB
OVERDOSE
The most distinctive and terrifying feature of GHB is its overdose
time course. Within 15 minutes a person’s state of mind becomes altered
and there is a high possibility of a loss of consciousness or an actual
coma. Breathing can slow to only four to six breathes per minute! Most
people do “sleep off” a GHB overdose; those who don’t are called “dead.”
A GHB overdose IS a 911 emergency.
THE
FUTURE OF GHB
Whether GHB continues to be a widely used drug depends on the
steps that are taken to educate the public. Instead of being perceived
as a dietary supplement, people need to recognize GHB for what it is:
an illict and dangerous drug. Even though GHB (also known as sodium oxybate,
tradename Xyrem) has been approved for medical purposes, its deadly risks
for recreational or any unsupervised and unmonitored use remain the same.
There is no evidence that professionally made GHB is any less dangerous
in the abuse arena. Health care providers and law enforcement officers
need to become fully aware of the effects and dangers of GHB so that they
can play an important role in informing the public.
GHB is usually
liquid & may be hidden in any type of container. Water/drink bottles,
eye & nasal spray & mouth wash containers are common. Because
of its usually salty or chemical taste, it is often disguised in sweet
or fruity drinks when given to unknowing victims for rape or robbery.
GHB—IS
IT ADDICTIVE?
Internet dribble to the contrary, gamma hydroxybutyrate (GHB)
is an addictive drug. Withdrawal can be severe and prolonged. Yet recognition
and treatment of GHB addiction/withdrawal isn’t readily available. Knowledge
of GHB by the public and in the fields of law enforcement/medicine is
typically limited to its abuse as an intoxicant and use as a rape weapon.
GHB addiction is characterized by around the clock dosing (every one to
three hours, day/night, with heavier doses at night to achieve sleep).
Addiction can develop in a few weeks. Use for four to eight months is
common among the 600 GHB addicts who have come forward for help through
the GHB Addiction Helpline via www.projectghb.org. Others have been using
for up to ten years, making it impossible to know at what point they became
addicted.
ADDICTION
SCENARIO
Occasional users are at risk from rape, overdose and death,
but are not as likely to become addicted. Those using GHB on a daily or
systematic basis as an anti-depressant, a sleep aid, a workout aid, weight
loss product, an anti-aging substance, etc., are at risk of addiction
by virtue of their pattern of regular, frequent use. From a nightly sleep
aid, for example, use casually moves into a morning “wake up” aid. Then
it is needed in the afternoon, to have sex, to go out in public, etc.,
until it has progressed to around the clock use. Often the pattern develops
without the user realizing what is happening since they typically didn’t
see it as a “drug” or unsafe in any way because of Internet assurances.
Initially users feel they have found the perfect supplement and swear
by the incredible benefits they feel they are seeing. Stage two, however,
comes when the honeymoon is over but the user is the last to know. Friends,
spouses, and co-workers begin to observe bizarre behavior changes, frequently
with no idea of the cause. Episodes may be as subtle as a single “head
snap” that occurs about 15 minutes after taking a dose, or may be several
minutes of twitching, strange behavior, or black outs. These episodes
may occur only following the heavier nighttime doses or after virtually
every dose. Thus, breaking the bathroom mirror while getting ready for
bed, or being found or waking up on the bathroom floor with a bloody (or
broken) nose is not uncommon as a result of the “head snap,” which may
result in hitting the mirror or the edge of the sink. Frequently, the
addict has no recall of such incidents. The addict grows distant from
spouse, family, and friends and may begin to withdraw from public contact
or become captivated by pornography or strip joints, which may be a total
behavior change from that exhibited prior to GHB use. GHB addicts typically
report numerous drunk/drugged driving episodes, which are frequently unidentified
or unrecognized by law enforcement officers, especially if there has been
no use of alcohol or other drugs. Many addicts report damage of “unknown
origin” appearing on their cars and being uncertain where their car may
be found in the morning, again due to the lack of memory of incidents
occurring while they were intoxicated.
WHO
ARE THE G-AHOLICS?
- Bodybuilders/other athletes, including pros, using GHB for
a sleep or workout aid or weight loss tool--the largest group.
- Business professionals who travel frequently and were introduced to GHB
as a “safe” sleep aid.
- The elderly, who have been told that GHB is an anti-aging compound.
- People with prior depression, who have been told that GHB is an anti-depressant.
Intoxicating effects of GHB may make it seem, initially, to have this
effect, but it later turns on many of them.
- People subject to drug testing programs who use GHB as an alcohol substitute
and to bypass testing.
- Website managers, especially those selling GHB and other sports/dietary
supplements, and computer programmers.
NOTE: Although GHB can be identified in tests, it remains in body fluids
for a relatively short period of time compared to other drugs; it lasts
in blood for four hours and in urine for twelve hours. However, GHB is
not yet included in the normal testing procedures of most agencies. .
ANALOGS
OF GHB
The product ingested may be actual GHB, ranging from home brew
to foreign pharmaceutical grade. It is often an analog of GHB, a chemical
cousin that converts to GHB in the body. This may be gamma butyrolactone
(GBL) or 1,4-butanediol (BD). GBL (aka 2(3)H furanone dihydroxy) is both
a precursor (primary ingredient in making GHB) and an active analog (converts
in the body to GHB, with the same effects). BD is an active analog. Another
analog is gamma hydroxyvalerate (GHV). GBL, BD and GHV are available at
gyms, chemical supply stores, and via Internet mail order. They are sold
as powders, capsules, gels or liquids and can be found in a variety of
concentrations, colors, and flavors. There are more than 80 street/trade
names for GHB/analogs. GBL especially may be found in the hardware story
are a primary ingredient in legitimate paint strippers; this level of
abuse is particularly dangerous as these products contain other ingredients.
Bogus Internet products are typically disguised as “ink jet cartridge
cleaners,” “fingernail polish removers,” etc.
GHB
OVERDOSE RE ADDICTS
GHB addicts typically experience frequent overdoses or mini-overdoses.
Thus, they are often treated as overdose victims, with no recognition
of the underlying addiction that causes these frequent episodes. GHB has
a steep dosage response curve and, even with development of tolerance,
its effects vary greatly. Addicts may dose in one of two patterns—1) Precise
dosing in regular intervals separated by one to three hours, with slightly
higher doses at night for sleep; or 2—Around the clock “sipping” from
a bottle of diluted product. Constant sipping is most likely to produce
mini-overdoses. Even with precise dosing, effects may vary based on tiny
variations in dose, differences in food intake, lack of food, or other
unknown reasons. A CEO of a major corporation relayed that he would try
to adjust his dose for meetings (dose at 9:30 before a meeting when the
dose was really due at 10:00); this would sometimes result in a head snap
episode early in the board meeting, leaving his staff baffled by his strange
behavior, which he simply tried to ignore.
GHB
WITHDRAWAL SYMPTOMS
Missing a dose by more than a few hours sends the addict into
significant withdrawal symptoms. This is first characterized by profuse
sweating, anxiety attacks, and may be accompanied by soaring blood pressure
and pulse. BP at dangerous levels has been documented. This may subside
on its own after two or three days or in response to medication. Thus,
on day three, a patient may “seem” to be doing “fine” and may be released
from a treatment center unfamiliar with GHB withdrawal. The second phase
of withdrawal, which may include hallucinations and altered mental state,
may begin earlier, but may also be delayed to around day four or five.
Thus, a patient released from a treatment center on day three was found
by his frantic wife hours later wandering through the city streets, hallucinating,
confused and in danger of wandering into traffic. Sometimes, clinicians
assume addicts to be psychotic and fail to recognize the underlying addiction/withdrawal.
GHB
DETOXIFICATION PROTOCOLS
Treatment of the GHB withdrawal syndrome is not yet clearly
defined. Treatment may involve use of benzodiazepines, antipsychotic medications,
or phenobarbital. It should be noted that although tapering GHB doses
prior to detoxification may help reduce the severity of the withdrawal,
attempts of some addicts to self-detoxify, without medical assistance,
have been fatal, as the withdrawal syndrome may be severe and unpredictable.
Further, as most addicts are unable to tolerate the ongoing symptoms of
withdrawal, this method is frequently unsuccessful as well as dangerous.
1—Miotto
and Roth, March 2001 article “GHB Withdrawal Syndrome,” posted on the
Texas Commission on Alcohol and Drug Abuse website (www.tcada.state.tx.us)
describe the severe withdrawal symptoms and recommend treatment involving
an aggressive 7-14 day inpatient strategy with close follow up. They
note “Benzodiazepines such as lorazepam, chlordiazepoxide and diazepam
are useful in ameliorating some of the signs and symptoms of GHB withdrawal.
Loading doses of oral or intravenous benzodiazepines do not decrease
the likelihood of withdrawal delirium, but are important for controlling
psychotic agitation.” This may require high doses of benzos. Anticonvulsants
and antipsychotics are also discussed. Antihypertensive medications
may be needed in early stages to deal with the racing heart and blood
pressure issues. NOTE: Another doctor who has dealt with numerous GHB
withdrawal cases reported a preference for clorazepate over other benzos
and stresses the need to employ an antipsychotic (such as olanzapine)
before psychosis develops.
2—Silvilotti,
Burns, Aaron and Greenberg, December 2001 Annals of Emergency Medicine,
discuss use of phenobarbital for withdrawal from GHB and discuss five
patients presenting with severe withdrawal from GBL, resulting in admission
to the ICU. They report a median hospital stay of five days. Bear in
mind, each patient had already endured four or five days without GHB/GBL
prior to admission, making this consistent with the 10-14 day period
seen overall for detox/withdrawal in the hundreds of cases coming through
our website. Nothing is documented re follow up with these five patients.
AFTER
THE DETOX—ONGOING AGONY
Multiple relapses are common in the majority of GHB addiction
cases. Many describe that GHB leaves a “hole in your soul.” Establishing
a decent sleep pattern is often a problem. Depression, even at suicidal
levels, is nearly standard. Anxiety attacks are also ongoing. Depression/anxiety
typically decrease with time, taking a few weeks for some and months or
even years for others. Many recovering addicts need medication at least
temporarily to deal with the sleep/depression/anxiety issues. Those with
prior depression seem to have the most difficulty finding a regime of
meds that work well after GHB use. Accidental overdoses on other drugs,
especially trying to detox without adequate medical supervision, are common,
sometimes resulting in death. These deaths may not be recognized as related
to GHB since there will be no GHB in their system. Suicides have been
noted from 36 hours into detox to several months later, whether or not
there were prior depression or mental health issues. Many have by now
lost jobs, financial security, family, and other relationships. Many do
not see themselves as “addicts” because of their unintentional involvement
with this drug and shy away from AA/NA meetings. They need to recognize
their status as indeed “addicted” and need understanding in treatment
and meetings to put aside this alienation. As with any drug, acceptance
of their addiction is crucial to management.
For
further information, please visit our website: http://www.projectghb.org.
Doctors & facilities experienced w/GHB withdrawal or willing to handle
these cases are asked to contact us so that they may be added to our referral
list. |
