1. GBL Dependence and withdrawal
James Bell
January 2014

2. GHB/GBL 2

3. Mr JL, 25 Presented February 2010, seeking to withdraw from GBL
First used GHB 6 years ago - “best thing I’d ever taken”. Euphoric, confident, and wanted more
Dependent use 2 years –2mL every1-2 hours
Three previous detoxifications
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.
Nov 2009 Detoxed in hospital following presentation with overdose – rapid relapse
Nov 2009 Then referred for ambulatory detox, did not begin 3

4. Mr JL – Medical events
Oct BIBA from club agitated and uncooperative having used GHB, ecstasy, cocaine and alcohol. Self-discharged
May 2007 BIBA from club with GHB, cocaine and ketamine intoxication. 3 tonic-clonic seizures prior to hospital. Required lorazepam and discharged home
Feb Presented to ED, Self-discharged before seen
April 2009 BIBA following GHB and methamphetamine use. Agitated and hyperventilating, given IV diazepam and self-discharged
May 2009 Admitted in coma (GCS 3). Crash intubation, ventilated on ITU and self-discharged from step-down
May 2009 Admitted with agitation and suicidal intent during GBL withdrawal. 4

5. 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) 5

6. 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Used to party, since becoming dependent increasingly withdrawn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 6

7. JL - Progress 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 7

8. Progress II
Day 15 – still difficulty sleeping, but more motivated, seeking work
Day 21 DNA for appointment
2 months later – brief lapse(3 days) to GBL use.
3 months – GBL free, well, still uses other party drugs 8

9. GBL
“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 9

10. GBL destined for industrial use10

11. Why do people use GBL?
Sociability
Sexuality
Sleep 11

12. GBL - toxicity
Narrow therapeutic window – small margin between dose and overdose
(sold with pipettes for accurate measurement)
About 3 presentations/ week to GSST with OD (GBL, GHB)
Rare deaths 12

13. GBL - dependence Uncommon Involves dosing every 1-2 hours
Can develop rapidly (eg after a “long weekend” of partying)
Often occurs when drug is used to facilitate sleep
Associated with social withdrawal, emotional blunting, and compromised social role

14. 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

15. Features of withdrawal
Tachycardia
Anxiety and insomnia ++
Formication, visual disturbances
Tremor
Sweaty palms
Delirium (psychotic features) 15

16. Rationale for treatment
Ambulatory withdrawal is the default option
Initiate treatment before withdrawal established
Use high dose diazepam (rapid oral absorption, long half-life) mg in first 24/24
Add baclofen (GABAb agonist) 10-20mg q8h 16

17. 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 17

18. 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 18

19. Why did people relapse? Move in GBL using circles?
Unable to have sex without GBL
Many “liked the person they were on GBL better than the person I am without it” 19

20. Why did people relapse? Move in GBL using circles
Unable to have sex without GBL
Many “liked the person they were on GBL better than the person I am without it”
Relapse after detox is typical of all drugs (especially nicotine, opioids, and GBL) 20

21. Party Drugs (legal highs, NPS, etc)
Bewildering array, commonly:
stimulants (amphetamine type stimulants, cathinones)
Prescription medications (ketamine, gaba agonists, opioids) 21

22. Used by 1. Gay club scene (GBL, mephedrone, viagra)
2. Internet “geeks”
3. Students 22

23. Further reading
Bell J & Collins R (2011) Gamma-butyrolactone (GBL) dependence and withdrawal Addiction 106(2);
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
Le Tourneau J, Hagg D, Smith S (2008) Baclofen and gamma-hydroxybutyrate withdrawal Neurocritical Care 8(3):430-3 23