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James Bell January 2014 GBL Dependence and withdrawal.

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Presentation on theme: "James Bell January 2014 GBL Dependence and withdrawal."— Presentation transcript:

1 James Bell January 2014 GBL Dependence and withdrawal


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

4 Mr JL – Medical events 2006-2009 ① Oct. 2006 BIBA from club agitated and uncooperative having used GHB, ecstasy, cocaine and alcohol. Self- discharged 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.

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)

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 Lost 3 jobs since becoming dependent on GBL  Used to party, since becoming dependent increasingly withdrawn  Could spend £200/week on drugs (GBL £60 for 1litre).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

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

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

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

10 GBL destined for industrial use

11 Why do people use GBL? 1.Sociability 2.Sexuality 3.Sleep

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

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)

16 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

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

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

19 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”

20 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)

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

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

23 Further reading Bell J & Collins R (2011) Gamma-butyrolactone (GBL) dependence and withdrawal Addiction 106(2); 442-447 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

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