- the agent is absorbed within 20 to 60 minutes
- only 2% to 5% of the agent is eliminated in the urine.
GHB—which comes in powder, tablet, and liquid form and is usually dissolved in water before use—often is mixed with other drugs or alcohol. Varying preparations and use with multiple substances can produce inconsistent GHB levels and decrease sensitivity and specificity in routine drug screening. GHB abusers also report the amount ingested in “capfuls,” ounces, and teaspoons, making accurate quantification harder still.2
Though infrequently used because of feasibility and cost, gas chromatography and infrared spectroscopy of a urine specimen are the only known methods for determining GHB levels. Chronic GHB use, negative polypharmacy history, and negative urine and blood analysis for alcohol, benzodiazepines, sedative-hypnotics, or other substances usually confirm GHB withdrawal diagnosis.1
Treatment: ‘Bad’ medicine
In the ER, Mr. R was given two 1-mg doses of lorazepam IV 1 hour apart. After 1 hour, his vital signs improved slightly (heart rate: 100/min; blood pressure: 165/99 mm Hg). Thiamine and folate were also started. Mr. R’s severe agitation and paranoia persisted, so three more 2-mg doses of lorazepam IV were given at 4-hour intervals.
Within 2 days, Mr. R was transferred to the voluntary inpatient psychiatric unit. His nausea, vomiting, and autonomic instability resolved, but his delirium and psychosis persisted. Quetiapine, 100 mg bid, was started to address his psychosis, and bupropion, 150 mg once daily, was restarted to manage his previously diagnosed depression. Three days after starting bupropion, Mr. R’s mood improved based on patient reports and Clinical Global Impression scores (6 at baseline, 2 at discharge), but his persecutory delusions persisted, causing mild anxiety.
The next day, Mr. R’s auditory and visual hallucinations had ceased, his preoccupation with terrorists began to subside, and his concentration, sleep, and appetite were improving. By day 6 of hospitalization, he still complained of mild tremors and anxiety, but his persecutory delusions resolved.
After 9 days, Mr. R was discharged. Autonomic stability was achieved and his delirium had mostly resolved. Outpatient drug rehabilitation and psychiatric services were arranged.
As of this writing, Mr. R had not sought outpatient treatment. His current medical status is unknown.
Related resources
- Miglani J, Kim K, Chahil R. Gamma-hydroxybutyrate withdrawal delirium: a case report. Gen Hosp Psychiatry. 2000;22:213-6.
- Columbo G, Agabio R, Lobina C, et al. Cross tolerance to ethanol and gamma-hydroxybutyric acid. Eur J Pharmacol. 1995;273:235-8.
- Project GHB. www.projectghb.org
Drug brand names
- Bupropion • Wellbutrin
- Lorazepam • Ativan
- Methylphenidate • Ritalin, Concerta
- Paroxetine • Paxil
- Quetiapine • Seroquel
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.