Gamma-hydroxybutyrate (GHB) is a naturally occurring endogenous compound, related to the inhibitory neurotransmitter, gamma-aminobutyric acid (GABA). It was synthesized for use as an anaesthetic agent in the 1960s, but it did not become an established agent due to adverse effects including nausea, vomiting and seizure-like activity.1,2 Over the next few decades, GHB first became abused by bodybuilders due to reported beneficial effects on growth hormone concentrations, and then by ‘clubbers’ and recreational drug users, who reported stimulant, euphoric and pro-sexual effects.3,4 Several case reports and case series in the 1990s highlighted the potential adverse effects of recreational use of GHB and its precursors, including seizures, drowsiness and coma, and associated respiratory compromise.5–12 Due to these reports, GHB was listed as a DEA Schedule I drug in 2000 in the US (although it is classified as a DEA Schedule II agent for medicinal prescription as Xyrem®). In the UK, the legislation concerning the possession and/or dealing of GHB was changed in June 2003, and it was classified as a Class C controlled substance under the Home Office Misuse of Drugs Act (1971).
The precursors of GHB, gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD), are chemically very similar to GHB. Both of these compounds are widely used in the chemical industry, as solvents in paints and cleaning products or in the production of rubber and plastics. GBL is a component of nail varnish remover pads. Both GBL and 1,4BD are rapidly broken down in vivo to GHB.13 Since 1,4BD is broken down by the same pathways as ethanol, co-ingestion of ethanol may lead to an inhibition of 1,4BD metabolism to GHB and therefore delayed onset of toxicity.14 Previous reports have noted clinical features of toxicity that is identical to that seen following GHB ingestion, following both GBL and 1,4BD ingestion.15–19 Despite these reports of similar patterns of toxicity, and the change in legal status of GHB in the UK, both GBL and 1,4BD remain legally available and potentially could be used recreationally instead of GHB.
It has been reported that there is high use of GHB, as well as other recreational drugs of abuse, amongst homosexual men.4,20–23 There are several large clubs used by the ‘gay’ or men who have sex with men (MSM) community within the catchment area of our inner-city Emergency Department (ED). These offer prolonged clubbing promotions, which cover the majority of the weekend (Friday evening to Tuesday lunchtime). There have been suggestions in the medical and general press that there has been a shift amongst GHB users to GBL and other precursors such as 1,4BD, due to the disparity in the current legislation.24–27 However, there are no published data to confirm or refute this. Therefore, we collected clinical and demographic data on patients presenting to our ED with GHB, GBL or 1,4BD toxicity, and compared their self-reporting of the drug ingested with analysis of drugs seized on the ‘club scene’.
Data on all patients presenting to our large inner-city ED with acute poisoning (recreational, deliberate or accidental) are collected prospectively on a dedicated clinical toxicology database. Retrospectively we searched this database to identify all cases of self-reported recreational use of GHB, GBL and 1,4BD associated with presentation to the ED between 1 January 2006 and 31 December 2006 inclusive. Basic demographic data were collected on the sex, date and time of presentation and clinical data including initial presenting Glasgow Coma Score (GCS), disposition from the ED and outcome/length of stay were collected. In addition self-reported co-ingested substances (ethanol, other recreational drugs or other over the counter/prescription medications) were also recorded. Routine toxicology screening is not currently undertaken in the UK as part of standard clinical practice and so all drugs ingested are purely on the basis of the patients’ self-report.
All people attending the MSM club venues in our ED catchment are routinely searched by door staff prior to entry to the venue. Any suspected recreational drugs or opened bottles of any description, which are often used to covertly carry GHB and its precursors into clubs, are seized and placed into a Metropolitan police locked and secured ‘drug collection’ bin. All of the seized samples and bottles are then transported by the Metropolitan Police to the Home Office approved drugs of abuse storage and screening laboratory at St George’s University of London, therefore maintaining a documented chain of custody. Samples are then analysed in batches to identify any illicit substances present, as described previously.2
Number of presentations and characteristics
There were a total of 420 drugs of abuse-related presentations to our inner-city hospital Emergency Department (ED) in the study period, of which 158 (37.6%) were related to GHB (150; 94.9%) and GBL (8; 5.1%) ingestion, as reported by the patient. There were no cases of self-reported 1,4BD ingestion. The majority of these presentations (96.8%) were self-reported recreational use, although there were 4 (2.5%) cases of attempted deliberate self-poisoning (3 GHB, 1 GBL) and one (0.7%) case of accidental ingestion (GHB). Basic presenting clinical parameters of patients on arrival in the ED are summarized in Table 1. There was significant variation in the time of presentation to the ED, with the majority of patients presenting outside of normal working hours (08:00–18:00) (Figure 1). The majority of patients were male (93.4%) and the largest number of presentations was in the 20–34 year age group (Table 1 and Figure 2).
Figure 1.
Open in new tabDownload slide
Time of presentation following self-reported GHB/GBL ingestion, demonstrating those presenting during normal ‘working hours (08:00–18:00)’ (striped bars) and those presenting outside ‘normal working hours’ (filled bars).
Figure 2.
Age distribution of patients presenting to the Emergency Department following recreational self-reported use of GHB or GBL.
D.M. Wood, C. Warren-Gash, T. Ashraf, S.L. Greene, Z. Shather, C. Trivedy, S. Clarke, J. Ramsey, D.W. Holt, P.I. Dargan
gbl europe worldwide
buy gbl europe
buy gbl online
gbl online safety
gbl delivery spain
shop gbl online
shop buy gbl
GBL Bitcoin payment
GBL Bitcoin payment
Buy Gamma Butyrolactone GBL Cleaner
Buy Gamma Butyrolactone GBL Cleaner
Buy Gamma Butyrolactone GBL Cleaner
how to get gamma butyrolactone online
Good Alloy Wheel cleaner