Characterization of the GHB Withdrawal Syndrome

Abstract

The gamma-hydroxybutyric acid (GHB) withdrawal syndrome can have a fulminant course, complicated by severe complications such as delirium or seizures. Detoxification by tapering with pharmaceutical GHB is a safe way to manage GHB withdrawal. However, a detailed description of the course of the GHB withdrawal syndrome is currently lacking. This study aimed to (1) describe the course of GHB withdrawal symptoms over time, (2) assess the association between vital signs and withdrawal symptoms, and (3) explore sex differences in GHB withdrawal. In this observational multicenter study, patients with GHB use disorder (n = 285) were tapered off with pharmaceutical GHB. The most reported subjective withdrawal symptoms (SWS) were related to cravings, fatigue, insomnia, sweating and feeling gloomy. The most prevalent objective withdrawal symptoms (OWS) were related to cravings, fatigue, tremors, sweating, and sudden cold/warm feelings. No association between vital signs and SWS/OWS was found. Sex differences were observed in the severity and prevalence of specific withdrawal symptoms. Our results suggest that the GHB withdrawal syndrome under pharmaceutical GHB tapering does not strongly differ from withdrawal syndromes of other sedative drugs. The lack of association between vital signs and other withdrawal symptoms, and the relative stability of vitals over time suggest that vitals are not suitable for withdrawal monitoring. The reported sex differences highlight the importance of a personalized approach in GHB detoxification.

Inpatient GHB withdrawal management in an inner-city hospital in Sydney, Australia: a retrospective medical record review

“…However, amongst convenience samples of some demographic groups, such as lesbian, gay, and bisexual people, rates 20-54 times greater have been recorded (Hammoud et al 2018;Mooney-Somers et al 2020). A global systematic review identified growing evidence for GHB-related adverse effects amongst people who use GHB regularly (Dijkstra et al 2021). Harms associated with the use of GHB include overdose and use disorder (Schep et al 2012).…”

“…The onset of withdrawal can be rapid-commencing within an hour of discontinuation and peaking at 24 h-and can last up to 3 weeks (Schep et al 2012). While the clinical characteristics of a withdrawal syndrome have not been well defined in the literature, case studies and reviews describe similarities between withdrawal symptoms of GHB and other CNS depressants such as alcohol or benzodiazepines (Wojtowicz et al 2008;Wolf et al 2021). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), characterises a withdrawal syndrome associated with sedative, hypnotic, or anxiolytic drugs by two or more symptoms including autonomic hyperactivity (e.g.…”

“…Due to the potential for severe physical or psychiatric complications, inpatient medical management of GHB withdrawal may be warranted for people who regularly consume high amounts (van Noorden et al 2015), although outpatient withdrawal management has been documented. A number of possible risk factors for GHB withdrawal complications have been identified, such as frequent intervals of GHB dosing prior to cessation (Kamal et al 2017); concomitant psychostimulant use (Kamal et al 2016a); or female gender (Wolf et al 2021). However, most studies report infrequent rates of delirium and are underpowered to examine for associated factors (Dijkstra et al 2017;Kamal et al 2016a), particularly studies examining tapering GHB pharmacotherapy, which likely ameliorates symptoms of withdrawal such as delirium (Wolf et al 2021).…”

“…A number of possible risk factors for GHB withdrawal complications have been identified, such as frequent intervals of GHB dosing prior to cessation (Kamal et al 2017); concomitant psychostimulant use (Kamal et al 2016a); or female gender (Wolf et al 2021). However, most studies report infrequent rates of delirium and are underpowered to examine for associated factors (Dijkstra et al 2017;Kamal et al 2016a), particularly studies examining tapering GHB pharmacotherapy, which likely ameliorates symptoms of withdrawal such as delirium (Wolf et al 2021).…”

Cognitive Impairments in Patients with GHB Use Disorder Predict Relapse in GHB Use

“…As memory problems were also frequently observed by the nursing staff in patients with GUD who applied for detoxification, we included patients referred to these clinics. Detoxification for patients with GUD often takes place in an inpatient setting, due to the potential fulminant course of GHB withdrawal [26]. During their stay patients’ withdrawal is closely monitored while they are gradually tapered off with pharmaceutical GHB according to the Dutch GHB guideline [6, 7, 27].…”