Weekly
`
`April 04, 1997 / 46(13);281-283
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`Gamma Hydroxy Butyrate Use -- New York
`and Texas, 1995-1996
`
`Gamma hydroxy butyrate (GHB) is a central nervous system depressant approved as an
`anaesthetic in some countries; however, with the exception of investigational research, it is not
`approved for any use in the United States. Primary groups using GHB include party and
`nightclub attendees and bodybuilders. In addition, GHB is one of several agents characterized
`as a "date rape" drug. During August 1995-September 1996, poison control centers in New
`York and Texas received reports of 69 acute poisonings and one death attributed to ingestion
`of GHB. This report describes two cases and summarizes the investigations of GHB use in
`Texas and New York. The findings of these investigations underscore the health hazards
`associated with use of GHB. Texas
`
`At 12:30 p.m. on August 5, 1996, a 17-year-old girl with no previous history of drug or alcohol
`use was admitted to an emergency department (ED) because of cardiac arrest with
`cardiopulmonary resuscitation in progress. She was pronounced dead at 12:40 p.m. On the
`night of August 4, she had been at a local dance club, where she was reported to have ingested
`soft drinks. An autopsy was performed; multiple toxicologic screens of blood and bile samples
`did not detect alcohol or other drugs. However, on September 13, a test on previously obtained
`serum detected a serum level of 27 mg/L of GHB.
`
`From November 14, 1995, through September 30, 1996, the Texas Department of Health
`received reports of 57 persons who had adverse health effects attributed to ingestion of GHB,
`including the one death described in this report. Of the 57 reports, 30 were received from the
`Dallas Poison Control Center, and 26 were received from the Galveston Poison Control
`Center. The death was reported by the Assistant Medical Examiner in Harris County, who
`listed the death as a homicide as the result of GHB toxicity. Of the 56 reports from the poison
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`control centers, 34 involved males; 10 reports involved teenagers aged 16-18 years. Nineteen
`persons were treated in and released from hospital EDs, and 25 were admitted to intensive-care
`units with severe clinical symptoms, including coma (15), respiratory depression (three), and
`agitation (one); six required intubation. Of the 56 reports, 12 included ingestion of both alcohol
`and GHB, and three included the use of GHB with other drugs. New York
`
`On October 30, 1996, a 20-year-old man who was unresponsive after several episodes of
`vomiting was taken to an ED 2 1/2 hours after ingesting a mixture of GHB and sodium
`hydroxide. He was intubated and admitted to the intensive-care unit, where a bronchoscopy
`indicated friable lung tissue that was attributed to aspiration of gastric contents containing
`sodium hydroxide. He developed bilateral pneumothoraces and had generalized seizures and
`was transferred to a third hospital for possible extracorporeal membrane oxygen therapy and
`lung transplant. However, his condition improved, and he was extubated and placed on
`supportive care and recovered.
`
`During August 27, 1995-October 30, 1996, the Long Island Regional Poison Control Center
`received reports of 13 persons with exposure to GHB. All 13 were evaluated in hospital EDs.
`Four of the 13 also consumed ethanol. All five persons initially had altered mental status,
`including coma (three), stupor (one), and inebriation (one). Eight of the 13 persons had
`prepared GHB at home using sodium hydroxide and butyrol lactone; of the eight, three
`required admission to a hospital.
`
`Reported by: J Carter, DO, H Mofenson, MD, T Caraccio, PharmD, Long Island Regional
`Poison Control Center, Winthrop-Univ Hospital, New York; P Smith, MD, State
`Epidemiologist, D Morse, MD, New York State Dept of Health. C Keys, MD, L Williams,
`Poison Center Network, Div of Emergency Medicine, Univ of Texas Southwestern School of
`Medicine, Dallas; G Coody, Drug and Medical Devices Div, Bur of Food and Drug Safety,
`Texas Dept of Health. Office of Diversion Control, Drug Enforcement Administration.
`Environmental Hazards Epidemiology Section, Health Studies Br, Div of Environmental
`Hazards and Health Effects, National Center for Environmental Health, CDC.
`
`Editorial Note
`
`Editorial Note: GHB increases dopamine levels in the brain and has effects through the
`endogenous opioid system; most GHB is excreted during the first hours after ingestion (1).
`Manifestations of acute GHB toxicity include coma, seizures, respiratory depression, and
`vomiting. Other documented effects of GHB include amnesia and hypotonia (associated with
`doses of 10 mg/kg body weight); a normal sequence of rapid eye movement (REM) and non-
`REM sleep (doses of 20-30 mg/kg body weight); and anesthesia (doses of approximately 50
`mg/kg body weight). Doses of greater than 50 mg/kg body weight can decrease cardiac output
`and produce severe respiratory depression, seizure-like activity, and coma (2); coma and
`respiratory depression may be potentiated by concomitant use of alcohol (3). There is no
`antidote for GHB overdose, and treatment is restricted to nonspecific supportive care. Patients
`in New York and Texas have required ED care; many of those hospitalized have required
`ventilatory support and intensive care.
`
`In the United States, GHB has been produced clandestinely in widely varying degrees of
`purity. GHB has been marketed as a liquid or powder and has been sold on the street under
`names such as "Grevious Bodily Harm," "Georgia Home Boy," "Liquid Ecstasy," "Liquid X,"
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`"Liquid E," "GHB," "GBH," "Soap," "Scoop," "Easy Lay," "Salty Water," "G-Riffick,"
`"Cherry Menth," and "Organic Quaalude." Improper preparation of GHB can result in a
`mixture of GHB and sodium hydroxide that can be severely toxic because of the combined
`effects of the GHB and the direct caustic effects of sodium hydroxide.
`
`In Dallas, GHB use has been associated with events at which several persons have been found
`comatose. Some persons who have sustained adverse effects of GHB have reported being
`given the drug surreptitiously (e.g., having it slipped into their drink), while others have
`admitted to intentional use. The Drug Enforcement Administration (DEA) is examining the
`distribution and abuse of GHB in the United States; although distribution has been documented
`in 27 states, GHB use is highly prevalent in California, Florida, Georgia, and Texas.
`
`In the United States, GHB is under specific Food and Drug Administration exemptions for
`investigational research protocols for the treatment of narcolepsy. Although possession of
`GHB is not illegal under federal law, its manufacture and sale is prohibited under the Food,
`Drug, and Cosmetic Act. In Georgia and Rhode Island, state controlled substances acts have
`classified GHB into Schedule I *, and other states are considering similar action. In addition,
`the DEA is gathering information and considering a scheduling review for possible control of
`GHB under the Federal Controlled Substances Act **. Public health officials should report
`episodes of adverse effects of GHB use to DEA, telephone (202) 307-7183.
`
`References
`
`1. Vayer P, Mandel P, Maitre M. Gamma-hydroxy butyrate, a possible neurotransmitter.
`Life Sci 1987;41:1547-57.
`
`2. CDC. Multistate outbreak of poisonings associated with illicit use of gamma hydroxy
`butyrate. MMWR 1990;39:861-3.
`
`3. Mamelak M. Gammahydroxybutyrate: an endogenous regulator of energy metabolism.
`Neurosci Biobehav Rev 1989;13:187-98.
`
`◦ Drugs that do not have currently accepted medical use in the United States, have a
`high abuse potential, and are not proven to be safe under medical supervision. **
`Public Law no. 91-513.
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