Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Mahr, G. Articles by Orringer, D. J. Search for Related Content PubMed Citation Articles by Mahr, G. Articles by Orringer, D. J. Other Addictive Disorders

Prolonged Withdrawal From Extreme -Hydroxybutyrate (GHB) Abuse

Key Words: Addictive Disorders • Substance Abuse

TO THE EDITOR: -Hydroxybutyrate (GHB), a compound introduced originally in the 1960s as an anesthetic agent, lately has become a popular drug of abuse that induces euphoria and hallucinations.^1–3 GHB may act on the central nervous system through GABA receptors, dopamine receptors, and possibly through receptors specific for GHB.⁴ Typically, the user will drink approximately 2 teaspoons of the tasteless, colorless liquid.⁴

We describe a case in which a high dose of GHB lead to prolonged hallucinations and delusions. Sustained delusions and hallucinations have not been described previously with GHB.

Case Report

Mr. Z. was a 22–year-old male college student who entered a chemical dependency treatment center after a 2-month addiction to GHB. Mr. Z. described using GHB heavily for 20 days. He reported that he had been purchasing GHB in 20-ounce plastic bottles and that his use had started with 3–5 capfuls and escalated within days to more than 15 capfuls at one time. On the last day of use, Mr. Z. had ingested approximately 20–30 capfuls over 1 hour and said that he felt like "a dead man walking...like I was sleeping with my eyes open."

Mr. Z. described detailed visual hallucinations during the first week of his hospitalization. He stated "little people," using each other as steps, climbed up a maze (the carpet in his room) in order to reach him and feed him drugs and alcohol. He said that there was a trigger to make them appear (the doorstop on the floor). The little people were "there for my entertainment, doing whatever they could to maximize my high, like blowing air into my eyes." This hallucination caused him to be "terrified" for days. He also described a tactile sensation of "lying on top of a dead man's body." He thought that he had killed this man, was arrested, died, and was resuscitated, only to see the accusing glare of the dead man's family members as the ambulance passed. He felt "already brain dead; a 12-year-old in a 22-year-old's body."

Mr. Z. was treated with haloperidol. He was also placed on quetiapine, clonidine, and lorazepam. Because of his continued hallucinations and violent outbursts after 3 days, Mr. Z. was sent to the emergency room, from which he was admitted to the intensive care unit (ICU).

In the ICU, Mr. Z. appeared diaphoretic, agitated, and grossly psychotic. He would not open his eyes, spoke very rapidly, but continued to answer questions. He was oriented to person, place, and time and was aware that he had overdosed on GHB.

On the second day after admission, Mr. Z.'s speech, although still rapid, was more coherent. He attempted to differentiate between reality and hallucination. In addition, he expressed paranoia, which he felt to be unreasonable, toward the hospital staff. He thought he had been arrested for speeding by policemen who had drawn their guns. He continued to receive lorazepam and haloperidol.

On the third day after admission, 6 days after his last ingestion of GHB, Mr. Z. appeared rested and calm. His speech was no longer rapid. He reported a lingering "fogginess," but he was able to fully distinguish reality from hallucination. In addition, Mr. Z. did not remember the hallucinations that he had described previously. He stated that he had slept for 8 hours for the first time in months. Mr. Z. was returned to the chemical dependency treatment center that day. He was reassessed there by the authors 14 days after his last ingestion of GHB. At that time, he still described hallucinations and continued to avoid doorstops and looking at his carpet.

Discussion

This case illustrates an exceptional reaction to overdose and withdrawal from GHB involving a prolonged course of hallucinosis. The patient continued to experience effects of the drug 14 days after his last use.

It is interesting to note that GHB has been used to treat alcohol withdrawal in the past.⁵ Its action on GABA receptors⁴ may induce a state similar to that of alcohol hallucinosis. Symptoms of alcohol withdrawal delirium include visual and tactile hallucinations and may be associated with a specific tactile trigger.^6,7 In Mr. Z., 14 days after his last administration of GHB, he continued to be apprehensive about triggers for his hallucinations.

With the increasing prevalence of GHB abuse, case studies continue to be invaluable for understanding the course of its withdrawal. This case illustrates that extreme GHB abuse can cause sustained withdrawal symptoms and hallucinosis.

REFERENCES

1. Graeme KA: New drugs of abuse. Emerg Med Clin North Am 2000; 18:625-636[CrossRef][Medline]
2. Shannon M, Quang LS: Gamma-hydroxybutyrate, gamma-butyrolactone, and 1,4-butanediol: a case report and review of the literature. Pediatr Emerg Care 2000; 16:435-440[CrossRef][Medline]
3. Li J, Stokes SA, Woeckener A: A tale of novel intoxication: seven cases of gamma-hydroxybutyric acid overdose. Ann Emerg Med 1998; 31:723-728[CrossRef][Medline]
4. Snead OC III: Evidence for a G protein-coupled -hydroxybutyric acid receptor. Neurochem 2000; 75:1986-1996
5. Gallimberti L, Canton G, Gentile N, et al: Gamma-hydroxybutyric acid for treatment of alcohol withdrawal syndrome. Lancet 1989; 2:787-789[Medline]
6. Kaplan and Sadock 1995. p 784
7. Gallant D: Alcohol, in The American Psychiatric Press Textbook of Substance Abuse Treatment, Second Edition. Edited by Galanter M, Kleber HD. Washington, DC, American Psychiatric Press, Inc., 1999, pp. 151-164

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Mahr, G. Articles by Orringer, D. J. Search for Related Content PubMed Citation Articles by Mahr, G. Articles by Orringer, D. J. Other Addictive Disorders

Get information about faster international access.

Privacy Policy

Copyright © 2001 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us