sodium-oxybate and Delirium

Management of a withdrawal syndrome following cessation of regular gamma-hydroxybutyrate (GHB) use, and its precursors, can represent a clinical challenge due to rapid onset delirium and/or seizures. Severe GHB withdrawal can be characterised by persistent or worsening features despite increasing benzodiazepine doses and regular baclofen. Barbiturates, such as phenobarbital, are an appealing option in this context due to their unique GABA-A receptor action.. This series describes the use of phenobarbital in 13 cases, 12 patients, across two hospitals in Sydney, Australia, with persistent or progressive GHB withdrawal despite benzodiazepine-based management. A median cumulative dose of oral diazepam prior to commencing phenobarbital was 120 mg (range 80-255 mg). The median time from the last GHB use to the first dose of phenobarbital was 24 h (range 7-57 h). Eight cases received phenobarbital orally on a general ward and 5 intravenously in intensive care units. An improvement in GHB withdrawal symptoms was observed after phenobarbital in all cases and there were no adverse events related to phenobarbital.. This case series suggests that phenobarbital for the management of benzodiazepine-resistant GHB withdrawal can be safe, even in general inpatient settings, and may avert the progression of delirium. Most data on the management of GHB withdrawal comes from case reports or series, such as this one. This highlights the need for prospective trials to establish an evidence base for therapeutic approaches, including validated measures of withdrawal severity and more information relating to the safe and effective dosing of phenobarbital.

Topics: Benzodiazepines; Delirium; Humans; Phenobarbital; Prospective Studies; Sodium Oxybate; Substance Withdrawal Syndrome

Regular consumption of gamma-hydroxybutyrate (GHB) may result in a dependence syndrome that can lead to withdrawal symptoms. There are limited data on medications to manage GHB withdrawal.. To examine characteristics associated with delirium and discharge against medical advice (DAMA), in the context of implementing a GHB withdrawal management protocol at an inner-city hospital in 2020.. We retrospectively reviewed records (01 January 2017-31 March 2021), and included admissions that were ≥ 18 years of age, admitted for GHB withdrawal, and with documented recent GHB use. Admissions were assessed for demographics, medications administered, features of delirium, ICU admission, and DAMA. Exploratory analyses were conducted to examine factors associated (p < 0.2) with features of delirium and DAMA.. We identified 135 admissions amongst 91 patients. Medications administered included diazepam (133 admissions, 98.5%), antipsychotics (olanzapine [70 admissions, 51.9%]), baclofen (114 admissions, 84%), and phenobarbital (8 admissions, 5.9%). Features of delirium were diagnosed in 21 (16%) admissions. Delirium was associated with higher daily GHB consumption prior to admission, while duration of GHB use, time from presentation to first dose of diazepam, and concomitant methamphetamine use were inversely associated with delirium. DAMA occurred amongst 41 (30%) admissions, and was associated with a longer time from presentation to first dose of baclofen, while being female and receiving a loading dose of diazepam were inversely associated.. This study adds to the literature in support of the safety and feasibility of diazepam and baclofen for the management of GHB withdrawal. Prospective, randomised trials are required.

Topics: 4-Butyrolactone; Baclofen; Delirium; Diazepam; Female; Hospitals, Urban; Humans; Inpatients; Male; Medical Records; Prospective Studies; Retrospective Studies; Sodium Oxybate; Substance Withdrawal Syndrome

GHB (gammahydroxybutyrate) and its precursors are popular recreational drugs due to their sedative, anxiolytic and sexually stimulating effects. Their use has been steadily increasing in recent years. The detoxification process is complex and prone to high rates of complications while little is known about the pathophysiology. This study aims to elucidate the characteristics of GHB-addicted patients and to evaluate the risks and complications of GHB withdrawal treatment.. This observational study describes prospectively the socioeconomic status, clinical history and course of inpatient detoxification treatment of a group of 39 patients suffering from GHB substance use disorder. Detoxification treatment took place in a highly specialized psychiatric inpatient unit for substance use disorders.. GHB patients were characterised by being young, well-educated and by living alone. More than 50% of the patients had no regular income. The patients were male and female in equal numbers. Detoxification treatment was complicated, with high rates of delirium (30.8%) and high need for intensive care (20.5%).. In our sample, GHB users were young, well-educated people and male and female in equal number. Detoxification proved to be dangerous for GHB-addicted patients. The presence of delirium and the need for transfer to an intensive care unit during detoxification treatment was extraordinarily high, even with appropriate clinical treatment. The reasons for this remain unknown. Therefore an intensive care unit should be available for GHB detoxification treatment. Further studies are needed to evaluate the options for prophylactic treatment of delirium during detoxification.

Topics: Delirium; Female; Humans; Inpatients; Male; Sodium Oxybate; Substance Withdrawal Syndrome; Substance-Related Disorders

Postoperative delirium (POD) is a frequent complication after surgery. Older adult patients undergoing abdominal surgery are at higher risk for developing POD. Studies on the association of cholinesterase activities and POD are rare, but leading hypotheses implicate that the cholinergic pathway might play an important role in neuroinflammation and development of POD. The objective of this study was to figure out if there is an association between the development of POD and acetyl- and butyrylcholinesterase (AChE and BuChE) activities in older adult patients undergoing abdominal surgery.. The investigation was performed with a subpopulation of BioCog study patients. The BioCog project ( http://www.biocog.eu ) is a prospective multicenter observational study in older adult surgical patients. Patients ≥ 65 years undergoing elective surgery of at least 60 minutes who scored more than 23 points in the Mini-Mental-State-Examination were included. POD was assessed twice a day on seven consecutive days after the surgery, using the test instruments Nursing Delirium Screening Scale (Nu-Desc) and Confusion Assessment Method (CAM and CAM-ICU) and a patient chart review. Pre- and postoperative blood cholinesterase activities were measured with a photometric rapid-point-of-care-testing. The association between cholinesterase activities and POD was analyzed in a subpopulation of abdominal surgical patients using multivariable logistic regression analysis adjusting for confounders.. One hundred twenty-seven patients were included for analysis (mean age 73 years, 59% female). Fifty-two patients (41%) fulfilled the criteria of POD. These patients were significantly older, had a longer time of surgery and anesthesia and achieved higher comorbidity scores compared to patients without POD. After adjusting for age, duration of surgery and charlson comorbity index, we found an association between pre- and postoperative AChE activity (U/gHb) and the development of POD (Odds ratio (OR), [95% confidence interval (CI)], preoperative 0.95 [0.89-1.00], postoperative 0.94 [0.89-1.00]).. We found an association between POD and AChE activity and provided new information considering patients with abdominal surgery. Future analyses should examine course dynamics of postoperative cholinesterase activities in order to clarify interactions between the cholinergic system and pathophysiological mechanisms leading to POD.. ClinicalTrials.gov: NCT02265263.

Topics: Aged; Butyrylcholinesterase; Cholinergic Agents; Delirium; Female; Humans; Male; Postoperative Complications; Prospective Studies; Sodium Oxybate

Topics: Adult; Delirium; Diagnosis, Differential; Humans; Male; Prisoners; Sodium Oxybate; Substance Withdrawal Syndrome

The management of benzodiazepine-resistant GHB withdrawal requires careful consideration of GHB pharmacodynamics.. A young woman was admitted with tachycardia, confusion, agitation and delusions the day after attempting to quit a daily, high-dose GHB habit. A total of 225 mg of diazepam had no effect. She was sedated with propofol and intubated. An extubation attempt after 24 hours was followed by recurrence of delirium. After reintubation she required high doses of propofol, alfentanil and dexmedetomidine to maintain sedation for two days. Baclofen and diazepam were introduced on the third day, allowing dose reductions in anaesthetic agents the fourth day and extubation on the fifth day with resolution of the delirium.. GHB targets the GABAB receptor and downregulates it with abuse. Most anaesthetic agents affect the GABAA receptor. Our report suggests that baclofen, a GABAB receptor agonist, may reduce the need for anaesthetic agents and facilitate recovery.

Topics: Baclofen; Delirium; Female; Humans; Propofol; Sodium Oxybate; Substance Withdrawal Syndrome

We describe a case of a 51-year old man who used GHB only in the afternoon and evening during 10 consecutive days in a recreational way: 20 ml a day in 4 ml per 2-3 hrs. He developed an excited delirium syndrome at the second day after stopping. Apparently even after relatively short recreational use severe disruptive behavior can develop. This is a unique case in literature. References are provided.

Topics: Delirium; Humans; Male; Middle Aged; Sodium Oxybate; Substance Withdrawal Syndrome

Gamma-hydroxybutyrate (GHB) is a synthetic drug used mainly for recreational purpose. Although the prevalence of GHB abuse is low in Taiwan, GHB has become increasingly popular in certain subpopulations such as clubbers and men who have sex with men (MSM). GHB dependence could be associated with severe withdrawal syndrome including hallucinations and delirium. Despite systematic studies on detoxification and management of GHB withdrawal have been performed, no validated measurement for severity of GHB withdrawal syndrome is available. Here we present a case of GHB withdrawal delirium that was treated successfully with fixed and symptom-triggered benzodiazepine dosing regimen based on Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale. The utilization of CIWA-Ar in such cases could offer useful guidance for benzodiazepine dosing. To the best of our knowledge, this is the first case report of GHB withdrawal delirium in Taiwan.

Topics: Adult; Benzodiazepines; Delirium; Disease Management; Drug Administration Schedule; Humans; Male; Severity of Illness Index; Sodium Oxybate; Substance Withdrawal Syndrome; Taiwan

Topics: Delirium; Dexmedetomidine; Female; Humans; Hypnotics and Sedatives; Sodium Oxybate; Substance Withdrawal Syndrome; Young Adult

In emergency medicine and anesthaesiology liquid ecstasy (LE), the street name for GHB, GBL or 1,4-B, has become infamous for causing severe intoxications and withdrawal. In general psychiatry, however, it is little known. Therefore, we set out to gather data about the role of LE in general psychiatry, typical users and common clinical problems associated with the use of LE.. We retrospectively identified and studied all patients with a reported the use of LE seen at the Department of Psychiatry, University of Ulm, Germany, between 1998 and 2011.. In 14 years, 19 users of LE were identified, the first dating from 2005. The majority reported a use of GBL (63 %), GHB was less common, and 1,4-B was not reported. Patients were predominantly young men (median age 25 years, 79 % men) with a history of multiple substance abuse. Ten patients had only a former use of LE, the other nine patients used it at the time of presentation. Of these, every third patient had to be transiently treated in an intermediate care unit, usually because of very severe and sudden withdrawal symptoms. Otherwise, detoxification was possible in psychiatry, but often required high doses of benzodiazepines. Three patients met the criteria for dependence from GBL.. In recent years, a small number of users of LE is seen also in general psychiatry, The problem is rather the severity of withdrawal than the number of cases. Close cooperation with intermediate care units is needed. In any case of coma of unknown origin or delirium with sudden onset LE use or withdrawal has to be taken into consideration, respectively. Many clinical problems result from the fact that LE cannot be detected in routine drug screenings. According to our experience, withdrawal from LE can be controlled with benzodiazepines.

Topics: Adult; Delirium; Emergency Medical Services; Female; Humans; Legislation, Drug; Male; Retrospective Studies; Sodium Oxybate; Substance Withdrawal Syndrome; Substance-Related Disorders; Young Adult

Much of what is understood regarding gamma hydroxybutyrate (GHB) treatment is based on hospital case studies for overdose and withdrawal, and there are currently no measures developed specifically for GHB or its analogs (e.g., gamma butyrolactone and 1,4-butanediol) to assess drug effect expectancies, reasons for starting use, withdrawal effects, and knowledge and opinions about use.. This pilot study (N = 61) was conducted to begin measures development to assess experiences, functions of use, and opinions regarding use as indicated by respondents taking a Web-based survey.. Minimum average partial correlation and parallel analysis procedures are employed to create scales.. Scales were developed to assess expectancies, reasons for use, withdrawal, and knowledge/opinions of use with median α = .79 and that account for 8.69-24.17% of the variance.. Scales have relatively good psychometric properties and replication is needed.. GHB-specific measures may greatly assist in furthering our understanding of protective and risk factors for use, and withdrawal phenomena.

Topics: Adult; Anxiety; Delirium; Drug Users; Female; Hallucinations; Humans; Illicit Drugs; Male; Pilot Projects; Psychiatric Status Rating Scales; Sodium Oxybate; Substance Withdrawal Syndrome; Surveys and Questionnaires

A 35-year-old man had been using high doses of gamma-hydroxybutyrate (GHB) for many years. He had been trying to cut down on use of this drug for 2 months. He was admitted to the hospital suffering from a withdrawal delirium accompanied by hallucinations and agitation. Use of GHB is increasing in the Netherlands. Along with serious intoxication and dependency, the possibility of withdrawal symptoms should also be taken into consideration. Administration of high doses of benzodiazepines is an effective treatment for these withdrawal symptoms.

Topics: Adult; Benzodiazepines; Delirium; Hallucinations; Humans; Male; Psychoses, Substance-Induced; Sodium Oxybate; Substance Withdrawal Syndrome

Topics: Adult; Delirium; Female; Humans; Sodium Oxybate; Substance Withdrawal Syndrome

Benzodiazepine treatment of life-threatening gamma-hydroxybutyrate (GHB) withdrawal is frequently unsatisfactory. Animal studies suggest strongly that treatment with GABA(B) agonists, such as baclofen, will be a more effective strategy.. A case report from the medical intensive care unit (ICU) of the university tertiary care hospital.. A 61-year-old woman was admitted to the medical ICU for severe withdrawal symptoms from chronic GHB use. This manifested as delirium, tremor, and seizures despite only small decreases in GHB dose and treatment with benzodiazepines. The addition of baclofen allowed the rapid sequential decreases in the GHB dose without seizure or delirium and resulted in long-term improvement of her tremor.. Baclofen, a GABA(B) agonist, may be a useful agent in the treatment of severe GHB withdrawal.

Topics: Adjuvants, Anesthesia; Baclofen; Benzodiazepines; Delirium; Epilepsy; Female; GABA Agonists; Humans; Middle Aged; Sodium Oxybate; Substance Withdrawal Syndrome; Tremor

Many psychiatric professionals are unfamiliar with gamma-hydroxybutyrate (GHB), an increasingly popular drug of abuse. GHB withdrawal can lead to psychosis and agitation, and patients may present to psychiatric facilities for treatment. Withdrawal may progress to delirium, with the potential for severe or even fatal medical complications. Therefore, it is imperative for psychiatric professionals to understand how to treat these patients. In this article, we describe two cases of severe GHB withdrawal syndrome that were treated in our inpatient psychiatric unit. These are among the most severe cases reported. Pertinent literature is reviewed and suggestions for treatment are discussed.

Topics: Adult; Anticonvulsants; Antihypertensive Agents; Clonazepam; Clonidine; Delirium; Hospitalization; Humans; Lorazepam; Male; Phenobarbital; Practice Guidelines as Topic; Psychoses, Substance-Induced; Sodium Oxybate; Substance Withdrawal Syndrome

Topics: Adult; Blood Pressure; Butylene Glycols; Charcoal; Consciousness Disorders; Delirium; Diagnosis, Differential; Electrocardiography; Gastric Lavage; Humans; Male; Poisoning; Sodium Oxybate; Sweating

Gamma-hydroxybutyrate (GHB) withdrawal syndrome is increasingly encountered in emergency departments among patients presenting for health care after discontinuing frequent GHB use. This report describes the characteristics, course, and symptoms of this syndrome.. A retrospective review of poison center records identified 7 consecutive cases in which patients reporting excessive GHB use were admitted for symptoms consistent with a sedative withdrawal syndrome. One additional case identified by a medical examiner was brought to our attention. These medical records were reviewed extracting demographic information, reason for presentation and use, concurrent drug use, toxicology screenings, and the onset and duration of clinical signs and symptoms.. Eight patients had a prolonged withdrawal course after discontinuing chronic use of GHB. All patients in this series were psychotic and severely agitated, requiring physical restraint and sedation. Cardiovascular effects included mild tachycardia and hypertension. Neurologic effects of prolonged delirium with auditory and visual hallucinations became episodic as the syndrome waned. Diaphoresis, nausea, and vomiting occurred less frequently. The onset of withdrawal symptoms in these patients was rapid (1 to 6 hours after the last dose) and symptoms were prolonged (5 to 15 days). One death occurred on hospital day 13 as withdrawal symptoms were resolving.. In our patients, severe GHB dependence followed frequent ingestion every 1 to 3 hours around-the-clock. The withdrawal syndrome was accompanied initially by symptoms of anxiety, insomnia, and tremor that developed soon after GHB discontinuation. These initial symptoms may progress to severe delirium with autonomic instability.

Topics: Adult; Autonomic Nervous System Diseases; Delirium; Diagnosis, Differential; Doping in Sports; Emergency Treatment; Fatal Outcome; Female; Humans; Hypertension; Male; Psychoses, Substance-Induced; Retrospective Studies; Sodium Oxybate; Substance Abuse Detection; Substance Withdrawal Syndrome; Tachycardia; Time Factors

Topics: Adult; Chloral Hydrate; Delirium; Female; Humans; Psychoses, Substance-Induced; Sodium Oxybate; Substance Withdrawal Syndrome; Substance-Related Disorders

We describe what we believe is the first psychiatric hospitalization due to GHB-induced delirium reported in the medical literature. We examine the use of the substance gamma hydroxybutyric acid (GHB) and describe the clinical findings in a patient who presented to an acute inpatient psychiatric unit with a chief complaint of feeling suicidal and a 1-year history of GHB use. A review of the literature and GHB's availability through the Internet are discussed.

Topics: Adjuvants, Anesthesia; Adult; Delirium; Female; Hallucinations; Humans; Mental Status Schedule; Psychoses, Substance-Induced; Sodium Oxybate; Substance Withdrawal Syndrome; Substance-Related Disorders; Suicide; Suicide Prevention