Letters to the Editor
Gamma Hydroxybutyrate Withdrawal in an Orthopedic Trauma Patient
Dear Editor:
Gamma hydroxybutyrate (GHB) is a chemical initially developed in the 1960s as an anesthetic agent. It is now being investigated for use in the management of narcolepsy (1) and withdrawal from opiates (2) and alcohol (3). Recreationally, it is used as a drug that induces euphoria (4), as a supplement for bodybuilders (5), and as a sexual enhancer (6). We present a case of GHB withdrawal in a 32-year-old trauma patient.
Case Report
Mr C, a 32-year-old man with a 2-year history of panic disorder, presented to the hospital following a car accident. He did not lose consciousness but suffered multiple fractures of his pelvic girdle. His vital signs were within normal limits and his CT head and toxicology screen were negative. He did not experience any panic attacks around the time of the accident or upon admission. On his second day in hospital, his heart rate rose to 110 beats per minute. He continued to remain tachycardic, and the following day, his blood pressure rose to 170/100. On his seventh day in hospital (1 day after surgery), he began to complain of confusion. Shortly thereafter, he became agitated and began having visual and auditory hallucinations. Psychiatry was consulted and he was found to be delirious according to DSM-IV criteria (7).
Risperidone was initiated (initially 1 mg orally at night, with 0.5 mg every 2 hours as needed, then 2 mg at night the following day), with minimal effect. Collateral information suggested that chronic GHB use for anxiety (1 to 5 “capfuls” daily for 2 years) might be related to this resistance. We reviewed the literature and found that Mr C’s autonomic instability and delirium were consistent with GHB withdrawal (6). Benzodiazepines have been shown to effectively sedate patients suffering from GHB withdrawal, although the appropriate dosages remain unknown (6). We initiated treatment with diazepam 10 mg daily on day 3 of his delirium. Twenty-four hours later, his delirium had resolved and his sleep-wake cycle returned to normal. His vital signs normalized within 3 days.
Mr C’s presentation had several aspects consistent with GHB withdrawal: autonomic changes within 24 hours of discontinuing GHB use, anxiety, restlessness, confusion, delirium, visual hallucinations, and resistance to neuroleptics. However, the late onset of the delirium and the relatively quick response to diazepam are not as consistent with most reports of GHB withdrawal. Mr C’s case is complicated by several factors. First, he presented as a trauma patient rather than as a patient with withdrawal symptoms, as has been seen in most case reports. Second, he had surgery and was given morphine during his hospital stay, both of which are known to cause delirium. However, it is most likely that he was experiencing GHB withdrawal, because many of his symptoms preceded both the surgery and his brief morphine use. We present this case to illustrate both the importance of considering GHB withdrawal in the differential of the causes of delirium and the need to treat the cause (in this case, GHB withdrawal was treated with diazepam), rather than attempting to manage the symptoms with a neuroleptic.
References
1. Mamelak M, Scharf MB, Woods M. Treatment of narcolepsy with gamma-hydroxybutyrate. A review of clinical sleep lab findings. Sleep 1986;9:285–9.
2. Gallimberti L, Cibin M, Pagnin P, Sabbion R, Pani PP, Pirastu R, and others. Gamma hydroxybutyric acid in the treatment of opiate withdrawal syndrome. Neuropsychopharmacology 1993;9:77–81.
3. Addolorato G, Balducci G, Capristo E, Attilia ML, Taggi F, Gasbarrini G, and others. Gamma-hydroxybutyric acid (GHB) in the treatment of alcohol withdrawal syndrome: a randomized comparative study versus benzodiazepine. Alcohol Clin Exp Res 1999;23:1596–604.
4. Galloway GP, Frederick SL, Staggers FE, and others. Gamma-hydroxybutyrate: an emerging drug of abuse that causes physical dependence. Addiction 1997;92:89–96.
5. Dyer JE. Gamma-hydroxybutyrate: a health-food product producing coma and seizure-like activity. Am J Emerg Med 1991;9:321–4.
6. Dyer JE, Roth B, Hyma B. Gamma-hydroxybutyrate withdrawal syndrome. Ann Emerg Med 2001;37:147–53.
7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text revision. Washington (DC): American Psychiatric Association; 2000.
Brad Slagel, BSc
Edward Kingstone, MD, D Psych, FRCPC
Shree Bhalerao, BSc, BA, Pgd, MD, FRCPC
Toronto, Ontario
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