U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES/Public Health Service
Morbidity and Mortality Weekly Report - April 4,
1997/Vol. 46/No. 13
Gamma Hydroxy Butyrate Use in 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 control centers, 34 involved
males; 10 reports involved teenagers aged 16-18 years. Nineteen
persons were treated in and re-leased 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 extra-corporeal
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: 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 >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.
Additional Data
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,"
"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
exemp-tions 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 Sub-stances
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. Neuro-sci 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
Courtesy of the Center For Disease Control, Atlanta,
GA
Vol. 46/No. 13 MMWR 283 -Gamma Hydroxy Butyrate Use