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Gamma Hydroxy Butyrate Usage, Effects and UK Prices

Results from 1999-2002 IDMU Surveys

1       Introduction

1.1       Gamma hydroxy butyrate (GHB) usually appears as an odorless, colorless, tasteless liquid - in proprietary form as a 20% solution [1] , but can also be found as a powder, or capsule [2] . GHB is a neurotransmitter [3] which occurs naturally at low concentrations in mammalian brains [4] acting as a central nervous system depressant [5]

1.2       GHB was originally described as an anaesthetic [6] and widely-used in Italy [7] , particularly for obstetric operations [8] , maxillofacial [9] or laryngial surgery [10]   Lane [11] considered GHB to be a “valuable and safe paediatric anaesthetic”.    However, GHB is not currently licenced for medical use in the UK.

1.3       Recreational use of GHB has become popular among clubbers and as a dietary supplement by bodybuilders [12] , it has also been cited more recently as a ‘date-rape’ drug [13] .  In the UK GHB is controlled under the Misuse of Drugs Act from July 2003, previously control of manufacture and supply was in the hands of the Medicines Control Agency [14] .

2       Recreational GHB use in the UK - IDMU survey results.

2.1       Each year since 1997, IDMU has conducted large-scale surveys of drug users monitoring consumption patterns and prices, using anonymous questionnaires distributed at pop festivals and similar outdoor events.  GHB was added to the list of named drugs in 1999, as it had been one of the more commonly-reported ‘other’ (write-in) drugs during previous years.  Approximately 3.4% of all drug users in our surveys conducted between 1999 and 2002 (8030 total respondents) admitted ever having used GHB, with a small but steady year-on-year rise in prevalence.

GHB Indicators by Year

Year

Total

GHB Rating

Total Users

Spending

 

Sample

n

mean

n

%

n

mean

1999

2173

247

2.42

61

2.81%

3

14.33

2000

2352

249

2.49

79

3.36%

8

7.88

2001

681

252

2.38

24

3.52%

1

10.00

2002

2825

1204

1.91

111

3.93%

6

22.67

Total

8031

1952

2.11

275

3.42%

18

14.00

2.2       The maximum spending per month was 120, and the maximum quantities used were 250-500ml per month (based on spending, bottle size and cost), with average monthly spending of 14.00 by users.  However the surveys involved only small numbers of current GHB users, and it is unclear how representative the levels of use reported may be of usage patterns among other GHB users.  Internet resources warn of the addictive qualities of GHB [15]

Frequency of GHB Use, Ratings & Spending [16]

Frequency of Use

Count

% of GHB Users

% of Total

Rating

Spending

Experimental

142

52.2%

1.77%

4.20

13.25

Occasional

30

11.0%

0.37%

6.35

2.33

Regular

17

6.3%

0.21%

6.32

21.50

Daily

10

3.7%

0.12%

2.57

10.00

Ex-users

73

26.8%

0.91%

3.57

0.00

Total Used

275

100%

3.42%

4.38

14.00

Sample size

8030

 

100%

2.11

 

2.3       The vast majority of those who had used GHB had done so experimentally or had stopped using the drug.  Only 10% of those who had tried GHB claimed to use on a regular basis.  The drug was not popular among users as a whole, with a low subjective rating (2.11 on a scale of 0 to 10), although users (4.38) and non-users who might try the drug (4.61) gave higher ratings than non-users as a whole (1.84) or those who stated they would never consider using the drug (1.38).  The overall rating in 2002 was significantly lower than in previous years  (Fisher PLSD, p<.05), possibly reflecting increased publicity surrounding use of the drug as a date-rape agent.

2.4       GHB is not normally a drug used by naive drug users, most users will have tried many other drugs before experimenting with GHB, the peak ages of initiation falling in young adulthood (fig 1). 

Fig1 - Age of first GHB use

2.5       The relatively wide spread of initiation ages is consistent with the relatively recent arrival of GHB on the club-scene.  Few individuals had used the drug prior to 1994 and very few prior to 1990 (fig 2).

Fig2 - Year of first GHB use

2.6       Of those who had not tried the drug and who expressed an intention, 18% stated they might try it, whereas 82% stated they would never consider using the drug.


3.       GHB Prices

3.1       There were no significant change in GHB prices between 1999 and 2002 (table 3).

Table - GHB Price Trends 1999-2002

Year

1999

2000

2001

2002

Overall

 

n

Mean

n

Mean

n

Mean

n

Mean

n

Mean

Dose

10

8.30

24

7.06

2

6.75

20

6.40

56

7.04

Bottle

7

29.21

6

24.17

2

6.50

4

19.50

19

23.18

Bottle Size ml

2

125

4

267.5

0

0

4

62.5

10

157

Price per ml

-

0.23

 

0.09

 

0.04

 

0.31

 

0.15

3.2       “Dose’ prices typically were 5 or 10, with bottles between 10 and 20, although much higher prices were also reported.  The wide spread of prices (fig 3) suggests the market not to be organised.

Fig 3 - GHB Price Distributions

 

3.3       The most expensive  ‘deal’ was a 30ml bottle for 30 (1/ml), the cheapest a 500ml bottle for 20 (4p/ml).  ‘Bottle sizes’ ranged from 10ml to 500ml.

4       Effects of GHB

4.1       At low doses, GHB encourages a reduction of social inhibitions, similar to alcohol,  euphoria, and increased libido. Higher doses lead to feelings of sedation, and can cause symptoms including vomiting, drowsiness, dizziness, vertigo, and seizures. After excessive use, some users have experienced loss of consciousness, irregular and depressed respiration, tremors, or coma [17] .  Cole [18] reported intravenous dosages of 60-70mg/kg to be sufficient to induce anaesthesia in healthy patients, whereas up to 200mg/kg are needed in laboratory animals [19] .  Greenblatt [20] reported “GHB is being marketed in England as an anti-aging medicine which allegedly increases the libido, decreases body fat, aids alcohol withdrawal, and induces sleep.”  Gallimberti [21] reported therapeutic uses for the treatment of alcohol withdrawal.

4.2       A number of deaths have been attributed to recreational GHB use [22] .  A total of 69 poisonings and one death were reported in New York & Texas by the Centre for Disease Control (CDC).  One 17 year old girl who died of cardiac arrest was found to have 27mg/l of GHB in her blood. “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.”  They also warned of the dangers of illicit GHB preparations “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.

4.3       Vayer et al [23]   reported the symptoms of acute GHB toxicity to include “coma, seizures, respiratory depression, and vomiting... 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.”    A Hungarian paper reported respiratory paralysis [24] , whereas Miglani et al [25] reported a case of GHB withdrawal delirium. 

5.       Conclusions

5.1       The recent decision to bring GHB within the scope of the Misuse of Drugs Act appears to be motivated more by a concern over the potential of GHB as a date-rape drug, than due to concerns over recreational use of the drug.  User-ratings, a measure of popularity, fell significantly in 2002 possibly reflecting these concerns.

5.2       Although prevalence of GHB usage appears to have  been increasing over the 4 years IDMU has been monitoring the drug, the number of users is still a very small percentage of the drug-user population.

5.3       The effect of legislative changes on GHB usage, prices and attitudes remains to be seen.  The bulk of respondents to the 2003 IDMU survey were sampled before the legislative changes were announced, although 2004 data may detect any changes in attitudes or prevalence when available in mid 2005. 

5.4       Already, anecdotal reports suggest that the quasi-legitimate commercial suppliers of GHB (hitherto sold as ‘legal’ ecstasy or ‘Liquid E’) are switching to metabolic precursors to by-pass the legislation.

Matthew J Atha & Simon T Davis

References

[1]            Cole WH. (1970) Observations on the pharmacology of gamma hydroxy sodium butyrate, with special reference to microsurgery of the larynx. Med J Aust 1(8):372-5

[2]            From the Centers for Disease Control and Prevention. (1997) Gamma hydroxy butyrate use--New York and Texas, 1995-1996. JAMA 277(19):1511

[3]            Vayer P, Mandel P, Maitre M. Gamma-hydroxy butyrate, a possible neurotransmitter. Life Sci 1987;41:1547-57.

[4]            Doherty JD, Roth RH. (1978) Metabolism of gamma-hydroxy-[1-14C] butyrate by rat brain: relationship to the Krebs cycle and metabolic compartmentation of amino acids. J Neurochem  30(6):1305-9

[5]            Puca FM, Genco S, Masi G, Federico F, Di Lauro L. (1973) [Vestibulo-oculomotor reflexes in relation to the level of vigilance. III. The vestibulo-oculomotor reflexes during central depression caused by sodium gamma-hydroxy-butyrate].[Article in Italian] Boll Soc Ital Biol Sper  49(17):1001-6

[6]            Laborit G, Kind A, de Leon RC (1960) [220 cas d’anaesthesie en neuro-chirugie avec le 4-hydroxybutyrate de sodium] [article in French] Presse Med 69 1216

[7]            Carboncini P, Mancini A, Stanca A. (1968) [Anesthesia and fetal distress. Trials of sodium thiopental and sodium hydroxy-butyrate].[Article in Italian] Atti Accad Fisiocrit Siena [Med Fis] 17(1):467-73

[8]            Carboncini P, Mancini A, Stanca A. (1968) [Anesthesia and fetal distress. Trials of sodium thiopental and sodium hydroxy-butyrate]. [Article in Italian]Atti Accad Fisiocrit Siena [Med Fis]  17(1):467-73

[9]            Antognini F, Giuliani R, Magagnoli PP, Romagnoli D. (1972) [General anesthesia with an association of gamma-OH(sodium 4-hydroxy-butyrate) and neuroleptoanalgesic drugs in dental and maxillofacial surgery].[Article in Italian] Minerva Stomatol  21(6):255-69

[10]          Cole WH. (1970) Observations on the pharmacology of gamma hydroxy sodium butyrate, with special reference to microsurgery of the larynx. Med J Aust 1(8):372-5

[11]          Lane RB. (1991) Gamma hydroxy butyrate (GHB) JAMA 265(22):2959

[12]          http://www.elitefitness.com/articles/ghb.html

[13]          From the Centers for Disease Control and Prevention. (1997) Gamma hydroxy butyrate use--New York and Texas, 1995-1996. JAMA 277(19):1511

[14]          Charles Clarke, Minister of State at the Home Office, 8-12-99 - House of Commons Written Answers. Hansard Session 1999-2000 volume 340 col 553W.

[15]          http://www.trendydrugs.org/ghb__gamma_hydroxy_butyrate.htm

[16]          IDMU 1999-2000 survey data (Regular Users IV/V) - novel analysis of data

[17]          CDC. (1990) Multistate outbreak of poisonings associated with illicit use of gamma hydroxy butyrate. MMWR 39:861-3.

[18]          Cole WH. (1970) Observations on the pharmacology of gamma hydroxy sodium butyrate, with special reference to microsurgery of the larynx. Med J Aust 1(8):372-5

[19]          Depoortere H, Rousseau A, Jalfre M. (1977) [Alerting effect of vincamine in rats (author's transl)].[Article in French] Rev Electroencephalogr Neurophysiol Clin 7(2):153-7

[20]          Greenblatt JC (1997) Gamma Hydroxy Butyrate (GHB) Abuse in the United States  Office of Applied Studies (Working Paper).  Substance Abuse and Mental Health Services Administration. Rockville MD USA.  http://www.health.org/govpubs/RPO963/

[21]          Gallimberti L, Gentile N, Cibin M, Fadda F, Canton G, Ferri M, Ferrara SD and Gessa GL. (1989) Gamma-hydroxybutyric acid for treatment of alcohol withdrawal syndrome. The Lancet, 787-9,

[22]          [No author listed] (1991) Gamma hydroxy butyrate poisoning. Med Lett Drugs Ther  33(836):8

[23]          Vayer P, Mandel P, Maitre M. Gamma-hydroxy butyrate, a possible neurotransmitter. Life Sci 1987;41:1547-57.

[24]          Jojart G, Grondzsak E. (1974) [Respiratory paralysis caused by gamma hydroxy butyric acid]. [Article in Hungarian] Orv Hetil  115(2):86

[25]          Miglani JS, Kim KY, Chahil R. (2000) Gamma-hydroxy butyrate withdrawal delirium: a case report.  Gen Hosp Psychiatry 22(3):213-5

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