see: [Austin - GHB Withdrawal](x-devonthink-item://BBBB3142-25B7-4BCE-ACE5-EB6C1160E623), [Murray - GHB](x-devonthink-item://DA1896AC-D57C-4A67-B2C7-65B1D27BB53E?page=259), Similar drugs: - liquid fantasy (Butane 1,4-diol) **Risk assessment** - usually distributed at strength ==1g/mL==, but concentrations vary - recreational dose ~30mg/kg - \>50mg/kg can cause coma ad resp depression **Effects** - [[Coma]] - respiritory depression - agitation/delirium - miosis - myoclonic movements may occur; seizures are rare - [[Bradycardia]] - mild hypotension - mild hypothermia - vomiting generally onset within 20 minutes and lasts 4-8 hours **When to intubate?** - airway obstruction - ventilatory failure -- cannot maintain sats >92% on RA - vomiting threatens airway **Dispo** - asymptomatic at 2 hours post ingestion can be discharged - symptomatic pts are fit for discharge once ambulant with normal observations and conscious state ## GHB Withdrawal - tolerance to GHB develops with regular use - symptoms may develop within hors of the last dose of GHB and persist for 2-3 weeks - clinical features of GHB withdrawal: - mild: - anxiety - diaphoresis - restlessness - tremor - insomnia - severe - hallucinations - disorientation / [[Confusion]] - paranoia - [[Seizures]] - delirium - muscle rigidity - rare: - [[Heat-related illness|hyperthermia]] - [[rhabdomyolysis]] - [[Acute Renal Failure|AKI]] **Risk factors for delirium or severe withdrawal:** - short time intervals between dosing <4 hours - waking during night to dose - high daily doses > 15mL **Management of GHB withdrawal:** - may need inpatient treatment - benzos or baclofen; large frequent doses are usually required - may need ICU - *diazepam* 20mg orally Q1H up to 60mg then 10-20mg diazepam Q1H PRN *AND* - *baclofen* 25mg po TDS consider barbituates (eg oral phenobarbitone) 30mg Q1H max 120mg if above treatment doesn't work (d/w toxicologist or drug and alcohol services) if intubation required for severe symptoms, IV phenobarbitone 5mg/kg Q2H max daily dose 2g *antipsychotics* can be used as an adjunct, but they are NOT a substitute for GABA agonists *clonidine* 75mcg (max 375mg/od) to manage features of symathetic overactivity eg tachycardia, HTN, tremor, restlessness **Dispo** - minor symptoms 24-48 h after last GHB do not require admission - severe symptoms should be in HDU - all other patients at risk of severe GHB withdrawal should be admitted to an inpatient setting