The American Journal on Addictions, 17: 456457, 2008

C American Academy of Addiction Psychiatry

Copyright

ISSN: 1055-0496 print / 1521-0391 online
DOI: 10.1080/10550490802266193

Letter to the Editor

Withdrawal, Recovery, and Long-Term Sequelae of
Gamma-Butyrolactone Dependence: A Case Report
David L. Henderson, MD,1 Jack P. Ginsberg, PhD2
1
2

Department of Neuropsychiatry and Behavioral Sciences, The University of South Carolina, Columbia, South Carolina
Department of Neuropsychology, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina

Our patient is a 32-year-old, married, white male brought to

the ER after a neighbor found him outside talking nonsense.
He was responding to internal stimuli, talking to customers
at an auto repair shop where he works. His neighbor was
unable to provide any other relevant history. His physical exam
showed a well-developed Caucasian male in severe distress,
acting paranoid and anxious. His vital signs showed a BP
of 159/92, a pulse of 110, respirations of 20, an afebrile
temperature, and an O2 Sat of 99% on room air. He was
diaphoretic with tachycardia, and he had some ecchymosis
over the left ribs. Neurological exam was grossly normal
except for his disoriented state. His laboratory findings were
essentially normal including his urine drug screen. ECG
showed a normal sinus rhythm and a head CT performed after
sedation was also negative.
When the patients wife arrived, she explained that her
husband had been using gamma butyrolactone (GBL), the
proform of GHB, since 1997 to treat social anxiety as well as
several other perceived problems. The patient had heard about
GHB from a news report describing its use at clubs and raves.
He looked it up on the Internet and what he found seemed
good: purported anti-aging properties, muscle enhancement,
increased sexual desire, and energy-boosting effects. He also
discovered that it made him more talkative and outgoing.
Because of these benefits, the patient used GBL daily from
1997 until 2005. He ordered it as a packet of GBL and sodium
hydroxide, which, when mixed, would create GHB. After
2000, however, he started using pure GBL, which he could
obtain more easily. He would order 99.9% 40 ml solutions of

Received March 21, 2008; accepted March 22, 2008

Address correspondence to Dr. Henderson, The University of
South Carolina Department of Neuropsychiatry and Behavioral
Sciences, 15 Medical Park Suite 141, Columbia SC 29203. E-mail:
livingstonepresumed@yahoo.com.
456

GBL and add water to create 8 ounces of liquid. He would

then drink 1 ounce every two to four hours with higher doses
at night for sleep. He enjoyed GBL because it did not give
him a hangover like alcohol. I also realized it could not be
detected on my breath and it didnt show up on drug screens.
After several months of use, he did notice that his anxiety
worsened as the effects of the drug wore off. This reinforced
his continued use. The failure of a scheduled shipment of GBL
to arrive led to this hospitalization.
Prior to admission, the patient was treated with ativan and
a single dose of haldol. When he arrived on the floor, the
department of Family Medicine placed him on serax 30 mg tid.
Psychiatry was consulted when his symptoms did not resolve
and we switched the patient to valium, giving him an initial
dose of 20 mg and then 10 mg q6 hours prn anxiety and
agitation. He also received risperdal 0.5 mg bid. The patients
symptoms waxed and waned during the hospitalization. His
confusion cleared prior to his psychosis. After six days, he
was discharged on valium with follow-up at a local CDIOP
program.
Two years later, the patient continues to follow-up with a
private addiction psychiatrist. His current medication regimen
includes prozac 40 mg qday, klonopin 0.5 mg qid, and
trazadone 100 mg qhs. He has also been placed on antabuse
because of a desire to return to alcohol. Neuropsychological
testing shows no cognitive deficits or long-term sequelae
from his chronic substance use, even after ten years of
daily consumption. Personality testing revealed depressive,
schizoid, and obsessive personality traits, which might give an
indication to the type of patient who is attracted to this drug
of abuse.

CONCLUSION
Though GBL and GHB are normally used at clubs
and raves,4 our case report shows that because of its

availability, other potential uses may be on the rise. To

date, the best evidence for treatment of GHB withdrawal
is from reviews of published case reports.1 The evidence
suggests that successful management of the syndrome can
be accomplished with benzodiazepines in combination with
supportive care.14 Antipsychotics might also be effective
in treating the psychotic symptoms of withdrawal.1 Based
on the two-year follow-up of the patient in this case,
long-term prognosis appears to be good despite chronic
use.

Henderson & Ginsberg

REFERENCES
1. McDonough M, Kennedy N, Glasper A, Bearn J. Clinical features and
management of gamma-hydroxybutyrate (GHB) withdrawal: A review.
Drug Alcohol Depend. 2004;75:39.
2. Dyer JE, Roth B, Hyma BA. Gamma-hydroxybutyrate withdrawal
syndrome. Ann Emerg Med. 2001;37:147153.
3. Snead OC, Gibson KM. -Hydroxybutyric acid: Review article. N Engl
J Med. 2005;352:27212732.
4. Wojtowicz JM, Yarema MC, Wax PM. Withdrawal from gammahydroxybutyrate, 1,4-butanediol and gamma-butyrolactone: A case report
and systematic review. CJEM. 2008;10:6974.

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