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CORK Bibliography: GHB (Gamma-Hydroxybutyrate)

97 citations. January 2003 to present

Prepared: September 2008

Abanades S; Farre M; Segura M; Pichini S; Barral D; Pacifici R et al. gamma-Hydroxybutyrate (GHB) in humans - Pharmacodynamics and pharmacokinetics. Annals of the New York Academy of Sciences. Cellular and molecular mechanisms of drugs of abuse and neurotoxicity. 1074: 559-576, 2006. (40 refs.)

Despite gamma-hydroxybutyrate (GHB) therapeutic uses and the increasing concern about its toxicity, few studies have addressed GHB dose-related effects under controlled administration and their relationship with its pharmacokinetics. The study design was double-blind, randomized, crossover, and controlled. As a pilot pharmacology phase I study, increasing doses of GHB were given. Single oral sodium GHB doses (40, 50, 60, and 72 mg/kg) were administered to eight volunteers. Plasma and urine were analyzed for GHB by gas chromatography-mass spectrometry. Physiological effects, psychomotor performance, and subjective effects were examined simultaneously. GHB produced dose-related changes in subjective effects as measured by questionnaires and VAS. GHB showed a mixed stimulant-sedative pattern, with initially increased scores in subjective feeling of euphoria, high, and liking followed by mild-moderate symptoms of sedation with impairment of performance and balance. Mean peak GHB plasma concentrations were 79.1, 83.1, 113.5, and 130.1 mu g/L for 40, 50, 60, and 72 mg/kg, respectively. GHB-mediated physiological and subjective effects were dose dependent and related to GHB plasma concentrations. GHB urinary excretion was mainly related to administered doses. GHB-mediated subjective and physiological effects seem dose dependent and related to GHB plasma concentrations. Results suggest a high abuse liability of GHB in the range of dose usually consumed.

Abanades S; Farre M; Barral D; Torrens M; Closas N; Langohr K et al. Relative abuse liability of gamma-hydroxybutyric acid, flunitrazepam, and ethanol in club drug users. Journal of Clinical Psychopharmacology 27(6): 625-638, 2007. (62 refs.)

Objectives: Despite the increasing concern about gamma-hydroxybutyric acid (GHB) toxicity, there are few studies examining the clinical pharmacology of GHB and its abuse potential. To evaluate GHB-induced subjective and physiological effects, its relative abuse liability and its impact on psychomotor performance in club drug users. Materials and Methods: Twelve healthy male recreational users of GHB participated in 5 experimental sessions in the framework of a clinical trial. The study was randomized, double-blind, double-dummy, and crossover. Drug conditions were a single oral dose of GHB (40 or 60 mg/kg), ethanol (0.7 g/kg), flunitrazepam (1.25 mg), and placebo. Study variables included vital signs (blood pressure, heart rate, oral temperature, pupil diameter), psychomotor performance (digit symbol substitution test, balance, Maddox-Wing), subjective effects (a set of 13 visual analogue scales, Addiction Research Center Inventory-49 items, and Evaluation of the Subjective Effects of Substanceances with Potential of Abuse questionnaires), and pharmacokinetics. Results: All active conditions induced positive effects related to their abuse potential. The administration of GHB produced euphoria and pleasurable effects with slightly higher ratings than those observed for flunitrazepam and ethanol. gamma-Hydroxybutyric acid induced a biphasic time profile with an initial stimulantlike effect related to the simultaneous rise of plasma concentrations and a latter sedative effect not related to GHB kinetics. gamma-Hydroxybutyric acid increased blood pressure and pupil diameter. Ethanol induced its prototypical effects, and flunitrazepam produced marked sedation. gamma-Hydroxybutyric acid and flunitrazepam impaired psychomotor performance, digit symbol substitution test, and balance task, whereas ethanol, at the dose tested, induced only mild effects exclusively affecting the balance task. Conclusions: Our results suggest a high abuse liability of GHB and flunitrazepam in club drug users.

Anderson IB; Kim SY; Dyer JE; Burkhardt CB; Iknoian JC; Walsh MJ et al. Trends in gamma-hydroxybutyrate (GHB) and related drug intoxication: 1999 to 2003. Annals of Emergency Medicine 47(2): 177-183, 2006. (16 refs.)

Study objective: To analyze changes in gamma-hydroxybutyrate (GHB) case reporting, we review GHB or congener drug cases reported to the California Poison Control System, comparing these to other data sets. Methods: We identified cases from the California Poison Control System computerized database using standardized codes and key terms for GHB and congener drugs ("gamma butyrolactone," "1,4-butanediol," "gamma valerolactone"). We noted California Poison Control System date, caller and exposure site, patient age and sex, reported coingestions, and outcomes. We compared California Poison Control System data to case incidence from American Association of Poison Control Centers and Drug Abuse Warning Network data and drug use prevalence from National Institute for Drug Abuse survey data. Results: A total of 1,331 patients were included over the 5-year period (1999-2003). California Poison Control System-reported GHB exposures decreased by 76% from baseline (n=426) to the final study year (n=101). The absolute decrease was present across all case types, although there was a significant proportional decrease in routine drug abuse cases and an increase in malicious events, including GHB-facilitated sexual assault (P=.002). American Association of Poison Control Centers data showed a similar decrease from 2001 to 2003. Drug Abuse Warning Network incidence flattened from 2001 to 2002 and decreased sharply in 2003. National Institute for Drug Abuse survey time trends were inconsistent across age groups. Conclusion: Based on the precipitous decrease in California Poison Control System case incidence for GHB during 5 years, the parallel trend in American Association of Poison Control Centers data, and a more recent decrease in Drug Abuse Warning Network cases, a true decrease in case incidence is likely. This could be due to decreased abuse rates or because fewer abusers seek emergency medical care. Case reporting may account for part of the decrease in the incidence of poison center contacts involving GHB.

Barker JC; Harris SL; Dyer JE. Experiences of gamma hydroxybutyrate (GHB) ingestion: A focus group study. Journal of Psychoactive Drugs 39(2): 115-129, 2007. (37 refs.)

GHB (gamma hydroxybutyrate) is a significant new drug of abuse added to the United States Controlled Substance Act in 2000. The majority of the published literature on GHB consists of clinical case reports, mainly from emergency departments, and a collection of laboratory-based studies, focused mainly on anesthesia. While comments about the various experiences and behaviors of human users are often included in such studies or reports, these aspects of GHB are only just beginning to be systematically investigated or detailed. Reported here are data from a qualitative study using focus group methods on the consumption habits, experiences, and beliefs of GHB users. A total of 51 people, 30 men and 21 women, mean age of 31.1 +/- 7.6 years (range 18 to 52 years), who report having used GHB for an average of 4.3 +/- 2.5 years (range one to I I years), were interviewed in 10 separate groups held in 2004. This article discusses broadly the general experience of the GHB high, major perceived benefits including sexual responses to the drug, perceived risks and dangers of ingestion, co-ingestion, and various contexts of use. It concludes with a discussion of the implications drawn from this information for clinicians treating patients who use GHB.

Barrett SP; Gross SR; Garand I; Pihl RO. Patterns of simultaneous polysubstance use in Canadian rave attendees. Substance Use & Misuse 40(9-10): 1525-1537, 2005. (22 refs.)

The aim of this study was to examine rave-related polydrug drug use and to determine if patterns of substance use were associated with previous rave attendance. One hundred and eighty-six rave attendees (50% female) representing a wide range of ages (16 to 47 years; mean = 23.5, sd = 5.15) and levels of rave attendance experience (I to 400 events) completed structured interviews in Montreal, Canada between November 2002 and September 2003 about their rave attendance patterns and their use of various licit and illicit substances at the most recently attended event. On average, participants reported using 2.5 different psychoactive substances (excluding tobacco) at the most recent event attended. Cannabis, alcohol, MDMA (ecstasy), amphetamine, cocaine, ketamine, and GHB were the most frequently reported substances, and details about their orders of administration, dosages, and patterns of co-administration are presented and discussed. The total lifetime number of raves attended by participants varied considerably (mean = 48.6; sd = 69.7; median = 25), and there was a positive correlation between the number events attended and number of substances used at the most recent event attended (p < 0.001). Analyses revealed that individuals reporting the use of ketamine, GHB, and/or cocaine at the most recent event had attended significantly more events than nonusers even when controlling for various demographic variables. A subset of respondents (n = 27) completed a second interview to determine the reliability of their responses. Results indicated that respondents could reliably recall details about which drugs were used, the total doses administered, as well as order of drug administration.

Bennett WRM; Wilson LG; Roy-Byrne PP. Gamma-hydroxybutyric acid (GHB) withdrawal: A case report. Journal of Psychoactive Drugs 39(3): 293-296, 2007. (22 refs.)

GHB is an increasingly popular drug of abuse that can be associated in select cases with growing dependence and a severe withdrawal syndrome. While benzodiazepines are recommended for treatment of the withdrawal syndrome, some cases have been described as benzodiazepine-resistant. The authors describe treatment of such a case, which was unsuccessfully treated initially with benzodiazepines, then successfully treated with adjuvant atypical neuroleptics, and offer a possible neurochemical explanation for why such agents may be theoretically more effective than benzodiazepines in treating GHB withdrawal.

Bodson Q; Denooz R; Serpe P; Charlier C. Gamma-hydroxybutyric acid (GHB) measurement by GC-MS in blood, urine and gastric contents, following an acute intoxication in Belgium. Acta Clinica Belgica 63(3): 200-208, 2008. (65 refs.)

Gamma-hydroxybutyrate (GHB, sodium oxybate) is a compound related to neuromodulator gamma-aminobutyric acid (GABA), emerging as a recreational drug of abuse and as a rape drug. GHB-related emergencies have dramatically increased in the 1990s, but a decrease is observed since 2000. We describe the case of an acute GHB intoxication in a 28-year-old male who fell unconscious after ingestion of a mouthful of an unknown beverage, and required medical support for 2 days. A cocaine abuse was also detected by preliminary toxicological screening, but the clinical presentation was not typical of cocaine intoxication. A simple liquid-liquid extraction was used for quantitation of GHB, followed by disityl-derivatization and analysis in selective ion monitoring (SIM) mode by gas chromatography-mass spectrometry (GC-MS), using GHB-d6 as internal standard. High concentrations of GHB were detected in urine (3020 mg/L) and gastric contents (71487 mg/L) at admission. After a 6-hours delay, GHB was still present in urine at 2324 mg/L and in blood at 43 mg/L. The clinical symptoms of cocaine intoxication were diminished by GHB consumption, and the cerebral scan was modified. Attention must thus be paid to acute intoxications with surprising clinical symptoms, and GHB has probably to be added to the preliminary toxicological screening. Data available regarding GHB are briefly reviewed, and our results are compared with previously published reports of non-fatal GHB intoxication.

Britt GC; McCance-Katz EF. A brief overview of the clinical pharmacology of "club drugs". Substance Use & Misuse 40(9-10): 1189-1201, 2005. (56 refs.)

Four different "club drugs" are reviewed: MDMA (methylenedioxymethamphetamine, "Ecstasy"), GHB (gamma-hydroxybutyrate), ketamine, and Rohypnol (R) (flunitrazepam). The neurobiology, clinical pharmacology, and treatment issues for each are discussed.

Camacho A; Matthews SC; Dimsdale JE. Use of GHB compounds by HIV-positive individuals. American Journal on Addictions 13(2): 120-127, 2004. (29 refs.)

Gamma hydroxybutyrate (GHB) has been used by body-builders to enhance performance and by young adults in rave parties. Warnings have been posted about its addictive potential. The use of these dietary compounds is currently banned by the Food and Drug Administration, but they are widely available through the Internet and in certain communities. The purpose of the study was to examine the use of these compounds by HIV-positive individuals and to investigate their knowledge of the addictive potential of GHB and its related dietary compounds. One hundred HIV-positive individuals from the UCSD outpatient HIV clinic responded to an anonymous survey that inquired about their knowledge, use, and effects produced by GHB containing dietary compounds. The most common reported dietary compound beside GHB was Growth Hormone Release Extract (GHRE). Fifty-two percent of individuals reported using at least one GHB containing dietary compound. Gay subjects reported the highest use of GHB compounds (76.9%; p less than or equal to 0.001). The most common effect reported by users was increased energy (71%). Only 24% of the total responders knew about GHB's addictive potential. Among reported users of GHB containing compounds, fourteen (27%) knew about its addictive potential and nine (17%) knew that the compound is illegal. This study shows that HIV-positive gay individuals attending our clinic are using GHB compounds. Reported GHB users have limited knowledge about its addictive potential and serious adverse effects. More controlled studies are needed to evaluate long-term effects of dietary compounds containing GHB, especially among HIV-positive individuals who are actively receiving antiretroviral treatment.

Camacho A; Matthews SC; Murray B; Dimsdale JE. Use of GHB compounds among college students. American Journal of Drug and Alcohol Abuse 31(4): 601-607, 2005. (23 refs.)

There are increasing reports about the misuse of gamma hydroxybutyric acid (GHB) related compounds. The objective of this article is to examine the use of GHB- containing dietary supplements among college students. An anonymous survey was completed at a university health clinic. The survey asked participants about their experience using GHB compounds and their knowledge about the legal status of GHB and its addictive potential. Two hundred fifteen students responded to the survey. Twenty-eight percent had used GHRE and 19% had used GHB. Growth Hormone Release Extract (GHRE) users reported consumption 2 - 3 times per month and GHB users reported 1 - 2 times per month. Males tended to use GHB for euphoria and energy, while females tended to use the compounds for weight loss. GHB was particularly popular among homosexual and bisexual responders. There was little knowledge of the addictive potential and illegal status of GHB and related compounds. GHB compounds are commonly used among college students. Given the different reasons for use according to gender and sexual orientation, prevention programs need to sculpt their message according to the target audience.

Caputo F; Addolorato G; Stoppo M; Francini S; Vignoli T; Lorenzini F; Alcohol Treatment Study Group. Comparing and combining gamma-hydroxybutyric acid (GHB) and naltrexone in maintaining abstinence from alcohol: An open randomised comparative study. European Neuropsychopharmacology 17(12): 781-789, 2007. (53 refs.)

Maintaining abstinence from alcohol is the main goat in treating alcohol dependence. Our aim was to evaluate the efficacy of gamma-hydroxybutyric acid (GHB) and naltrexone (NTX), and their combination in maintaining abstinence. Fifty-five alcoholics were randomly enrolled in three groups and treated for 3 months with GHB, GHB plus NTX, and NTX, respectively. At the end of treatments, abstinence was maintained by 13 patients (72.2%) in combination group, 8 patients (40%; P=0.03) in GHB group, and one patient (5.9%; P=0.0001) in NTX group. Relapses in heavy drinking tended to occur more frequently in GHB group (15%) than in either combination group (no cases) or NTX group (5.9%), but such differences were not statistically significant. The GHB/NTX combination was more effective than either drug given atone; this suggests that the two drugs combine their different actions synergistically without suppressing the favourable effects of each other.

Caputo F; Addolorato G; Lorenzini F; Domenicali M; Greco G; del RE A et al. Gamma-hydroxybutyric acid versus naltrexone in maintaining alcohol abstinence: an open randomized comparative study. Drug and Alcohol Dependence 70(1): 85-91, 2003. (44 refs.)

Maintaining abstinence from alcohol is the main goal in the treatment of alcohol dependence. Naltrexone (NTX) and gamma-hydroxybutyric acid (GHB) have proved able to maintain alcohol abstinence in alcoholic subjects. The aim of our study was to evaluate the efficacy of GHB compared with NTX in maintaining abstinence from alcohol after 3 months of treatment. A total of 35 alcohol-dependent outpatients were randomly enrolled in two groups: the GHB group consisted of 18 patients treated with oral doses of GHB (50 mg/kg of body weight t.i.d) for 3 months; the NTX group consisted of 17 patients treated with oral doses of NTX (50 mg/day) for 3 months. At the end of the study, a statistically significant difference (P=0.02) was found in the number of abstinent patients between the GHB and the NTX groups. In patients who failed to be abstinent, no relapses in heavy drinking were observed in the NTX group, while in the GHB group all patients relapsed. The results of the present study show that GHB is more effective than NTX in maintaining abstinence from alcohol in a short-term treatment period; on the other hand, NTX confirmed its ability to reduce alcohol relapses.

Caputo F; Stoppo M; Vignoli T; Francini S; Lorenzini F; Bernardi M. Use of alcohol during the treatment of alcohol dependence with gamma-hydroxybutyric acid. (letter). Journal of Clinical Psychopharmacology 27(4): 418, 2007. (10 refs.)

Carter LP; Chen W; Wu H; Mehta AK; Hernandez RJ et al. Comparison of the behavioral effects of gamma-hydroxybutyric acid (GHB) and its 4-methyl-substituted analog, gamma-hydroxyvaleric acid (GHV). Drug and Alcohol Dependence 78(1): 91-99, 2005. (47 refs.)

Gamma- hydroxybutyrate (GHB), a metabolite of GABA, is a drug of abuse and a therapeutic. The illicit use of GHB precursors and analogs reportedly has increased worldwide. Gamma-hydroxyvaleric (GHV) is a 4-methyl- substituted analog of GHB that reportedly is abused and is marketed as a dietary supplement and replacement for GHB. The purpose of these studies was to compare the pharmacological and behavioral profiles of GHV and GHB. In radioligand binding studies, GHV completely displaced [H-3]NCS-382 with approximately 2-fold lower affinity than GHB and did not markedly displace [3 H]GABA from GABA(B) receptors at a 20-fold larger concentration. In drug discrimination procedures, GHV did not share discriminative stimulus effects with GHB or baclofen. GHV shared other behavioral effects with GHB, such as sedation, catalepsy, and ataxia, although larger doses of GHV were required to produce these effects. Lethality (50%) was observed after the largest dose of GHV (5600 mg/kg), a dose that produced less-than-maximal catalepsy and ataxia. To the extent that large doses of GHV might be taken to in an attempt to produce GHB-like effects (e.g., hypnosis) GHV toxicity may pose a greater public health concern than GHB.

Carter LP; Richards BD; Mintzer MZ; Griffiths RR. Relative abuse liability of GHB in humans: A comparison of psychomotor, subjective, and cognitive effects of supratherapeutic doses of triazolam, pentobarbital, and GHB. Neuropsychopharmacology 31(11): 2537-2551, 2006. (57 refs.)

Although preclinical studies suggest that GHB has low likelihood for abuse, case reports indicate that GHB is abused. This study evaluated the relative abuse liability of GHB in 14 volunteers with histories of drug abuse. Psychomotor, subjective, and cognitive effects of a broad range of GHB doses ( 2-18 g/70 kg), up to a dose that produced severe behavioral impairment in each participant, were compared to placebo and two abused sedative/hypnotic drugs, triazolam ( 0.5 and 1 mg/70 kg) and pentobarbital ( 200 and 400 mg/70 kg), under double-blind, double-dummy conditions at a residential research facility. In general, GHB produced effects similar to triazolam and pentobarbital, although GHB was not identified as a benzodiazepine or barbiturate by participants that correctly identified triazolam and pentobarbital as such. On most measures of likelihood of abuse ( eg ratings of liking, reinforcing effects), effects of pentobarbital were significantly greater than those of triazolam, with GHB being intermediate. GHB produced significantly greater negative subjective effects, including nausea, than the other drugs. Memory impairment after GHB was less than that after triazolam and pentobarbital. Within participants, the dose-effect function for sedation was steeper for GHB than for triazolam and pentobarbital. Also, at higher doses, GHB was associated with greater sedation and more variability across participants in sedation. Taken together, these data suggest that the profile of effects of GHB only partially overlaps with that of triazolam and pentobarbital. Although the likelihood for GHB to be abused is intermediate to triazolam and pentobarbital, the possibility of accidental overdose (i.e. greater sedation than intended) with GHB appears to be greater.

Chanteloup F; Lenton S. Western Australian Party Drug Trends 2003: Findings from the Party Drug Initiative (PDI). NDARC Technical Report No. 187. Sydney: National Drug and Alcohol Research Centre, 2004. (15 refs.)

In 2000 the Illicit Drug Reporting System (IDRS) was expanded from previous years to explore the feasibility of monitoring trends in the market for party drugs using the existing IDRS methodology. This report presents the findings of the first year of data collection in Perth, W.A. These trends are based on three data sources: Quantitative interviews with 100 current regular ecstasy users; Qualitative interviews with 10 key informants (KIs) who have regular contact with ecstasy users and are employed in areas including health, outreach, and law enforcement; and Analysis of various indicator data from health and law enforcement sources. Demographic characteristics of party drug users: This population is defined by their regular use of tablets sold as ecstasy. This sample of ecstasy users was young, relatively well-educated, employed or studying. Patterns of drug use: While 52% of respondents nominated ecstasy as their drug of choice, polydrug use was common. Participants had used an average of 8.7 drugs in their lifetime and 6.4 within the preceding six months. Eighty five percent of respondents reported using other drugs with ecstasy and76% reported using other drugs during the acute recovery phase after ecstasy use. A mean of 3 drugs was used with ecstasy. Those that were regularly used with ecstasy by substantial numbers of respondents included tobacco, alcohol methamphetamine powder, cannabis and crystal methamphetamine. Additionally, a mean of 2 drugs was used after ecstasy use. Drugs that were regularly used in this context included cannabis, tobacco and alcohol. The patterns of use are described along with patterns of use for cocaine, MDA, LSD, GHB, and methamphetamines. For each drug class there is data on access, venues of use, perceived harms, associated problems including encounters with police, and perceived purity and drug price. There are 31 tables and figures.

Chanteloup F; Lenton S. WA Trends in Ecstasy and Drug Related Markets 2004: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 220. Sydney: National Drug and Alcohol Research Centre, 2005. (15 refs.)

This report deals with ecstasy and the related drug markets in West Australia. Following an executive summary there is a brief description of the characteristics of regular ecstasy users. Following are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics of users, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Chyka PA. Health risks of selected performance-enhancing drugs. Journal of Pharmacy Practice 16(1): 37-44, 2003

This article reviews adverse effects of and the difficulty of attributing toxic effects to selected drugs and dietary supplements that purportedly enhance athletic performance. On surveys estimating the extent of performance-enhancing drug use, 5% of high school students indicated anabolic-adrenergic steroid use, and approximately 28% of collegiate athletes and 5.6% of middle and high school athletes admitted creatine use. Many adverse health effects from the abuse of androgenic-anabolic steroids and androstenedione (a prodrug) are exaggerations of excessive testosterone on hepatic, cardiovascular, reproductive, and behavioral functions that can produce permanent changes. With creatine use, nausea, vomiting, diarrhea, elevated serum transaminase concentrations, hypertension, fluid retention, muscle cramping, and muscle strains have been reported. Ephedra stimulates adrenergic receptors, leading to tachycardia and hypertension, with central nervous system effects of anxiety, tremor, and hyperactivity. From 1997 to 1999, 10 people died and 13 suffered permanent disabilities due to ephedra. Hydroxybutyrate and several prodrugs (-butyrolactone and 1,4-butanediol) can produce alternating agitation and coma, amnesia, hypotonia, ataxia, nystagmus, tremors, bradycardia, respiratory depression, and apnea. Although hydroxybutyrate abuse began as a bodybuilding aid, most serious adverse effects are from acute overdoses. Adverse effects from performance-enhancing drugs do occur, but their extent and frequency are unknown.

Community Epidemiology Work Group, eds. Epidemiologic Trends in Drug Abuse. Volume I: Proceedings of the Community Epidemiology Work Group. June 2004. Bethesda MD: National Institute on Drug Abuse, 2005. (Chapter refs refs.)

This volume provides the presentations by the 21 Community Epidemiology Work Groups, as well as the results of a special expert panel on presectip drug abuse. The first introductory section of the volume provides a bried description of the CEWG roles, functions, and attributes as well as the major data sources used. This is followed by a discussion of the key findings in respect to presectiption drug abuse, polysubstance abuse, cocaine/crack/heroin, methamphetamine, marijuana, club drugs (MDMA/ecstasy, GHB, ketamine), phencyclidine, and also infectious deseases related to drug abuse. The next section presents the discussion and presentation on trends in prescription drug aubse, with summaries on the general epidemiology, student use of prescription drugs, treatment admissions related to the use of narcotic painkillers, teen's use and abuse of benzodiazepines, the nonmenidal use of prescription drugs by college students, and finally prescriptiondrug abuse among ecstaasy users in Miami. The final section is an international paper on Mexico, and

Degenhardt L; Agaliotis M; White B; Stafford J. New South Walses Trends in Ecstasy and Related Drug Markets 2004: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 221. Sydney: National Drug and Alcohol Research Centre, 2005. (48 refs.)

This report deals with ecstasy and the related drug markets in New South Wales. Following an executive summary there is a brief description of the characteristics of regular ecstasy users. Following are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics of users, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Degenhardt L; Copeland J; Dillon P. Recent trends in the use of "club drugs": An Australian review. (review). Substance Use & Misuse 40(9-10): 1241-1256, 2005. (107 refs.)

The use of "club drugs" such as MDMA, ketamine, and GHB appears to have increased in Western countries over the last 20 years, and Australia is no exception to that trend. While levels of use appear to be relatively low in the general population, among users of these drugs a number of adverse health and psychological problems, including dependence, have been reported. MDMA or ecstasy is the third most commonly used illicit drug in Australia, and relatively more information is available on its use in Australia than of drugs such as GHB or ketamine. Although there are no population level data available, levels of ketamine use in the general population appear to be lower than those of MDMA. In addition, the harms reported by recreational users are not excessive and the mortality rate is low. At the individual level, many of those who experiment find the effects aversive and do not persist. The harms that require-further investigation are the association between ketamine and unsafe sex and injecting behaviors, the neurotoxic effects, and use in situations where there is a heightened risk of accidental death when the user's cognition is grossly impaired. In contrast, while least is known of the epidemiology of GHB use, there is mounting evidence suggesting significant acute and long-term risks associated with the use of this drug. This suggests an urgent need for international research on the patterns of use, health, and psychosocial consequences of GHB use. In order to address public health issues associated with a range of club drug use, there is a need for research to identify the trends in population prevalence of these drugs. This could be most easily achieved by the inclusion of MDMA, ketamine, and GHB in household surveys that are currently collected routinely in a number of countries.

Degenhardt L; McGuigan D; Clayton S. Rapid assessment of crystal methamphetamine and GHB use in the gaylesbianbisexual and transgender community in New South Wales. NDARC Technical Report No. 235. Sydney: National Drug and Alcohol Research Centre, 2005

In recent years there has been an increase in concern about the extent of use and harms related to the use of crystal methamphetamine and GHB in the gay, lesbian, bisexual and transgender (GLBT) community in NSW. Anecdotal reports of an increase in the use of these drugs has been mirrored by reports of harms related to the use of these drugs that has included concerns about GHB overdose, reports of increased sexual risk behaviours among persons using crystal methamphetamine, and concerns about increases in problematic use of crystal methamphetamine. The current report is the result of a rapid assessment conducted jointly by the AIDS Council of New South Wales (ACON) and the National Drug and Alcohol Research Centre (NDARC) that aimed to do the following: 1. Review the existing literature on the effects of GHB and crystal methamphetamine and harms related to their use, with a particular focus upon evidence from GLBT populations; 2. Summarise existing data on the extent of use of these drugs in the GLBT community in NSW; 3. Conduct interviews with key experts working within the GLBT community, who had knowledge about trends in use and harms related to the use of these drugs, as well as obtain information from the GLBT community itself; 4. Summarise existing programmes designed to address the harms related to the use of these drugs; and 5. Consider the implications of this exercise for future research, public health interventions, and programme development.

Degenhardt L; Stafford J; Kinner S; Johnson J; Fry C; Bruno R et al. Reflections on a Two-year National Pilot study of the Party Drugs Initiative (PDI). NDARC Technical Report No. 236. Sydney: National Drug and Alcohol Research Centre, 2005. (0 refs.)

The PDI is a national monitoring system for ecstasy and related drugs that is intended to serve as a strategic early warning system, identifying emerging trends of local and national interest in ecstasy and related drug (ERD) markets. The PDI was conducted across Australia for the first time in 2003; monitoring of these markets has been undertaken since 2000 in NSW, SA and Qld. The PDI is based on the IDRS methodology and consists of three components: 1. interviews with regular ecstasy users (REUs), considered a sentinel group of drug users who could comment on these drug markets; 2. interviews with key experts (KEs), professionals who have regular contact with REUs through their work; and 3. indicator data sources related to ERDs. The PDI monitors the price, purity, availability and patterns of use of ecstasy, methamphetamine, cocaine, ketamine, GHB and other related drugs. It also monitors harms related to these drug types. It is designed to be sensitive to trends, providing data in a timely manner, rather than describing issues in extensive detail. The results of the two-year national pilot PDI indicate that regular ecstasy users tend to be young, relatively well-educated, and likely to be employed or engaged in studies. Small proportions of participants in all years were currently in drug treatment or had previously been incarcerated. This is in strong contrast to the demographic profile of the regular injecting drug users (IDUs) accessed for the IDRS, who are typically older, unemployed, and with both drug treatment and incarceration histories. Details about the harms, patterns of use and the price, purity and availability of ecstasy and related drugs can be obtained from the national and jurisdictional reports in 2003.

Dietze PM; Cvetkovski S; Barrat MJ; Clemens S. Patterns and incidence of gamma-hydroxybutyrate (GHB)-related ambulance attendances in Melbourne, Victoria. Medical Journal of Australia 188(12): 709-711, 2008. (23 refs.)

Objective: To examine the nature and extent of ambulance attendances involving gamma-hydroxybutyrate (GHB) and to compare these with heroin-related attendances in Melbourne, Victoria. Design: Retrospective analysis of a database of ambulance service records on attendances at non-fatal drug overdoses, March 2001 - October 2005. Participants and setting: Patients who took GHB and were attended to by an ambulance, as recorded by Metropolitan Ambulance Service (Melbourne) paramedics. Main outcome measures: Transportation to hospital by ambulance; other outcomes included number, age, sex and Glasgow Coma Score (GCS) of patients, characteristics of attendances (in public or private space, others present, police co-attendance). Results: There were 618 GHB-related ambulance attendances across the 46 months of data collection; 362 involving GHB only and 256 involving the concurrent use of GHB and other drugs. These figures compare to 3723 heroin overdoses observed during the same period. The number of GHB-related attendances increased by around 4% per month, which was a higher rate of increase than that found for heroin overdose attendances. Most patients were younger than 25 years, were attended in public spaces, and had a GCS < 10. Around 90% of patients were transported to hospital, compared with 21% of heroin overdose attendances. Conclusions: Ambulance attendance data can be used to index GHB-associated harms. The clear increases in GHB-related ambulance attendances over time highlights the need for further research on how best to respond to this emergent drug-related harm.

Drasbek KR; Christensen J; Jensen K. Gamma-hydroxybutyrate - a drug of abuse. (review). Acta Neurologica Scandinavica 114(3): 145-156, 2006. (96 refs.)

Gamma-Hydroxybutyrate (GHB) is a drug of abuse that causes euphoria, anxiolysis, and hypnosis. The recent rise in the recreational intake of GHB, as well as its association with 'drug rape', has turned the attention to GHB in acute hospital settings. Acutely admitted GHB intoxicated patients may display various levels of sedation or coma, but may also show paradoxical agitation, combativeness, or self-injurious behaviors. The symptoms can be nonspecific and the definite diagnosis therefore normally relies on the detection of GHB in blood or body fluids, which is an analysis that may not be promptly available. As a basis for understanding the clinical features of GHB intoxication and abuse, we here review the pharmacological and neurophysiological knowledge about GHB, which stems from decades of clinical and basic GHB research. In addition, we discuss the latest discoveries in the quest for distinct GHB receptors in the brain, and their possible implications for future therapies of GHB abuse.

Dresen S; Kempf J; Weinmann W. Prevalence of gamma-hydroxybutyrate (GHB) in serum samples of amphetamine, metamphetamine and ecstasy impaired drivers. Forensic Science International 173(2/3): 112-116, 2007. (19 refs.)

Two hundred and forty-seven serum samples which have been collected by police during roadside testing and have been found positive for amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxymethamphetamine (MDMA) and/or 3,4-methylenedioxyethamphetarnine (MDE) were analyzed for y-hydroxybutyrate (GHB). Serum samples were spiked with deuterated GHB as internal standard and acetonitrile was added to achieve dilution and protein precipitation. Samples were analyzed with a LC-MS/MS system operated in the multiple reaction monitoring mode (MRM) using a TurbolonSpray source. Chromatographic separation was achieved using a Synergi Polar RP column applying a gradient elution with a runtime of 15 min. To differentiate between endogenous and exogenously administered GHB a cut-off concentration of 10 mu g/mL was applied. Five samples exceeded this concentration and were found positive for GHB. These samples were only found positive for amphetamine but no other amphetamine derivatives were detected, while in three samples THC and in one sample cocaine, benzoylecgonine and ethanol were found.

Elliott SP. Nonfatal instances of intoxication with gamma-hydroxybutyrate in the United kingdom. Therapeutic Drug Monitoring 26(4): 432-440, 2004. (27 refs.)

There has been much publicity regarding the use and abuse of gamma-hydroxybutyrate (GHB, "liquid ecstasy," or "GBH"). GHB has been found to be an endogenous compound but has also been used for various therapeutic applications in addition to illicit use, particularly as a dietary supplement, sexual adjunct, and "party drug." Toxicological analysis was performed using urine and/or plasma specimens from 27 nonfatal instances of suspected GHB intoxication in the United Kingdom between May 1998 and May 2003. GHB was detected in the plasma and urine, invariably with the additional presence of ethanol and other drugs of abuse (eg, amphetamines, cocaine, and morphine). GBL was also detected in the majority of urine specimens analyzed but was not detected in the plasma samples (<10 mg/L). The mean plasma and urine concentrations measured as "total GBL" were found to be 245 mg/L (range 86-551 mg/L) and 1732 mg/L (range 5-5581 mg/L), respectively. This is believed to be the largest compilation of nonfatal cases from the United Kingdom.

Elliott S; Burgess V. The presence of gamma-hydroxybutyric acid (GHB) and gamma-butyrolactone (GBL) in alcoholic and non-alcoholic beverages. Forensic Science International 151(2-3): 289-292, 2005. (8 refs.)

Gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL) are regularly implicated in instances of surreptitious drug administration, particularly in beverages (so-called "spiked drinks"). In order to assist in the interpretation of cases where analysis of the actual beverage is required, over 50 beverages purchased in the UK were analysed for the presence of GHB and GBL. It was found that naturally occurring GHB and GBL were detected in those beverages involving the fermentation of white and particularly red grapes. No GHB or GBL was detected in other drinks such as beer, juice, spirits or liqueurs. GHB/ GBL was detected in red wine vermouth (8.2 mg/L), sherry (9.7 mg/L), port (GBL), red wine (4.1-21.4 mg/L) and white wine (< 3-9.6 mg/L). The presence of GHB/GBL did not appear to be influenced by the alcohol content or the pH of the beverage. In addition, the concentration in wines did not appear to be related to the geographical origin of the grape type. This is believed to be the first published data concerning the endogenous presence of GHB and GBL in the beverages described.

Fernandez MI; Perrino T; Bowen GS; Hernandez N; Cardenas SA; Marsh D et al. Club drug use, sexual behavior, and HIV risk among community and internet samples of Hispanics. Journal of Social Work Practice in the Addictions 5(4): 81-100, 2005. (47 refs.)

Hispanic men who have sex with men (MSM) are at high risk of HIV infection. This study reports on the club drug use and sexual behaviors of two distinct samples (community and Internet) of Hispanic MSM living in the AIDS epicenter of Miami-Dade County. Both samples reported high rates of unprotected anal sex and high numbers of sex partners; rates of club drug use (cocaine, ecstasy, methamphetamines, GHB, amyl nitrites, and Viagra) were also high. Recent use of club drugs was associated with both unprotected receptive and insertive anal sex in the Internet sample, but not in the community sample. Implications for social work practice are discussed.

Fernandez MI; Perrino T; Collazo JB; Varga LM; Marsh D; Hernandez N. Surfing new territory: Club-drug use and risky sex among Hispanic men who have sex with men recruited on the internet. Journal of Urban Health 82(1 Supplement 1): I79-I88, 2005. (37 refs.)

The Internet presents unique and growing opportunities for conducting HIV/STD research. This article reports on the first 171 participants enrolled in an ongoing study examining use of the Internet to recruit Hispanic men who have sex with men (HMSM) living in an AIDS epicenter to participate in community-based studies. First, it describes initial success with chatroom recruitment. Second, it compares the demographic, psychosocial, and sexual risk practices among HMSM recruited through the Internet who had used club drugs in the last 6 months and those who had not. In 2 months, 211 hours were spent recruiting in chatrooms; 735 chatroom users were engaged. Researchers used a scripted dialogue to describe the study and to invite chatroom users to visit the study's community sites for screening and enrollment. One hundred and seventy-six men came to the community sites; 172 (98%) were eligible and completed an audio-computer assisted self-interview. In the last 6 months, 48.5% of the sample bad used club drugs [defined as cocaine, crystal methamphetamines (crystal), amyl nitrites (poppers), Ecstasy, gamma-hydroxybutyrate (GHB), ketamine (Special K), and Viagra]. The proportion of men reporting use of each drug was: cocaine (15.8%), crystal (11.7%), poppers (31.6%), Ecstasy (14%), GHB (3.5%), Special K (3.5%), and Viagra (19.3%). In multivariate analyses, having higher number of sex partners, having higher social isolation scores, and having engaged in unprotected receptive anal intercourse were significantly associated with club-drug use. These initial findings suggest that high-risk HMSM can be successfully recruited through chatroom dialogues to participate in community-based HIV studies. The alarmingly high rates of club-drug use and risky sexual practices among HMSM underscore the need for effective HIV preventive interventions for this population.

Fischer J; Kinner S. Queensland Trends in Ecstasy and Related Drug Markets 2004: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 223. Sydney: National Drug and Alcohol Research Centre, 2005. (8 refs.)

This report deals with ecstasy and the related drug markets in Queensland. Following an executive summary there is a brief description of the characteristics of regular ecstasy users. Following are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics of users, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Gable RS. Acute toxic effects of club drugs. (review). Journal of Psychoactive Drugs 36(3): 303-313, 2004. (141 refs.)

This article summarizes the short-term physiological toxicity and the adverse behavioral effects of four substances (GHB, ketamine, MDMA, and Rohypnol(R)) that have been used at late-night dance clubs. The two primary data sources were case studies of human fatalities and experimental studies with laboratory animals. A safety ratio was calculated for each substance based on its estimated lethal dose and its customary recreational dose. GHB (ganuna-hydroxybutyrate) appears to be the most physiologically toxic; Rohypnol(R) (flunitrazepam) appears to be the least physiologically toxic. The single most risk-producing behavior of club drug users is combining psychoactive substances, usually involving alcohol. Hazardous drug-use sequelae such as accidents, aggressive behavior, and addiction were not factored into the safety ratio estimates.

Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), rohypnol, and ketamine. American Family Physician 69(11): 2619-2626, 2004. (59 refs.)

Club drugs are substances commonly used at nightclubs, music festivals, raves, and dance parties to enhance social intimacy and sensory stimulation. The most widely used club drugs are 3,4-methylenedioxymethamphetamine (MDMA), also known as ecstasy; gamma-hydroxybutyrate (GHB); flunitrazepam (Rohypnol); and ketamine (Ketalar). These drugs are popular because of their low cost and convenient distribution as small pills, powders, or liquids. Club drugs usually are taken orally and may be taken in combination with each other, with alcohol, or with other drugs. Club drugs often are adulterated or misrepresented. Any club drug overdose should therefore be suspected as polydrug use with the actual substance and dose unknown. Persons who have adverse reactions to these club drugs are likely to consult a family physician. Toxicologic screening generally is not available for club drugs. The primary management is supportive care, with symptomatic control of excess central nervous system stimulation or depression. There are no specific antidotes except for flunitrazepam, a benzodiazepine that responds to flumazenil. Special care must be taken for immediate control of hyperthermia, hypertension, rhabdomyolysis, and serotonin syndrome. Severe drug reactions can occur even with a small dose and may require critical care. Club drug overdose usually resolves with full recovery within seven hours. Education of the patient and family is essential.

George J; Lenton S. West Australian Trends in Ecstasy and Related Drug Markets 2005: Findings from the Party Drugs Initivative (PDI). NDARC Technical Report No. 253. Sydney: National Drug and Alcohol Research Centre (Australia), 2006. (14 refs.)

This report presents the results of an ongoing study monitoring ecstasy and related drug markets within WA. It begins with a description of the demographic characterisitcs of regular ecstasy users and patterns of use. The price, purity and availability of ecstasy, the markets, patterns of purchasing, and sources of information about purity and content of drugs, risk behavior, health related issues, criminal activity and market changes. Less but similar information is also provided for methamphetamine, cocaine, LSD, ketamine, MDMA, GHB, and drinking patterns. Data is presented in 35 tables and 46 figures.

Glasper A; McDonough M; Bearn J. Within-patient variability in clinical presentation of gamma-hydroxybutyrate withdrawal: A case report. European Addiction Research 11(3): 152-154, 2005. (10 refs.)

The emergence of gamma-hydroxybutyrate (GHB) dependence in the UK is described, with specific reference to a case study of serial episodes of GHB withdrawal. Symptoms are broadly similar to those for alcohol withdrawal, and rapid deterioration into delirium is common in severe dependence. This case report reflects the variability in clinical presentation of GHB withdrawal and response to treatment, even within the same patient. It is concluded that GHB withdrawal requires vigorous clinical management, preferably on an elective basis, in an inpatient setting if dependence is severe.

Goldsamt LA; O'Brien J; Clatts MC; McGuire LS. The relationship between club drug use and other drug use: A survey of New York City middle school students. Substance Use & Misuse 40(9-10): 1539-1555, 2005. (36 refs.)

In order to explore the relationship between use of club drugs (crystal methamphetamine, ecstasy, GHB, ketamine), and use of other drugs, survey data collected from 23,780 middle school students in New York City during 2002-2003 was examined. Results of HGLM analyses (a generalization of HLM to accommodate nonlinear outcomes), controlling for the effect of school, indicate that Black students are less likely than White students to use club drugs depending on the time frame of use. The use of alcohol and/or marijuana predict club drug use regardless of the timeframe of use, and lifetime cigarette use predicts lifetime club drug use. Recommendations for future research and prevention efforts are discussed.

Greydanus DE; Patel DR. The adolescent and substance abuse: Current concepts. Disease-a-Month 51(7): 392-431, 2005. (93 refs.)

This review addresses alcohol and other drug use among adolescents. The article addresses its etiology, adolescent development and how this is affected by and influences substance use. It also addresses factors which may be risk factors including the presence of psychiatric illness, environmental stresses and the widespread availability and access to drugs. The symptoms and stages of drug use and abuse are described. Specific attention is directed to alcohol, marijuana, nicotine, cocaine, opiates, amphetamines, methamphetamines, ecstasy, ketamine, the inhalants, gamma-hydroxybutyrate, barbiturates, PCP, as well as agents used to enhance athletic performance, including the anabolic steroids. There is also discussion of management and approaches to treatment. There are twenty-nine accompanying tables.

Grov C; Bimbi DS; Nanin JE; Parsons JT. Exploring racial and ethnic differences in recreational drug use among gay and bisexual men in New York City and Los Angeles. Journal of Drug Education 36(2): 105-123, 2006. (57 refs.)

Reported rates of recreational drug use among gay and bisexual men are currently rising. Although there has been much empirical research documenting current trends in drug use among gay and bisexual men, little research has empirically contrasted differential rates across urban epicenters, while even less has addressed racial or ethnic variation (between and within cities). This knowledge is essential both for the development of effective culturally-sensitive health education prevention/services and for understanding drug use prevalence among urban epicenters. Using the men's data gathered from large-scale gay, lesbian, and bisexual (GLB) community events in New York and Los Angeles in the fall of 2003 and spring of 2004 (N = 2,335), this study explored racial and ethnic variance in the use of methamphetamine, cocaine, MDMA/ecstasy (methylenedioxymethamphetamine), ketamine, GHB (gamma-hydroxy-butyrate), marijuana, and nitrate inhalants (poppers) among gay and bisexual men both between and within cities (NYC and LA). Levels of recent drug use were fairly consistent between New York City and Los Angeles; however there was some between and within city racial and ethnic variance. In particular, Asian/Pacific Islander men were among those least likely to report use of some drugs. Findings suggest substance use in the gay community permeates geographic boundaries in addition to some racial and ethnic boundaries such that interventions targeting drug-using gay and bisexual men should appropriately attend to racial and ethnic diversity within communities.

Halkitis PN; Palamar JJ. GHB use among gay and bisexual men. Addictive Behaviors 31(11): 2135-2139, 2006. (26 refs.)

The recreational use of gamma-hydroxybutyrate (GHB) has been relatively understudied, despite its popularity in gay communities. We examined the use of GHB in a sample of 450 club drug using gay and bisexual men. Of these, 29% indicated use of the substance in the recent past. GHB users were similar to those in the sample who reported no use along key demographic factors, although GHB users were more likely to identify as gay than bisexual and were slightly older. Poly-drug use was common, with close to half of GHB users combining with methamphetamine, MDMA, or ketamine; approximately one quarter also used GHB with alcohol. Participants reported that GHB was often used at nightclubs, circuit parties, sex parties, and sex clubs, with HIV-positive men more likely to use the substance in sexual contexts. Use of GHB is common among a certain subset of gay men despite warnings within the community about the potentially fatal effects of the substance, suggesting that more effort be given to educate drug using gay men about GHB.

Halkitis PN; Palamar JJ. Multivariate modeling of club drug use initiation among gay and bisexual men. Substance Use & Misuse 43(7): 871-879, 2008. (23 refs.)

This paper documents patterns and sequence of initiation of club drug use in a sample of 450 gay and bisexual men in New York City. Quantitative and qualitative baseline data from a yearlong longitudinal investigation conducted between 2001 and 2005 were analyzed. The study focused on the use of five club drugs - cocaine, GHB, ketamine, ecstasy, and methamphetamine - using self-reported indications of use for a period of 4 months prior to assessment. Patterns of club drug use among gay and bisexual demonstrated that poly-club-drug use is common, and that patterns of use can be differentiated along the lines of age, race/ethnicity, and sexual orientation, with those who are older, Black, and bisexual, reporting less club drug use. The majority of the men initiated use of the five club drugs as follows: (a) cocaine, (b) ecstasy, (c) ketamine, (d) methamphetamine, and (e) GHB. Variations in patterns were related to both age and level of poly-club-drug use. The sequencing and/or patterns of club drug use may be better explained by socialization processes in the gay community than by Gateway Theory, which has been traditionally used to explain patterns of drug use in the population. Future research should more closely examine the synergy of drug use combinations with an emphasis on measuring the extent to which the drugs are taken in synchronicity.

Halkitis PN; Palamar JJ; Mukherjee PP. Poly-club-drug use among gay and bisexual men: A longitudinal analysis. Drug and Alcohol Dependence 89(2/3): 153-160, 2007. (43 refs.)

Objective: We sought to delineate patterns of poly-club-drug use among gay and bisexual men. Data were drawn from a large-scale 12-month longitudinal investigation of club drug use and sexual behavior among 450 racially, ethnically, and geographically diverse sample of gay and bisexual men in New York City. Methods: Using community-based sampling, we recruited the sample from numerous venues and assessed the self-reported use of five drugs and their relation to one another: cocaine, ecstasy, GHB, ketamine, and methamphetamine. Multivariate hierarchical linear modeling (HLM) was utilized to examine associations of usage over the 12-month data collection period. Results: Use of the five club drugs was highly related as noted by both parametric and non-parametric analyses of the cross-sectional data. Patterns of use over time also indicated significant longitudinal associations. Specifically, the use of methamphetamine over time was related to both the use of ecstasy and GHB. Conclusions: The analyses suggest that usage patterns of individual club drugs such as methamphetamine, ecstasy, and GHB among gay and bisexual men are highly related across time. These findings hold implications for the treatment approaches that are utilized to address substance abuse in this segment of the population, and suggest that practitioners focus on the totality of the substance abuse behaviors and not necessarily individual drugs which are administered.

Hopfer C; Mendelson B; Van Leeuwen JM; Kelly S; Hooks S. Club drug use among youths in treatment for substance abuse. American Journal on Addictions 15(1): 94-99, 2006. (16 refs.)

We describe lifetime rates of club drug use among 782 youths in treatment for substance abuse. Rates (%) for youths under eighteen (N=486) were methylenedioxymethamphetamine ( MDMA), 32.3; gamma-hydroxybutyrate (GHB), 7.0; lysergic acid diethylamide ( LSD), 48.6; ketamine, 18.3; and methamphetamine, 30.2. For youths 18-32 (N=289) rates (%) were MDMA, 37.0; GHB, 13.1; LSD, 42.9; ketamine, 17.0; and methamphetamine, 31.5. Older youths reported significantly more use of GHB than younger youths (p <.01). Youths reported using club drugs frequently outside of rave settings. Club drug use is common among youths in treatment for substance abuse and has spread beyond the rave culture.

Hovda KE; Bjornaas MA; Skog K; Opdahl A; Drottning P; Ekeberg O et al. Acute poisonings treated in hospitals in Oslo: A one-year prospective study (I): Pattern of poisoning. Clinical Toxicology 46(1): 35-41, 2008. (25 refs.)

Objectives. Prospective design is mandatory to study pattern of poisoning and suicidal intention of patients. Material and Methods. Prospective cross-sectional multi-center study of all patients contacting health care services because of acute poisoning during one year in Oslo, irrespective of intention. Data on the adult hospitalized patients ( :16 years) are presented here. Results. Of a total of 3,775 such adult contacts (3,025 episodes), there were 947 (31%) hospitalizations; annual incidence 1.9 (per 1,000) in males and 2.1 in females. Median age was 36 years (range 16 - 89); 54% females. Benzodiazepines (18%), ethanol (17%), paracetamol (12%), opioids (7%), and gamma hydroxybutyric acid (GHB) (7%) were most frequently taken. Patients stated suicidal intention in 29% of the admissions; physicians in 10%. Conclusion. Benzodiazepines and ethanol were the most common agents, but newer illicit drugs were frequent, especially GHB. Males often took ethanol and drugs of abuse; females often used prescription drugs with suicidal intention.

Johnston J; Jenkinson R. Victorian Trends in Ecstasy and Related Drug Markets 2005: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 246. Sydney: National Drug and Alcohol Research Centre (Australia), 2006. (26 refs.)

This report presents the results of an ongoing study monitoring ecstasy and related drug markets within Victoria Australia. It opens with a description of the demographic characterisitcs of regular ecstasy users and patterns of use, including use of the other drugs. The price, purity and availability of ecstasy, the markets, patterns of purchasing, and sources of information about purity and content of drugs, the associated risk behavior, health related issues, criminal activity and market changes are also discussed. Similar data is presented in respect to other drugs commonly used: methamphetamine, cocaine, LSD, ketamine, GHB, and drinking patterns. Data is presented in 40 tables and 35 figures.

Johnston LD; O'Malley PM; Bachman JG; Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2004. Bethesda MD: National Institute on Drug Abuse, 2005. (0 refs.)

This is a summary of the key finding from the Monitoring the Future's 2004 survey of 8th, 10th, and 12th graders in respect to alcohol and other drug use, levels of perceived risk, and approval/disapproval of different substance use, as well as trend in drug use, with data from 1991-2004 provided. For this survey there are declines in several classes of drug use (marijuana, amphetamines, methamphetamines, anabolic steroids). Among those whose use has held steady are the hallucinogens, heroin and other narcotics (except for OxyContin and Vicodin) cocaine, tranquilizers, and two of the "club drugs", Rohypnol and GHB. Drugs with increased use include the inhalants and OxyContin. In terms of licit drugs more than half of teens have tried cigarettes by 12th grade, a quarter by 8th grade and 11% are current smokers, this represents a slight improvement over recent years. Drinking too remains widespread, with three-quarters being drinkers by senior year, although the figures are slightly improved for the two younger age grouups. The findings are summarized in 13 tables and 64 figures.

Kankaanpaa A; Liukkonen R; Ariniemi K. Determination of gamma-hydroxybutyrate (GHB) and its precursors in blood and urine samples: A salting-out approach. Forensic Science International 170(2/3, Special Issue): 133-138, 2007. (30 refs.)

gamma-Hydroxybutyrate (GHB) is an increasingly popular drug of abuse that causes stimulation, euphoria, anxiolysis or hypnosis, depending on the dose used. Low doses of the drug are used recreationally, and also implicated in drug-facilitated sexual assaults. Because of the unusually steep dose-response curves, accidental GHB overdosing, leading to coma, seizures or death can occur. Being a controlled substance, GHB is often substituted with its non-scheduled precursors gamma-butyrolactone (GBL) and 1,4-butanediol (131)), which are rapidly metabolized into GHB in the body. Here we describe an assay for GHB, GBL and BD in blood and/or urine samples. GHB and BD were extracted from diluted 200 mu L aliquots of samples with t-butylmethylether (plus internal standard benzyl alcohol) in test tubes preloaded with NaCl. After acidification and centrifugation the solvent phase was transferred to a test tube preloaded with Na2SO4, incubated for 30 min, centrifuged again, and evaporated in vacuum. The residue was mixed with N-methyl-N-trimethylsilyl-trifluoroacetamide (MSTFA) in acetonitrile, and injected into a GC-MS. When analyzing GBL, the salting-out step was omitted, and analysis was performed with a GC-FID apparatus. As revealed by the validation data this procedure is suitable for quantitative determination of GHB and its precursors in blood and/or urine samples.

Kelly BC; Parsons JT; Wells BE. Prevalence and predictors of club drug use among club-going young adults in New York City. Journal of Urban Health 83(5): 884-895, 2006. (36 refs.)

"Club drugs" encompass a diverse range of substances. Although efforts have been made to determine the extent of club drug use among the general population, it is equally important to assess patterns of use among key target populations from which drug trends typically diffuse. This paper describes the results of a survey focused upon club drug use among club-going young adults in NYC. Time-space sampling generated a sample of 1, 914 club-going young adults (ages 18-29) who provided data on their use of six key club drugs: ecstasy, ketamine, cocaine, methamphetamine, GHB, and LSD, as well as data on their gender, sexual orientation, race/etimicity, and other demographic variables. Club-going young adults report drug use at high rates-70% report lifetime illicit drug use and 22% report recent club drug use. Rates of club drug use differ by gender, sexual orientation and race/ethnicity. Male gender is predictive of ketamine, GHB, and methamphetamine use, while female gender is predictive of cocaine use. Gay/ bisexual orientation and White race are predictive of the use of several club drugs. Greater health promotion efforts are warranted among this population. Intervention programs and campaigns should tailor specific drug messages to differentially target various segments of dance club patrons.

Kim SY; Anderson IB; Dyer JE; Barker JC; Blanc PD. High-risk behaviors and hospitalizations among gamma hydroxybutyrate (GHB) users. American Journal of Drug and Alcohol Abuse 33(3): 429-438, 2007. (21 refs.)

Introduction: Little is known about behaviors linked to gamma hydroxybutyrate (GHB) morbidity. Methods: We surveyed 131 GHB users, using logistic regression to test the associations between the high risk behaviors and hospital treatment for GHB (26 [20%] of subjects). Results: Increased risk of GHB hospital treatment was associated with: co-ingestion of ethanol (OR 5.2; 95% CI 1.7-16), driving under the influence of GHB (OR 3.2; 95%, CI 1.3-7.8), use of GHB to treat withdrawal symptoms (OR 2.9; 95% CI 1.1-7.9), and co-ingestion of ketamine (OR 2.7; 95% CI 1.1-6.7). Conclusion: Targeted prevention activities could focus on selected high-risk behaviors.

Kim SY; Barker JC; Anderson IB; Dyer JE; Earnest G; Blanc PD. Systematic assessment of gamma hydroxybutyrate (GHB) effects during and after acute intoxication. American Journal on Addictions 17(4): 312-318, 2008. (17 refs.)

We adapted and tested a previously published questionnaire battery eliciting sensory and cognitive symptoms during (acute) and immediately after (post-acute) GHB intoxication. Studying 125 GHB users, we assessed the instrument's internal consistency using Cronbach's alpha (CA) and responsiveness to change comparing acute and post-acute symptoms. The final 14-item battery demonstrated good internal consistency (CA 0.85, both acute and post-acute). The median symptom score (possible range 0-64) was 30 (acute) and 6 (post-acute; difference p 0.001). This modified substance-specific symptom battery, which is easily administered, demonstrated excellent performance characteristics. It can be used to study GHB and, potentially, related drugs of abuse.

Knudsen K; Greter J; Verdicchio M. High mortality rates among GHB abusers in Western Sweden. Clinical Toxicology 46(3): 187-192, 2008. (24 refs.)

Background. GHB is a drug of abuse and acute poisonings have been an increasing medical problem over the last decade in Sweden. Objectives. To document all cases of GHB poisonings in Gothenburg during 1995-2004 and to record drug-related deaths to compare the toxicity of GHB with other illicit drugs, such as heroin and amphetamine. Methods. The number of GHB-poisoned patients treated at the Sahlgrenska University Hospitalital has been recorded with the help of an in-house database. The number of deaths by illicit drugs was recorded during 2004. Seizures of the drugs GHB, 1,4-butanediol, and GBL were registered between 1996 and 2004. Results. The number of poisoned patients was 259. The number of seizures with GHB was 743, GBL 343, and 1,4-butanediol 236. In 2004 the number of deaths was 6 with heroin, 7 with GHB, 32 with amphetamine, 6 with cocaine, and one with methadone. One patient with GHB poisoning died during hospital care. Conclusions. Intoxication by GHB has substantial morbidity and abuse of GHB has substantial mortality. The acute prognosis is good but long-term prognosis is insecure with an increased risk for drug dependency and an early death.

Kranzler HR; Ciraulo DA, eds. Clinical Manual of Addiction Psychopharmacology. Washington DC: American Psychiatric Press, 2005. (chapter refs.)

This volume deals with the pharmacology of addictive drugs and the medications used to treat substance use disorders. This edited volume has 24 contributors and is organized into 9 chapters. These cover all of the major classes of that are clinically important in the substance use field. These include the following: alcohol, opioids, sedative-hypnotics, cannabis, cocaine and psychostimulants, hallucinogens and phencyclidine, club drugs (gamma-hydroxybutyrate, ecstasy, and ketamine), inhalants, and tobacco. For each of thee chapters there is consideration of three central aspects of a major drug group: an overview of the clinical pharmacology of the abused substance, phenomenology or pharmacological treatment with the abstinence syndrome, and pharmacological treatment for relapse prevention. In addition there is also discussion of the psychosocial treatment combined with drug therapies for alcohol, cocaine, and opiates use disorders. The goal is to illustrate how patient characteristics, such as substance use disorder typology, severity, family history, and comorbid psychopathology, may interact with psychosocial and pharmacological treatment. For disorders in which no clear pharmacotherapy has proven effective (e.g., cocaine dependence), or for disorders in which no clear abstinence syndrome has been established (e.g., marijuana dependence), authors review the basic pharmacology of the drug and the phenomenology of withdrawal to enable clinicians to evaluate new clinical research in medications development for those disorders.

Kranzler HR; Ciraulo DA. Alcohol. IN: Kranzler HR; Ciraulo DA, eds. Clinical Manual of Addiction Psychopharmacology. Washington DC: American Psychiatric Press, 2005. pp. 1-54. (212 refs.)

This chapter dealing with cannabis is one of 8 chapters dealing with a major psychoactive drug class. While marijuana use can be seen as normative, it is the most commonly illicit drug used, for the majority of persons there is neither abuse nor dependence. The presence of abuse or dependence with marijuana were questioned until recently. Based on treatment episode data, in 2000, marijuana use was the primary drug problem, and a secondary problem for an additional 22% of those admitted to public facilities. There is discussion of the prevalence based on a number of studies, as well as discussion of withdrawal. The chapter concludes with a brief discussion of social and pharmacological treatment.

LeBeau MA; Montgomery MA; Morris-Kukoski C; Schaff JE; Deakin A. Further evidence of in vitro production of gamma-hydroxybutyrate (GHB) in urine samples. Forensic Science International 169(2/3 special issure): 152-156, 2007. (31 refs.)

This study was designed to supplement previous studies that documented in vitro production of gamma-hydroxybutyrate (GHB) in urine samples. Urine samples were provided by subjects who reported that they had never used GHB (n = 3 1). The specimens were stored under standard conditions of refrigeration (5 degrees C) without any preservatives added. All specimens were repeatedly analyzed for the presence of endogenous GHB over a 6-month period using a previously reported headspace GC-MS method. Significant elevations in GHB were observed in many of the urine samples as storage time increased. As a result, the in vitro production of GHB may increase the apparent GHB concentrations in urine during storage. This potential for an artificial increase in GHB concentration must be appreciated when establishing the threshold between endogenous and exogenous concentrations of GHB.

LeTourneau JL; Hagg DS; Smith SM. Baclofen and gamma-hydroxybutyrate withdrawal. Neurocritical Care 8(3): 430-433, 2008. (26 refs.)

Introduction: Benzodiazepine treatment of life-threatening gamma-hydroxybutyrate (GHB) withdrawal is frequently unsatisfactory. Animal studies suggest strongly that treatment with GABA(B) agonists, such as baclofen, will be a more effective strategy. Methods A case report from the medical intensive care unit (ICU) of the university tertiary care hospital. Results: A 61-year-old woman was admitted to the medical ICU for severe withdrawal symptoms from chronic GHB use. This manifested as delirium, tremor, and seizures despite only small decreases in GHB dose and treatment with benzodiazepines. The addition of baclofen allowed the rapid sequential decreases in the GHB dose without seizure or delirium and resulted in long-term improvement of her tremor. Conclusions: Baclofen, a GABA(B) agonist, may be a useful agent in the treatment of severe GHB withdrawal.

Liechti ME; Kunz I; Greminger P; Speich R; Kupferschmidt H. Clinical features of gamma-hydroxybutyrate and gamma-butyrolactone toxicity and concomitant drug and alcohol use. Drug and Alcohol Dependence 81(3): 323-326, 2006. (17 refs.)

Objective: To describe the clinical features of gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL) toxicity. Methods: Retrospective case-study of 65 GHB and GBL intoxications seen in an urban emergency department. Results: 63% of intoxications occurred in male patients. The median age was 24 years (range 16-41 years). 65% co-ingested alcohol or illicit drugs, mostly MDMA and cocaine. 83% presented with coma. The mean +/- S.D. time to regain consciousness among comatose patients was 111 +/- 61 min and was significantly longer in patients who co-abused illicit drugs such as cocaine or MDMA (155 +/- 60 min). Bradycardia occurred in 38%, hypotension in 6% and hypotherinia in 48%. Agitation was observed in 17% of all patients and was significantly more frequent in patients with alcohol co-use (29%). Vomiting occurred in 31% of all patients and tended to be more frequent in patients who co-used alcohol (39%). Management of GHB and GBL overdose was supportive. Four patients needed admission to an intensive care unit for mechanical ventilation (6%). Conclusions: Overdosing of GHB and GBL frequently results in non-reactive coma reflecting the severity of poisoning. Multiple drug use is common and significantly influences the clinical presentation.

Lora-Tamayo C; Tena T; Rodriguez A; Morena D; Sancho JR; Ensenat P et al. The designer drug situation in Ibiza. Forensic Science International 140(2-3): 195-206, 2004. (23 refs.)

A total of 137 urine samples and 46 serum samples, corresponding to 154 self-confessed designer drugs consumers in Ibiza island, were analyzed for the presence of designer drugs: amphetamine and amphetamine derivatives (methamphetamine, methylenedioxymethamphetarnine (MDMA), methylenedioxyethylamphetamine (MDEA), methylenedioxyamphetamine (MDA), p-methoxymethylamphetamine (PMMA), p-methoxyamphetamine (PMA), etc.), ketamine and gamma-hydroxybutyric acid. Among this population, coming both from the forensic clinic and from the emergency room of a hospital, a total of 99 cases were found positive for some designer drug. This study shows the prevalence of methylenedioxymethamphetarnine (MDMA) among designer drug users, sole or in association with other drugs. Also, the mixture of MDMA with other designer drugs, ethanol and/ or cocaine is shown to be more likely to produce toxic symptoms requiring clinical attendance in a hospital emergency room. These findings along with the consumption history, the concentrations of drugs and metabolites in urine and serum and the toxicological significance for the interpretation of some MDMA metabolites such as 4-hydroxy-3-methoxymethamphetamine (HMMA) are discussed in this study.

Matthews A; Bruno R. Tasmanian Trends in Ecstasy and Related Drug Markets 2004: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 225. Sydney: National Drug and Alcohol Research Centre, 2005. (22 refs.)

This report deals with ecstasy and the related drug markets in Tasmania. Following an executive summary there is a brief description of the characteristics of regular ecstasy users. Following are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics of users, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Matthews A; Bruno R. Tasmanian Trends in Ecstasy and Related Drug Markets 2005: Findings from the Party Drug Initiative (PDI). NDARC Technical Report No. 251. Sydney: National Drug and Alcohol Research Centre (Australia), 2006. (35 refs.)

This report presents the results of an ongoing study monitoring ecstasy and related drug markets within Tasmania. It begins with a description of the demographic characterisitcs of regular ecstasy users and patterns of use. The price, purity and availability of ecstasy, the markets, patterns of purchasing, and sources of information about purity and content of drugs, risk behavior, health related issues, criminal activity and market changes. Similar information is also provided for methamphetamine, cocaine, LSD, ketamine, MDMA, GHB, and drinking patterns. Data is presented in 66 tables and 29 figures.

Maxwell JC. Party drugs: Properties, prevalence, patterns, and problems. (review). Substance Use & Misuse 40(9-10): 1203-1240, 2005. (172 refs.)

This review summarizes the latest literature on "party" or "club" drugs, defined as MDMA, GHB, ketamine, and Rohypnol, as published from 2002 to early 2005. Club drugs have been categorized as being used at raves and dance parties. The literature shows that each drug has different properties, users, and settings. Each drug has different adverse effects and requires different acute care protocols. Although these drugs were identified early, scientific information about them, including the toxicological tests to identify them, is still evolving. Increasing numbers of studies on the short- and long-term effects of these drugs on humans are being published, but because of limitations on research using human subjects, they may not always be as rigorous as desired and can be cited by drug users to discredit findings of harm. The lack of research-based information on these drugs has led to the emergence of web sites that may or may not provide accurate data. Evaluated chemical dependency treatment protocols using the latest research for each of these different drugs are needed.

Maxwell JC; Spence RT. Profiles of club drug users in treatment. Substance Use & Misuse 40(9-10): 1409-1426, 2005. (31 refs.)

There is little in the literature about treatment of persons with problems with "club" or "party" drugs. This paper looks at the characteristics of individuals admitted to treatment for primary, secondary, or tertiary problems with club drugs such as ecstasy, gamma-hydroxybutyrate (GHB), ketamine, flunitrazepam (Rohypnol), methamphetamine, and hallucinogens (e.g., LSD) in programs funded by the Texas Commission on Alcohol and Drug Abuse. Some 38,350 unduplicated records front 1988 through 2003 of persons admitted with problems with club drugs were compared against users of alcohol or other drugs. Club drug users were more impaired on five of six Addiction Severity Index (ASI) indices at admission and they were more likely to use multiple substances more often. They were more likely than users of alcohol or other drugs to complete treatment, but this varied by drug. At follow-up 90 days after discharge, club drug users continued to report more ASI problems. Profiles of these clients show that ecstasy use has spread beyond the club culture, as indicated by the changes in client demographics over time. GHB clients presented a mixed picture of severe problems at admission and good response to treatment. Hallucinogen clients were young and less likely to complete treatment, while Rohypnol users were on the Texas-Mexico border The methamphetamine epidemic has resulted in increased admissions, and the proportion of "Ice" smokers has increased. However, methamphetamine clients were less likely to complete treatment and their higher level of problems at admission and follow-up are of concern. Of special note are the indications of co-occurring problems and the need for both mental health and substance dependence treatment for some clients.

McCambridge J; Winstock A; Hunt N; Mitcheson L. 5-year trends in use of hallucinogens and other adjunct drugs among UK dance drug users. European Addiction Research 13(1): 57-64, 2007. (33 refs.)

Aims: To describe and assess trends in the use of hallucinogens and other adjunct drugs over a 5-year period. Design: Repeated-measures cross-sectional survey. Setting and Participants: Annual magazine-based survey targeting people who use drugs in dance contexts. Measurements: Lifetime use prevalence (ever used); age of first use; current use prevalence (any use within the last month), and extent of use within the last month (number of days used) for LSD, psilocybin, ketamine, GHB and nitrates. Findings: Prevalence increases for psilocybin, ketamine, GHB and nitrates use have been detected, with a sharp recent rise in current psilocybin use in 2002-2003 contrasting with more gradual and comprehensive evidence of increased ketamine use throughout the period 1999-2003. The declining prevalence of LSD use in general population surveys is replicated in this sentinel population study. Conclusions: The rise in prevalence of hallucinogen and other adjunct drugs identified among dance drug users may be mirrored by wider prevalence increases among young people with a consequent need to study these trends carefully and to develop effective interventions, where required.

McDonough M; Kennedy N; Glasper A; Bearn J. Clinical features and management of gamma-hydroxybutyrate (GHB) withdrawal: A review. (review). Drug and Alcohol Dependence 75(1): 3-9, 2004. (25 refs.)

Aim: To examine the clinical course of gamma-hydroxybutyrate (GHB) withdrawal and generate management guidelines. Design: Review and analysis of all published reports of GHB or GHB precursor withdrawal identified from electronic searches. Findings: In total, 38 cases of GHB (n=28) or GHB precursor (n=10) withdrawal were identified, 36 of which were from the US. A rapidly deteriorating course into delirium (53% of cases) was typical for heavily dependent users. Symptoms were broadly similar to alcohol withdrawal but often occurred earlier in usage with delirium being associated with severe dependence as determined by more frequent ingestion. High dose benzodiazepines were effective in pharmacological management of GHB withdrawal. In benzodiazepine refractory cases withdrawal responded to other sedative agents, mainly pentobarbital or chloral hydrate. No withdrawal seizures but one death was recorded. Conclusions: GHB withdrawal is potentially life threatening and requires vigorous clinical management, preferably as an inpatient for severe cases. A management algorithm is proposed.

McDowell D. Marijuana, hallucinogens, and club drugs. IN: Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. pp. 157-183. (121 refs.)

This chapter provides summaries of marijuana, hallucinogens, and the "club drugs" -- ecstasy, ketamine, GHB. The history of use, the mechanisms of action are outlined, as well as their physiolgoical effects and treatment approaches.

Mokhlesi B; Garimella PS; Joffe A; Velho V. Street drug abuse leading to critical illness. (review). Intensive Care Medicine 30(8): 1526-1536, 2004. (133 refs.)

Critical care physicians are frequently confronted with intoxicated patients who have used street drugs. In the last decade there has been an upward trend in the use of these substances, particularly amongst adolescents and young adults in large urban areas. In excess quantities all street drugs can lead to critical illness. Early and appropriate medical attention by emergency medicine physicians and intensivists can improve outcomes. In this review article we intend to familiarize critical care physicians with the most common street drugs such as amphetamines, ecstasy, cocaine, gamma hydroxybutyrate, opioids, and phencyclidine.

Morral AR; McCaffrey DF; Chien S. Measurement of adolescent drug use. Journal of Psychoactive Drugs 35(3): 301-309, 2003. (22 refs.)

There is widespread agreement that estimates of adolescent drug use prevalence from the National Household Survey of Drug Abuse (NHSDA) and Monitoring the Future (MTF) are subject to considerable measurement error. Nevertheless, some have suggested that trends over time in these prevalence estimates probably reflect true trends in drug use, since underreporting may be assumed to be constant over time. A recent National Research Council report criticizes this assumption on logical grounds. The present study examines adolescent drug use responses on the NHSDA and MTF for evidence of "drug omission," "jargon confusion" and "conceptual confusion," three types of misreporting expected to vary in magnitude with changes in drug use practices and changes in survey items. Results demonstrate that adolescent drug users are significantly more likely than adults to report use of drugs not listed in the NHSDA. Among adolescents who wrote in the "other" drugs they used, 66% and 86% of hallucinogen and inhalant, responses showed confusion over the meaning of the pharmacological terms used in the NHSDA. Almost 20% of MTF respondents who report lifetime use of Rohypnol or ecstasy, when specifically queried about these drugs, deny lifetime use of any substances in the drug classes intended to assess use of Rohypnol and ecstasy. MTF respondents reporting lifetime use of PCP underreport use of hallucinogens at rates that vary substantially over time, from a high of 45% (in 1986), to a low of just 8% (in 1998). The implications of these findings for adolescent drug use prevalence estimation and survey design are discussed.

Nava F; Premi S; Manzato E; Lucchini A. Comparing treatments of alcoholism on craving and biochemical measures of alcohol consumptions. Journal of Psychoactive Drugs 38(3): 211-217, 2006. (39 refs.)

An open randomized study was conducted to compare different treatments of alcoholism on ethanol intake, craving, and on biochemical measures of alcohol consumptions. Eighty-six alcoholics were abstinent for a mean of two weeks prior to random assignment to g-hydroxybutyrate (GHB, 50 mg/kg of body weight t.i.d), naltrexone (NTX, 50 mg/day) or disulfiram (DSF, 200 mg/day) treatment for 12 months. All treatments were equally effective in reducing alcohol intake and in maintaining abstinence. In all patients, the treatments were able to reduce both craving and the altered biological markers of alcohol abuse. The maximum effects were observed in GHB-treated patients. The results of the present study suggest that GHB might act both as anticraving and cellular protector agent.

Nava F; Premi S; Manzato E; Campagnola W; Lucchini A; Gessa GL et al. Gamma-hydroxybutyrate reduces both withdrawal syndrome and hypercortisolism in severe abstinent alcoholics: An open study vs. diazepam. American Journal of Drug and Alcohol Abuse 33(3): 379-392, 2007. (72 refs.)

In 42 alcoholic inpatients we performed an open randomized study to compare the effects of diazepam and gamma-hydroxybutyrate (GHB) on the suppression of severe alcohol withdrawal syndrome and hypercortisolism. Both diazepam (.5mg/kg bodyweight, q.i.d.) and GHB (50 mg/kg bodyweight, q.i.d.) were orally administered for three weeks. During all study period, GHB was more able than diazepam in reducing both withdrawal syndrome and hypercortisolism. These effects were evident during the first week of treatment and persisted throughout the study period. The results confirm a strict correlation between high levels of plasma cortisol and alcohol withdrawal symptoms and they show a slight superiority of GHB over diazepam in the suppression of both ethanol withdrawal and hypercortisolism. Taken together, our data suggest that GHB may act as potent anti-withdrawal agent in severe abstinent alcoholics.

Newman J; Moon C. Northern Territory Trends in Ecstasy and Related Drug Markets 2004: Findings from the Party Drug Initiative (PDI). NDARC Technical Report No. 222. Sydney: National Drug and Alcohol Research Centre, 2005. (32 refs.)

This report deals with ecstasy and the related drug markets in the Northern Territory. Following an executive summary there is a brief description of the characteristics of regular ecstasy users. Following are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics of users, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Newman J; Moon C. Northern Territory Trends in Ecstasy and Related Drug Markets 2005: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 244. Sydney: National Drug and Alcohol Research Centre (Australia), 2006. (33 refs.)

This report presents the results of an ongoing study monitoring ecstasy and related drug markets within the Northern Territory (Australia). It opens with a description of the demographic characterisitcs of regular ecstasy users and patterns of use, including use of the other drugs. The price, purity and availability of ecstasy, the markets, patterns of purchasing, and sources of information about purity and content of drugs, the associated risk behavior, health related issues, criminal activity and market changes are also discussed. Similar data is presented in respect to other drugs commonly used: methamphetamine, cocaine, LSD, ketamine, GHB, and drinking patterns. Data is presented in 75 tables and 62 figures.

Office of Applied Studies. Emergency Department Trends from Drug Abuse Warning Network (DAWN), Preliminary Estimates, January-June 2002. DAWN Series D-22. Rockville MD: Substance Abuse and Mental Health Services Administration, 2003. (0 refs.)

This report includes data generated by the Drug Abuse Warning Network (DAWN). It includes major substance of abuse, by drug category and drug name. (alcohol in combination with other drugs, heroin, marijuana, methamphetamines, ketamine, LSD, PCP, club drugs, GHB, Data is presented in 210 tables and 4 figures. It includes preliminary estimates for January through June of 2002, annual estimates for 1994-2001, and semi-annual estimates for the second half of 1997 through June 2002. The estimates are for the coterminous U.S. and for 21 major metropolitan areas.

Public Domain

Palamar JJ; Halkitis PN. A qualitative analysis of GHB use among gay men: Reasons for use despite potential adverse outcomes. International Journal of Drug Policy 17(1): 23-28, 2006. (35 refs.)

This paper examines the use of gamma-hydroxybutyrate (GHB) among a sample of gay men in New York City, who identify GHB as their most frequently used club drug. The sample was drawn from a larger longitudinal investigation of club drug using men. Thematic analysis yielded findings regarding perceived stigma for GHB use, tolerance of potential adverse side effects, and reasons for why some prefer this substance to other club drugs. Specifically, our findings suggest that GHB is viewed unfavorably in many social circles, that side effects are tolerated by frequent GHB users, and that the drug is chosen over other substances because the short duration of action, energy boost, sleep assistance, increase in libido, and limited after-effects. Examining the reasons why men use this substance will lead to the development of GHB specific prevention strategies, which accurately address the consequences of use as well as the motivations that individuals possess for using the substance.

Parks KA; Kennedy CL. Club drugs: Reasons for and consequences of use. Journal of Psychoactive Drugs 36(3): 295-302, 2004. (33 refs.)

This preliminary descriptive study was designed to assess the reasons, primary contexts, and consequences (physical, psychological, lifestyle) of club drug use in a sample of young adults in a mid-size U.S. city. Fifty young adults (18 to 30 years old) reported on their use of club drugs (Ecstasy, GHB, ketamine, Rohypnol(R), methamphetamine, LSD) in face-to-face interviews that included quantitative and qualitative measures. Ecstasy was the most frequently used club drug followed by ketamine, LSD and methamphetamine. All of the participants reported using club drugs to "experiment" and most reported using these drugs to feel good and enhance social activities. Club drugs were frequently used at raves, in bars or clubs, and at home with friends. An average of 16 negative physical, psychological, and lifestyle consequences were reported for club drug use. Despite substantial negative consequences, participants perceived several positive consequences of regular recreational club drug use. These findings corroborate descriptions of club drug use in other countries (e.g., Australia, United Kingdom) and provide additional information on perceived positive consequences that users experience with club drug use. Further exploration of the reasons and positive consequences that are associated with use of each of the club drugs may provide important information on the growing trend in use of these drugs.

Parsons JT; Halkitis PN; Bimbi DS. Club drug use among young adults frequenting dance clubs and other social venues in New York City. Journal of Child & Adolescent Substance Abuse 15(3): 1-14, 2006. (38 refs.)

A convenience sample of young adults (ages 18-25) in New York City was recruited to complete anonymous surveys in social venues (either dance clubs or other social settings, such as coffee shops and university "hangouts") regarding their use of "club drugs" (e.g., MDMA/Ecstasy, GHB, ketamine, crystal methamphetamine, cocaine, and LSD). Participants indicated their frequency of use for each drug and whether or not they had used each drug for the first time in the past six months. A total of 566 surveys were collected and 38.9% of participants reported the use of at least one club drug. Overall, males were significantly more likely than females to report club drug use. There were some differences in club drug use based on sexual orientation, comparing heterosexually identified youth to gay/bisexually identified youth. There were no differences in use among those recruited at dance clubs compared with those recruited from other social venues. The use of club drugs is a growing problem among young adults, as evidenced by the number of participants reporting having tried club drugs for the first time in the past six months. Educational interventions, 'particularly those designed to reach young adults who are just initiating the use of club drugs, are needed.

Parsons JT; Kelly BC; Wells BE. Differences in club drug use between heterosexual and lesbian/bisexual females. Addictive Behaviors 31(12): 2344-2349, 2006. (15 refs.)

Although there has been much empirical research documenting current trends in club drug use among gay and bisexual men, little research has addressed the variance among lesbian, bisexual, or heterosexual women. Using data collected through time-space sampling from dance clubs in New York City during 2005 (N = 1104), this study explored sexual identity variance among women in the reported use of six club drugs: methamphetamine, cocaine, MDMA, ketamine, GHB, and LSD. Significant differences were found in that younger women were more likely to be active club drug users. Lesbian and bisexual women reported significantly higher lifetime rates of ecstasy, cocaine, methamphetamine, and LSD use compared to heterosexual women. These data suggest a need to better understand the influence of sexual orientation and sexual culture in relation to club drug use and to tailor health promotion efforts to meet the needs of various groups of club drug using women.

Proudfoot P; Ward J. Australian Capital Territory Party Drug Trends 2003: Findings from the Party Drug Initiative (PDI). NDARC Technical Report No. 188. Sydney: National Drug and Alcohol Research Centre, 2004. (10 refs.)

This report provides information on the club drugs, their patterns of use, epidemiology, perceived purity, availability, price, perceived benefits and risks, and related crime. The drug classes included in the report are ecstasy, methamphetamine, cocaine, ketamine, GHB, and other drugs (alcohol, cannabis, antidepressants, inhalants, benzodizaepines, and other opiates.)

Proudfoot P; Ward J; Buckingham K; Sparks R. Australian Capital Territory Trends in Ecstasy and Related Drug Markets 2004: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 227. Sydney: National Drug and Alcohol Research Centre, 2005. (23 refs.)

This report deals with ecstasy and the related drug markets. There are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Proudfoot P; Ward J; Staniforth A; Buckingham K. Australian Capital Territory Drug Trends in Ecstasy and Related Drug Markets 2005: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 247. Sydney: National Drug and Alcohol Research Centre (Australia), 2006. (23 refs.)

This report presents the results of an ongoing study monitoring ecstasy and related drug markets within the Australian Capital Territory. It opens with a description of the demographic characterisitcs of regular ecstasy users and patterns of use, including use of the other drugs. The price, purity and availability of ecstasy, the markets, patterns of purchasing, and sources of information about purity and content of drugs, the associated risk behavior, health related issues, criminal activity and market changes are also discussed. Similar data is presented in respect to other drugs commonly used: methamphetamine, cocaine, LSD, ketamine, MDMA, GHB, and drinking patterns. Data is presented in 54 tables and 17 figures.

Rosenberg MH; Deerfield LJ; Baruch EM. Two cases of severe gamma-hydroxybutyrate withdrawal delirium on a psychiatric unit: Recommendations for management. American Journal of Drug and Alcohol Abuse 29(2): 487-496, 2003. (21 refs.)

Many psychiatric professionals are unfamiliar with gamma-hydroxybutyrate (GHB), an increasingly popular drug of abuse. GHB withdrawal can lead to psychosis and agitation, and patients may present to psychiatric facilities for treatment. Withdrawal may progress to delirium, with the potential for severe or even fatal medical complications. Therefore, it is imperative for psychiatric professionals to understand how to treat these patients. In this article, we describe two cases of severe GHB withdrawal syndrome that were treated in our inpatient psychiatric unit. These are among the most severe cases reported. Pertinent literature is reviewed and suggestions for treatment are discussed.

Rosenthal RN; Solhkhah R. Club drugs. IN: Kranzler HR; Ciraulo DA, eds. Clinical Manual of Addiction Psychopharmacology. Washington DC: American Psychiatric Press, 2005. pp. 243-267. (208 refs.)

This chapter deals with the club drugs, which do not represent a single drug class, but are drugs associated with the rave scene. There are sections devoted to GHB (gamma-hydroxybutyrate), ecstasy, and ketamine, a veterinary anesthetic with dissociative properties. For each of these there is discussion of the epidemiology of use, clinical presentation, basic and clinical pharmacology, toxicity, and treatment.

Royal Canadian Mounted Police. Drug Situation Report 2005. Ottawa: Royal Canadian Mounted Police, 2006. (0 refs.)

This report deals provides a strategic overview of the illicit drug trade in Canada. Separate sections are directed to cocaine, heroin, opium, cannabis derivatives, ecstasy/MDMA, methamphetamine, other synthetic drugs (ketamine and GHB, and other controlled drugs), khat. It also includes a section on precursor chemicals, concludes with a summary of drug offenses. Drug seizure data is provided in an appendix. For each of the sections on drugs, key findings related to the substances are outlined, along with the level of demand, the drug source, the means of smuggling, trafficking patterns within the country, and major seizures.

Sorensen JK. Recreational drug use and risk estimation. IN: Lalander P; Salasuo M, eds. Drugs and Youth Cultures: Global and Local Expressions. NAD Monograph No. 46. Helsinki Finland: Nordic Council for Alcohol and Drug Research, 2005. pp. 15-30. (28 refs.)

Despite governmental prevention efforts, young Danes increasingly use illegal drugs when thy go out on weekends, at a variety of locations and events. This study focuses on "techno events" and the drugs used in this context: amphetamines; cocaine, LSD, psilocybin, and the newer drugs such as ecstasy, GHB, and ketamine. The author analyzes how young people in Denmark aim to control their drug use, both in actual fact and in their imagination. This report is based on ethnographic fieldwork. it demonstrates that the young based their conceptions primarily on their own experience, both positive and negative, including their experience of risks involved. The effort is made to understand why young people continue to use drugs despite their awareness of risks.

Summers SA; Glynne PA. Acute poisoning on the medical admissions unit. (editorial). Clinical Medicine 7(3): 277-279, 2007. (19 refs.)

Alcohol intoxication, deliberate medicinal overdoses and ingestion of (illegal) substances are common reasons for admission to emergency departments in the UK, particularly in inner city hospitals. This review discusses problems related to the ingestion of selected toxins. In terms of alcohol, attention here is directed to ethylene glycol, methanol and isopropyl alcohol - each of which can produce fatal intoxication through the ingestion of relatively small doses. The most common medicinal agents involved in overdose are paracetamol and salicylate. As for illicit recreational drugs, the problems of securing an accurate history are noted, along with the limitations of drug testing. The most prominent recreational agents are 3,4-methylenedioxymethamphetamine (MDMA or ecstasy); gamma-hydroxybutyrate (GHB or liquid ecstasy); flunitrazepam (Rohypnol); and ketamine (Ketalar). Each is described, including its presentation and management.

Sumnall AR; Woolfall K; Edwards S; Cole JC; Beynon CM. Use, function, and subjective experiences of gamma-hydroxybutyrate (GHB). Drug and Alcohol Dependence 92(1/3): 286-290, 2008. (35 refs.)

Self-reported use of gamma-hydroxybutyrate (GHB) among clubbers has increased over the last decade, and is often reported in the scientific literature in association with negative events such as amnesia, overdose, and use in drug facilitated sexual assault. However, there has been relatively little work investigating the phenomenology, of GHB intoxication, and the reasons underlying use. In this study, 189 individuals reporting at least one lifetime use of GHB completed an online questionnaire recording GHB use behaviours, GHB use function, and subjective GHB effects. The. most frequently reported primary GHB use functions were for recreation (but not in nightclubs) (18.3%); to enhance sex (18.3%); to be sociable (13.1%); and to explore altered states of consciousness (13.1%). GHB was more commonly used within the home (67%) compared to nightlife environments (26.1%) such as clubs, although this differed on the basis of respondent's sexuality. Principle components analysis of GHB user responses to the subjective questionnaire revealed six components: general intoxication effects, positive intoxication effects, negative intoxication effects, negative physiological effects, positive sexual effects and negative sexual effects. Component scores predicted function of use.

Thai D; Dyer JE; Benowitz NL; Haller CA. Gamma-hydroxybutyrate and ethanol effects and interactions in humans. Journal of Clinical Psychopharmacology 26(5): 524-529, 2006. (24 refs.)

Background: Gamma-hydroxybutyrate (GHB) is a common drug of abuse that can produce serious toxicity, particularly when used with other sedatives. We examined the individual and combined effects of GHB and ethanol in human volunteers. Methods: Sixteen healthy adults (7 men) were given 50 mg/kg GHB (Xyrem), 0.6 g/kg ethanol in 2 doses, alone and combined in a double-blind, placebo-controlled, crossover study. Plasma concentrations, heart rate (HR), blood pressure (BP), and oxygen saturation (O(2)sat) were serially monitored for 24 hours. Results: Adverse events included 2 instances of hypotension and 6 episodes of vomiting with GHB-plus-ethanol ingestion. Oxygen saturation was decreased by GHB and ethanol individually, and maximally decreased by the drugs combined (max -2.1% +/- 0.3%, P < 0.0001 vs placebo). Compared with baseline, systolic and diastolic BP were significantly decreased, and HR was increased by ethanol but not affected by GHB alone (maximum systolic BP change -15.7 +/- 3.0 mm Hg, P = 0.0006; maximum HR change 13.5 +/- 2.3 beats per minute, P = 0.006). Ethanol coingestion resulted in 16% higher GHB maximal plasma concentration and 29% longer elimination half-life, indicating possible enhanced bioavailability or reduced clearance of GHB caused by ethanol, however, these effects were not statistically significant. Conclusions: Modest doses of GHB do not affect hemodynamic function, but O(2)sat was decreased. Gamma-hydroxybutyrate-plus-ethanol resulted in more adverse effects, including gastrointestinal disturbances, hypotension, and decreased O(2)sat, but only minimal pharmacokinetic interactions were observed.

Topp L; Breen C; Kaye S; Darke S. Adapting the Illicit Drug Reporting System (IDRS) to examine the feasibility of monitoring trends in the markets for 'party drugs'. Drug and Alcohol Dependence 73(2): 189-197, 2004. (47 refs.)

Since 1996, the Illicit Drug Reporting System (IDRS), Australia's strategic early warning system for illicit drug trends, has monitored annual trends in the markets for the four main illicit drug classes, cannabis, methamphetamine, cocaine and heroin. In 2000, a 2-year trial was implemented to examine the feasibility of using similar methodology to monitor trends in the markets for 'party drugs'. A triangulation of three data sources was sought: (1) quantitative interviews with a 'sentinel' population of drug users; (2) qualitative interviews with key informants (KIs), or those who have contact with drug users through their work; (3) extant indicator data sources such as the purity of illicit drugs seized by law enforcement agencies. The results suggested that the feasibility of collecting detailed, reliable and valid data about party drug markets is a direct function of the size of those markets. The trial demonstrated that the system would allow the successful monitoring of markets for party drugs that are relatively widely used, such as ecstasy, but would be less sensitive in monitoring markets for party drugs that are used by small proportions of the total population, such as gamma-hydroxy-butyrate (GHB) and ketamine. Methodological issues encountered during the conduct of this trial are discussed, including defining the appropriate sentinel population of drug users, identifying relevant key informants, and the relative absence of extant indicator data sources that could inform our understanding of party drug markets.

Uys JDK; Niesink RJM. Pharmacological aspects of the combined use of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) and gamma-hydroxybutyric acid (GHB): A review of the literature. Drug and Alcohol Review 24(4): 359-368, 2005. (124 refs.)

Epidemiological studies show that the use of club drugs is on the rise. Furthermore, the last few decades have seen a rise in patterns of polydrug use. One of the combinations frequently used is ecstasy (MDMA) with gammahydroxybutyrate (GHB). For effective prevention it is important to be aware of this phenomenon and of the pharmacology of these drugs. The effects of the combination extend to different neurotransmitter systems, including serotonin, dopamine and noradrenaline. Studies investigating the effects of combinations of psychoactive substances are limited. In this review we describe the subjective effects of the MDMA/GHB combination. Furthermore, we review the individual actions of MDMA on serotonin, dopamine and noradrenaline systems. In addition, actions of GHB on these systems are discussed as a possible pharmacological basis for the interaction of both drugs. It is postulated that GHB attenuates the unpleasant or dysphoric effects of MDMA by its effect on the central dopaminergic system.

Van Sassenbroeck DK; De Neve N; De Paepe P; Belpaire FM; Verstraete AG; Calle PA et al. Abrupt awakening phenomenon associated with gamma-hydroxybutyrate use: A case series. Clinical Toxicology 45(5): 533-538, 2007. (43 refs.)

Case reports mention a sudden awakening from GHB-associated coma but do not specify its time course. The aim of the present case series was to investigate the time course of the awakening from GHB intoxication and the relationship to plasma concentrations of GHB and the presence of other drugs. Unconscious (GCS <= 8) participants at six large rave parties who were treated at medical stations were included. Serial blood samples were taken every 10 to 30 minutes for toxicological analysis. At the same time-points, the depth of coma was scored with the Glasgow Coma Score (GCS). Fifteen out of 21 unconscious patients proved to be positive for GHB. Fourteen of these had ingested one or more other drugs. The median GHB plasma concentration upon arrival in the medical station was 212 mu g/ml (range 112 to 430 mu g/ml). In 10 patients the GCS was scored more than twice, allowing study of the time course. The GCS of these patients remained <= 8 for a median time of 90 minutes (range 30 to 105 minutes). The duration of the transition between GCS of <= 8 and >= 12 was 30 minutes (range 10 to 50 minutes). A subgroup of five patients had a GCS of 3 upon arrival and remained at 3 for a median time of 60 minutes (range 30 to 110 minutes), while the median time for the transition between the last point with GCS 3 and the first with GCS 15 was 30 minutes (range 20 to 60 minutes). This case series illustrates that patients with GHB intoxications remain in a deep coma for a relatively long period of time, after which they awaken over about 30 minutes. This awakening is accompanied by a small change in GHB concentrations. A confounding factor in these observations is co-ingested illicit drugs.

Weekley J; Pointer S; Ali R. South Australian Party Drug Trends 2003: Findings from the Party Drug Initiative (PDI). NDARC Technical Report No. 184. Sydney: National Drug and Alcohol Research Centre, 2004. (27 refs.)

This report presents the results of a study to monitor party drug markets in South Australia. Trends of the demographic characteristics and patterns of drug use among party drug users, their criminal behaviour, and perceptions of risks, benefits and harms related to use are presented. The drug classes included in the discussion are ecstasy, methamphetamine, cocaine, ketamine, GHB, LSD, and MDA. There are 75 figures and tables.

Weekley J; Pointer S; Ali R. South Australian Trends in Ecstasy and Related Drug Markets 2004: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 224. Sydney: National Drug and Alcohol Research Centre, 2005. (32 refs.)

This report deals with ecstasy and the related drug markets in South Australia. Following an executive summary there is a brief description of the characteristics of regular ecstasy users. Following are individual sections dealing with ecstasy, methamphetamine, cocaine, ketamine, gamma-hydroxybutyrate, LSD, with data on demographic characteristics of users, drug use history and current use patterns, as well as price, purity, perceived availability, and the perceived risks and benefits of use. Other drug use is also summarized -- alcohol, marijuana, nicotine, benzodiazepines, inhalants and other opioids. Sections are also devoted to associated risk activities including injecting risk behavior, sexual activity, tattooing and piercing, and driving risk behavior; and also health risks, with reports of overdose, symptoms of dependence, and help-seeking behavior. Criminal encounters are also described.

Weekley J; Simmonds L; Ali R. South Australian Trends in Ecstasy and Related Drug Markets 2005: Findings from the Party Drugs Initiative (PDI). NDARC Technical Report No. 255. Sydney: National Drug and Alcohol Research Centre (Australia), 2006. (15 refs.)

The report, part of a national Australian survey, deals with patterns and nature of ecstasy use. It begins with an overview of the demographic characteristics of regular ecstasy users and its use in the general population. The drug trade is also described -- price, purity, availability, ecstasy markets and patterns of purchase -- as well as discussion of ecstasy-related harm, and users perceptions of risks and benefits. There is also discussion of other drug use among regular ecstasy users, with attention to methamphetamine, cocaine, ketamine, GHB, LSD, MDA, as well as ecstasy users use of "other drugs" (alcohol, marijuana, tobacco, inhalants, pharmaceutical stimulants, benzodiazepines, anti-depressants, and magic mushrooms.) In addition there are separate sections that provide information of health-related issues, such as overdose, self-reported symptoms of dependence, help-seeking efforts; criminal activity and perceptions of policing. It concludes with discussion of policy implications of the findings.

White B; Degenhardt L; Breen C. New South Wales Party Drug Trends 2003: Findings from the Party Drug Initiative (PDI). NDARC Technical Report No. 182. Sydney: National Drug and Alcohol Research Centre, 2004. (41 refs.)

Executive summary. Demographic characteristics of party drug users: (PDU): The 2003 results indicate that party drug users, a population defined in this study by the regular use of tablets sold as 'ecstasy' (at least six days of use in the six months preceding interview), tend to be young, relatively well-educated, and likely to be employed or engaged in full time study. Less than one third reported engaging in crime, most of which is infrequent and accounted for by drug dealing. Seven participants were currently in treatment for a drug-related problem, and three participants had previously been incarcerated. Demographic characteristics of party drug users interviewed have changed little since 2000. Patterns of drug use: Participants could be characterised as extensive polydrug users, half of whom nominated ecstasy as their favourite or preferred drug. On average, participants had used ten drugs in their lifetime and had used seven in the preceding six months. Almost all reported lifetime use of alcohol, cannabis, tobacco and methamphetamine powder (speed). The prevalence and frequency of use of other party drugs such as ketamine, GHB and MDA stabilised in 2003 which may suggest that while substantial minorities continue to report recent and lifetime use of these drugs, there are relatively few regular users who have access to these drugs. They may not be as widely or consistently available as ecstasy and therefore the use of these drugs may be opportunistic in nature. There is increasing evidence that the use of ecstasy is widespread and that the market has increased or stabilised. The results of general population surveys (showing an increased prevalence of use over time), increases in arrests for possession or dealing ecstasy, increases in calls to telephone help lines about ecstasy, and reports from regular users, suggest that over time, this group is increasing in size and that ecstasy is being used more heavily. The PDI survey data show that regular ecstasy users score from a range of people and use in a wide variety of locations. All this information suggests that despite Australia's continued effort to reduce both the importation and local manufacture of ecstasy, it has remained readily available in Sydney since 2000. Detailed discussion is provided for different drugs (ecstsy, methamphetamine, cocaine, ketamine, GHB, MDA, and LSD, along with perceptions of ease of access and associated dangers, as well as criminal and police activity. There are 91 tables and figures.

Winger G; Galuska CM; Hursh SR. Modification of ethanol's reinforcing effectiveness in rhesus monkeys by cocaine, flunitrazepam, or gamma-hydroxybutyrate. Psychopharmacology 193(4): 587-598, 2007. (16 refs.)

Background: Although ethanol is frequently used in combination with other psychoactive drugs, the behavioral and pharmacological reasons for this form of polydrug abuse have not been well described. Materials and methods Rhesus monkeys with indwelling intravenous catheters produced intravenous injections of ethanol (50, 100, or 200 mg/kg/inj), flunitrazepam (0.001-0.03 mg/kg/inj), cocaine (0.01 or 0.03 mg/kg/inj), or combinations of ethanol and these drugs or gammahydroxybutyrate (GHB) (1.0 or 3.2 mg/kg/inj) by lever pressing according to a fixed-ratio schedule. The response requirement for each drug or drug combination was increased across sessions (10, 32, 100, 320, or 1,000). The dependent variables were rates of responding maintained by the drug or drug combination and the elasticity of drug demand when consumption was expressed as a function of price. Results Elasticity (P-max) values for each drug varied among the monkeys but retained the same rank order for the monkeys, suggesting a fundamental difference in the animals' apparent sensitivities to the reinforcing effects of the drugs. Combining ethanol with the other drugs did not increase their reinforcing effectiveness. GHB (ineffective in previous studies) did not modify ethanol's reinforcing effects; demand functions for the combination of ethanol and flunitrazepam were slightly less elastic than for ethanol alone, but no different from that for flunitrazepam alone; adding ethanol to cocaine detracted from the reinforcing effectiveness of cocaine. Conclusions: The hypothesis that use of ethanol in combination with sedative and stimulant drugs is due to an ability of ethanol to enhance the reinforcing effects of these drugs is not supported.

Winger G; Woods JH; Hoffmann FG. A Handbook on Drug and Alcohol Abuse: The Biomedical Apects. 4th edition. New York: Oxford University Press, 2004. (Chapter refs.)

This volume addresses the pharmacological, medical and legal aspects of drug abuse. It is directed to students in pharmacology and intended as well as a reference for physicians, and substance abuse clinicians. The volume is organized into 10 chapters. Individual chapters are directed to the following drugs: nicotine, opioids, central nervous system depressants (alcohol, barbiturates, and benzodiazepines); inhalants; Club Drugs (ecstasy, ketamine, and GHB); cannabinoids; and central nervous system stimulants (cocaine, amphetamines, khat, and caffeine). For the discussion of each of these classes there is presentation of the patterns of use, acute effects, chronic effects, mechanisms of action and absorption and metabolism. The final two chapters provide an overview of medical sequelae of drug use, organized by body system, and then pertinent US and international law related to drug use/abuse.

Wong CGT; Gibson KM; Snead OC. From the street to the brain: Neurobiology of the recreational drug gamma-hydroxybutyric acid. (review). Trends in Pharmacological Sciences 25(1): 29-34, 2004. (63 refs.)

Gamma-Hydroxybutyric acid (GHB) is a short-chain fatty acid that occurs naturally in the mammalian brain and is formed primarily from the precursor gamma-aminobutyric acid (GABA). The properties of GHB suggest that it has a neuromodulatory role in the brain and has the ability to induce several pharmacological and behavioral effects. GHB has been used clinically as an anesthetic and to treat alcoholism and narcolepsy. Furthermore, GHB has emerged recently as a major recreational drug of abuse. GHB appears to have dual mechanisms of action in the brain. Biochemical data suggest that the intrinsic neurobiological activity of GHB might be mediated through the GHB receptor, which is separate and distinct from the GABA(B) receptor. However, many of the pharmacological and clinical effects of exogenously administered GHB, including the properties of addiction, tolerance, withdrawal and intoxication, are probably mediated via the GABAB receptor, where GHB might act both directly as a partial agonist and indirectly through GHB-derived GABA.

Wood DM; Warren-Gash C; Ashraf T; Greene SL; Shather Z; Trivedy C et al. Medical and legal confusion surrounding gamma-hydroxybutyrate (GHB) and its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD). QJM. An International Journal of Medicine 101(1): 23-29, 2008. (33 refs.)

Background: Gamma-hydroxybutyrate (GHB) is used as a recreational drug, with significant associated morbidity and mortality; it is therefore a class C drug under the Misuse of Drugs Act (1971). However, its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD) remain legally available despite having similar clinical effects. Aim: The aim of this study was to determine whether the relative proportions of self-reported ingestions of GHB or its precursors GBL and 1,4BD were similar to those seen in analysis of seized drugs. Design and methods: Retrospective review of our clinical toxicology database to identify all cases of self-reported recreational GHB, GBL and 1,4BD use associated with ED presentation in 2006. Additionally all seized substances on people attending local club venues were analysed by a Home Office approved laboratory to identify any illicit substances present. Results: In 2006, there were a total of 158 ED presentations, of which 150 (94.9) and 8 (5.1) were GHB and GBL self-reported ingestions respectively; 96.8 (153) were recreational use. Of the 418 samples seized, 225 (53.8) were in liquid form; 85 (37.8) contained GHB and 140 (62.2) contained GBL. None of the seized samples contained 1,4BD and there were no self-reported 1,4BD ingestions. Conclusions: Self-reported GHB ingestion was much more common than GBL ingestion, whereas GBL was more commonly found in the seized samples. These differences suggest that GBL use may be more common than previously thought and we suggest that there should be further debate about the legal status of the precursors of GHB.

Wu LT; Schlenger WE; Galvin DM. Concurrent use of methamphetamine, MDMA, LSD, ketamine, GHB, and flunitrazepam among American youths. Drug and Alcohol Dependence 84(1): 102-113, 2006. (101 refs.)

Background: The magnitude and the characteristics of the use of methamphetamine, MDMA (Ecstasy), LSD (d-lysergic acid diethylamide), ketamine, GHB (gamma-hydroxybutyrate), and flunitrazepam (Rohypnol) were examined in a probability sample of the U.S. civilian population that included multiethnic urban, suburban, and rural youths aged 16-23 (N = 19,084). Methods: Data were drawn from the National Survey on Drug Use and Health (NSDUH). Logistic regression analyses were conducted to identify the characteristics associated with the use of each of these drugs and of multiple drugs. Results: Approximately 20% of youths aged 16-23 reported having ever used one or more of these drugs. Less than 1% of club drug users used club drugs only, and 82% of them had ever used three or more drug classes. Females were more likely than males to report using multiple club drugs. Recent users of methamphetamine were most likely to be females and adolescents aged 16 or 17. Recent users of MDMA tended to be young adults aged 18-21 and residents of metropolitan areas. Most recent users of LSD were adolescents aged 16-19 and those in low-income families. Ketamine users were primarily employed youths. Staying in school and getting married were associated with decreased odds of club drug use. Club drug use was highly associated with the presence of criminal behaviors and recent alcohol abuse or dependence. Conclusions: Adolescents are more likely than young adults to use multiple drugs. The clustering of multidrug use and alcohol use disorder is a cause of concern.

Zvosec DL; Smith SW. Agitation is common in gamma-hydroxybutyrate toxicity. American Journal of Emergency Medicine 23(3): 316-320, 2005. (56 refs.)

Gamma-Hydroxybutyrate (GHB)-related compounds are most commonly described as depressants, with emphasis on somnolence, obtundation, stupor, and coma (SOSC). We sought to demonstrate the full spectrum of clinical presentations of GHB intoxication, including agitation and other nonsedative effects. Our observational study identified 66 patients with GHB toxicity, 40 of whom manifested agitation; 25 had agitation before or after SOSC, 10 had agitation alternating abruptly with SOSC, and 5 had agitation only. Fourteen presentations also included "bizarre" or self-injurious behaviors. Of 40 presentations with agitation, 19 had stimulant co-intoxicants confirmed by screen (14) or history (5). The remaining 21 patients with agitation were negative for stimulants by screen (12) or history (9). Gas chromatography/mass spectrometry detected GHB in 25 cases; 12 manifested agitation, 4 of which also screened negative for stimulants. Clinicians should broaden their definitions of GHB toxicity to include nonsedative effects such as agitation, combativeness, and bizarre or self-injurious behavior.