Commentary on Bell & Collins (2011): Out-patient management of gamma-hydroxy butyric acid (GHB) withdrawal – an alternative strategy for the future?


The paper by Bell & Collins [1] adds an important perspective on the management of detoxification with the party drug gamma-hydroxy butyric acid (GHB) and its physiological precursor gamma-butyrolactone (GBL) in an out-patient setting. A couple of points deserve careful consideration when interpreting the data of this highly interesting case report series.

First and foremost, the fact that a significant amount of the data rely on self-report deserves careful consideration. Secondly, as stated in the paper [1] there are only few data available on the use of GHB and its precursors in adolescents. Despite publication of one case report of a 16-year-old patient with acute withdrawal symptoms, and a review on clinical implications for child psychiatrists [2,3] there is limited evidence on treatment strategies for both acute intoxication and also acute withdrawal delirium in younger patients. It is important to note that such a case series as published by Bell & Collins could not be carried out in adolescents, in particular because of ethical issues. Moreover, dosage of drugs for treatment of acute GHB/GBL withdrawal delirium in adolescents cannot be transferred from the adult literature [4].

From a clinical viewpoint, management of GHB/GBL detoxification in an out-patient setting requires a high amount of compliance by the patients, a feature which is somewhat problematic in frequent drug users. In the mentioned paper, incomplete follow-up, unanswered phone calls and erratic attendance at clinical appointments are just a few examples of this crucial issue. Following this, with respect to the existing literature, in-patient care still seems to be the primary setting to handle GHB/GBL detoxification, in particular when considering that the transition from overdose to withdrawal can be rapid, but also in the light of serious complications associated with GHB/GBL withdrawal such as acute renal failure and cardiac arrhythmia.

However, as shown by Bell & Collins [1] out-patient management can be an alternative option, in particular when considering that a significant number of patients in the mentioned case report series refused admission to an in-patient setting (17 of 19 patients). As stated by Bell & Collins, in 82% of cases in a previous case report series detoxification commenced unplanned [1,5]. This raises the question of whether planned detoxification in an out-patient setting is superior to unplanned detoxification beginning in an emergency department (which is often the case) with respect to compliance, lapses to GHB/GBL use and successful completion of withdrawal. Such studies would be of particular value in order to provide more effective future strategies for intervention for patients presenting with GHB/GBL abuse.

Declaration of interests

The author was the recipient of an unrestricted award donated by the American Psychiatric Association (APA), the American Psychiatric Institute for Research and Education (APIRE) and AstraZeneca (‘Young Minds in Psychiatry Award’). He has also received research support from the Federal Ministry of Economics and Technology (Bundesministerium für Wirtschaft und Technologie), the German Society for Social Pediatrics and Adolescent Medicine (Deutsche Gesellschaft für Sozialpädiatrie und Jugendmedizin, DGSPJ), from the Paul and Ursula Klein Foundation, the Dr August Scheidel Foundation, and a travel stipend donated by the GlaxoSmithKline Foundation.