Gamma hydroxybutyrate: an ethnographic study of recreational use and abuse.
GHB occurs naturally in the brain, being found in the substantia nigra, thalamus, hypothalamus, cerebellum, and certain areas in the cerebral cortex (Vayer et al. 1988; Bessman & Fishbein 1963; Snead & Morlet 1981). GHB has several different actions in the brain. Most significantly it is a potent central nervous system (CNS) depressant, binding to GABA-B receptors in the brain, though not in the spinal cord (Ito, Ishige & Zaitsu 1995; Bernasconi, Lauber & Marescaux 1992; Marescaux, Vergnes & Bernasconi 1992). It also causes elevations of acetylcholine (Giarman & Schmidt 1963), serotonin (Waldmeier & Dehr 1963), and dopamine (Godbout et al. 1995; Cheramy, Nieoullon & Glowinski 1977; Bustos & Roth 1972) in distinct parts of the brain though various direct and indirect pharmacologic actions. With respect to dopamine, GHB has a biphasic effect, inhibiting dopamine release at low doses and enhancing dopamine release at higher doses (Hechler, Peter & Gobaille 1993; Hechler, Gobaille & Bourguignon 1991). GHB is also associated with increased release of an opioid-like substance in the striatum (Cheramy, Nieoullon & Glowinski 1977) and decreased norepinephrine release in the hypothalamus (Miguel, Aldegunde & Duran 1988). Both effects are likely involved in GHB's sedating and euphorogenic effects.
Clinically GHB has an extremely narrow therapeutic window, with an oral dose of 25 mg/kg initiating REM sleep (Scrima, Hartman & Johnson 1990), and an oral dose of 60 mg/kg inducing coma (Mack 1993). Animal studies have shown lethal doses ranging from 5 to 15 times the dose that causes coma (Vickerks 1984). Combination with other CNS depressants has an additive effect, increasing the risk of coma and death. Recreational use of GHB is common in certain subcultures (Kurtz 2005; Lee et al. 2003), and the narrow therapeutic window makes it extremely dangerous. In 1996 there were 69 reports of GHB-related comas in Texas and New York (Li, Stokes & Woeckener 1998; CDC 1997). The DEA recorded over 9,600 cases of GHB-related overdoses and law-enforcement encounters during the period from 1990 to 2000 (LACES 2002), as well as 68 GHB-related deaths, with additional cases under investigation. In 2000, the DEA listed GHB as a Schedule I drug. However, in 2002, the drug's status changed, and the FDA approved GHB for the treatment of narcolepsy under the name sodium oxybate (brand name Xyrem[R], DEA Schedule CIII). The high addiction potential of this drug and the possibility of causing release in those in recovery from chemical addiction is a cause for concern.
This article is an ethnographic study that employed a semistructured interview to document the subjective experience of recreational GHB users. The purpose of this research is to better understand recreational GHB use and abuse in order to better inform the clinical treatment of GHB addiction.
Subjects were recruited through advertisements in a local newspaper and notices were placed on bulletin boards in three New York City college campuses and three New York City gyms during the summer of 2004. Notices advertised a research study about the GHB experience through anonymous interviews.
A semistructured interview was conducted in person when possible, or over the telephone. The questionnaire asked about demographics, extent of experience using GHB, ways of acquiring GHB, positive and negative experiences with GHB, and perception of an addiction problem with GHB. No monetary compensation was offered, but subjects were given the opportunity to call back the investigators at the conclusion of the study to learn the study results. All subjects were offered referrals for further evaluation and treatment.
The study protocol was approved by the New York State Psychiatric Institute-Columbia University Department of Psychiatry Institutional Review Board, Protocol #3633.
Twenty-one people responded to the advertisements, and 17 people agreed to be interviewed. Reasons for not participating included lack of compensation (one subject) and inability to arrange a convenient time for the interview (three Subjects). See Table 1 for a detailed description for respondents.
Subjects were almost exclusively male, with only one female respondent. Ages ranged from 22 to 50 (mean 31, SD = 7). Subjects were generally well educated, and were students or professionals (two were unemployed nonstudents); occupations included financial analyst, massage therapist, college administrator, and physician. The range of GHB experiences varied widely from experimenting with GHB only once to using "over 150 times."
Settings varied, with most respondents using GHB at parties and clubs. Seven people (41%) reported using GHB at home alone or in intimate settings. GHB was purchased almost exclusively in liquid form, but two people (12%) reported also using powdered GHB, which they mixed into liquids that they orally ingested, and one person reported buying GHB in both liquid and powder forms. The vast majority of respondents reported obtaining GHB from friends, preferring a "trusted source" to supply them with a drug that they felt had a dangerous reputation. Two of the 17 respondents (12%) reported making GHB from chemicals purchased over the Internet, four (24%) reported purchasing from drug dealers, and one (6%) reported buying GHB or related compounds in health-food stores in the past, though he could no longer find it sold legally.
Cost and dose were difficult for subjects to report because of the wide variability in the concentrations of GHB purchased. Those who made their own GHB from Internet kits (n = 2, 12%) estimated single doses were 2-3g. Others reported doses measured in teaspoons, bottle caps, and cubic centiliters (cc's) of liquids with unknown concentrations. Unless the subjects made their own GHB or bought GHB from health food stores, they noted some variability of concentration with each purchase. They reported being cautious of the danger of falling asleep or losing consciousness.
Duration of the subjective experience of intoxication was reported as "short" by all of the respondents, with a mean duration of two hours (SD = 1.1) and a range of one to five hours. Sixteen out of 17 respondents (94%) reported no hangover, while one (6%) reported feeling headaches and increased emotional reactivity the day after using GHB. The short duration and the lack of hangover were cited by many subjects as qualities that made GHB more appealing than other drugs.
The positive experiences most commonly reported by GHB users were increased sexual desire (n = 11, 65%) followed by decreased sexual inhibitions (n = 8, 47%; see Table 2).
Heightened or relaxed mood was the next most commonly reported experience, with seven subjects reporting euphoria (41%) and others using similar descriptors, such as "light" (n = 2, 12%), "dream-like" (n =1, 6%), "giggly" (n = 1, 6%), and "dancing was more fun" (n = 1, 6%). Five subjects reported feeling relaxed (30%), and five reported feeling behaviorally disinhibited (30%). Other similar descriptors included increased self-confidence (n = 2, 12%), decreased self-consciousness (n = 2, 12%), and feeling more powerful (n = 2, 12%). Two people reported feeling an increased sense of power (12%).
A few respondents reported improvement in health, consistent with the common notion in gyms that GHB-induced growth hormone secretion improves health and well-being. Two subjects attributed weight loss, toned muscles, and generally better appearance to their GHB use (12%).
Despite the CNS depressant activity of GHB, several subjects reported enhanced sensory experiences, such as vision, hearing, and touch.
GHB was compared to several other recreational chemicals to describe the high. Seven compared GHB to alcohol (41%), five described it as "like Ecstasy" (30%), two compared it to quaaludes (12%), and one compared it to a "mild heroin" (6%).
Most respondents reported some problems from the CNS depressive effects of GHB. Twelve complained of feeling sleepy or overly sedated (71 %), with three falling asleep when they did not want to (18%) and three reporting complete loss of consciousness (unarousable by friends, 18%) (see Table 3). Notably, one subject who was frightened by the experience of losing consciousness reported that he would still use GHB again because of its powerful sexually enhancing properties. Other commonly reported symptoms of CNS depression included motor incoordination (n = 8, 47%) with one reporting falling and two reporting inability to stand; dizziness (n = 5, 30%); speech problems (n = 5, 30%); and general confusion (n = 4, 24%). One highly experienced drug user reported two additional cases: one friend had a seizure and was hospitalized in a coma; a second friend who was "addicted and constantly high on G" died in a fire after falling into a deep sleep while smoking a cigarette in bed.
Three subjects described the disinhibiting properties of GHB as problematic (18%). One of them reported feeling "too sexual," and one reported being dependent on GHB to be able to have sex.
Other negative effects included nausea and vomiting (n = 7, 41%); sleep disruption, with inability to sleep longer than one to three hours at a time when not using GHB (n = 3, 18%); and body temperature dysregulation (n = 2, 12%).
Motivations for Use
When asked about reasons for trying GHB, the majority of respondents reported trying GHB at the suggestion of a friend or sex partner, sometimes described more generally as "peer pressure" (n = 12, 71%). Four people (24%) perceived GHB as a healthy alternative to other recreational substances because it is naturally present in the brain in small amounts and because of reports that it increases growth hormone levels. Three people (18%) identified "curiosity about the drug" as a motivation to try GHB, even though they had received negative information about it.
Nine subjects (53%) reported that they would use GHB again, some of them despite strong negative experiences, such as losing consciousness in public places or having severely impaired judgment. Most identified enhancement of sexual pleasure to be the primary attraction. One subject (6%) wished to continue GHB as an "antidepressant." Three subjects (18%) were unsure if they would try it again. Five subjects (30%) said they would not try it again. One subject cited the dangerous nature of GHB as a deterrent. Another subject reported feeling "locked in a cycle" of GHB use and wanted to avoid getting "stuck again."
Simultaneous Drug Use
After the first 4 interviews, the topic of simultaneous drug use was added to the questionnaire. All 13 of the remaining subjects reported using GHB together with other drugs, despite a general awareness of the dangers of combining GHB with other substances; however, some waited one to two hours after ingesting GHB as a safety measure. With regard to CNS depressants, five subjects (38%) reported using alcohol, and one reported taking clonazepam while intoxicated with GHB. Three of the people who ingested alcohol reported nausea and vomiting after ingesting a small amount of alcohol (one to two sips), which was a deterrent from repeating the combination. Five (38%) reported using ketamine, though this drug has some centrally activating properties, in addition to its CNS depressant activity.
The drugs most commonly combined with GHB were 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") (n = 7, 54%) and crystal methamphetamine (n = 7, 54%). Both are CNS stimulants, and subjects described them as intensifying the high while counteracting the sedating effects of GHB.
Other drugs used simultaneously with GHB include cannabis (marijuana), lysergic acid (LSD), nitrous oxide, and sildenafil (Viagra[R]).
The sample population was generally drug-experienced. All 13 subjects who were asked about other drugs admitted to use of other recreational substances independent of their GHB use. The most commonly used drug was MDMA (13/13,100%), followed by ketamine (10/13, 77%), cocaine (9/13, 69%), alcohol (6/13, 46%), and crystal methamphetamine (6/13,46%).
Simultaneous Medication Use
A small number of people were taking medications at the time of using GHB. Three participants (18%) were taking medications for anxiety and depression (fluoxetine, St. John's Wort, and clonazepam). One was taking nonprescription anabolic steroids (6%), and two were taking antiretroviral medications for HIV (12%).
Only three subjects (18%) reported feeling that their use of GHB was problematic. Two (12%) were concerned about sexually compulsive behavior and poor judgment. One (6%) was concerned about GHB addiction. No subjects had ever sought treatment for GHB addiction.
The majority of respondents reported a problem with addictive disorders, with 11(65%) reporting some addictive or abusive drug use history. Problem drugs included cocaine (n = 3, 18%), alcohol (n = 3, 18%), methamphetamine (n = 3, 18%), MDMA (n = 2, 12%), marijuana (n = 2, 12%), heroin (n = 1, 6%), and prescription drugs (n =1, 6%). One subject (6%) reported a problem with drugs in general. One subject (6%) felt that GHB led him to become curious about other "hard" drugs, serving as a gateway to experiment with many other substances.
GHB and Sex
Fifteen of the respondents (88%) reported feeling intensified sexual desire and pleasure while using GHB. The two subjects who reported no sexual enhancement had never tried GHB in sexual situations (both were heterosexual men who had never been with women while intoxicated). Twelve of the subjects (71%) reported having sex while high on GHB. Nine subjects (53%) reported that they were less likely to take precautions to protect themselves from HIV and other sexually transmitted infections (STIs) on GHB. Three (18%) reported having unprotected intercourse while high, with two (12%) of those stating that it was the first time they had had unsafe sex. One subject said he was at greater risk of unsafe sex, not because of clouded judgment, but because he became unconscious and awoke to find his sexual partner performing unsafe sex on him.
Perception of GHB in the Community
Most respondents felt that GHB was not a popular drug, with 12 (71%) describing it as rarely used. However, four subjects (24%) described GHB users as being very secretive, even when among other experienced polydrug users. They surmised that GHB use is much more popular than the general population believes.
Most subjects received their information about GHB from friends or by word of mouth. Seven (41%) reported using the Internet. Three subjects (18%) learned through self-experimentation, and two (12%) received most of their education from their drug dealers.
The Experience of GHB
Please see Table 4 for a representative sample of direct quotations about the GHB experience from the study participants.
GHB is a drug with significant potential for abuse, addiction, and toxicity. Though GHB has a highly negative reputation even within the drug-using community, it is still being actively abused. Because GHB is now legally available as sodium oxybate (brand name Xyrem[R])for the treatment of narcolepsy, there is the possibility of medication abuse, development of addiction, trigger of relapse onto other drugs of abuse, and diversion of sodium oxybate to underground markets.
Individuals using GHB are diverse, including students, unemployed people, and highly educated professionals. The age range of respondents also suggests a diverse group, ranging from 22 to 50 years old in this study. It is unclear if the overwhelmingly male sample is a true reflection of GHB users or a result of sample bias. A major recruitment site was gyms, where men seeking purported muscle building supplements may be overrepresented. The sample size is too small to draw statistical conclusions about the demographics of GHB users or the prevalence of specific motivations and consequences related to GHB use. Rather, this ethnographic pilot study sought to identify salient issues that can be further explored in subsequent larger-scale studies.
Subjects consistently reported CNS depression as a negative consequence of GHB use. However, the severity of CNS depression varied widely, from "mildly bothersome" to "severe," including loss of consciousness and significant impairment of judgment. More disturbingly, even this small sample was able to capture reports of GHB users who experienced seizure, coma, and death.
The attraction to GHB use is compelling, ameliorating negative affective states and enhancing sexual experiences. The sexual appeal of GHB is so strong that despite losing consciousness twice in public places, one subject in this study still wanted to use GHB specifically for its sexual properties.
The difficulty for subjects to describe the cost and the amounts that they ingested indicates the wide variability of GHB on the street market. This variability combined with the extremely narrow therapeutic window of the drug and the substantial risk of overdose makes GHB a matter of particular concern.
GHB is commonly mixed with other drugs, both recreational and prescribed, which could significantly increase the drug's toxicity. Several users have tried combining GHB with other depressants despite knowledge that this is a potentially fatal combination. Co-administration with prescription medications that slow the metabolism of GHB can increase toxicity. Considering GHB's narrow therapeutic window, a small increase in serum levels could change a typically recreational dose to one that causes loss of consciousness, respiratory depression, and coma. Additionally, the combination of GHB with stimulant drugs such as crystal methamphetamine (Lee 2006; Levounis & Ruggiero 2006) and cocaine increases toxic exposure to the Stimulants--more of the stimulant can be ingested because of the sedating effects of GHB.
GHB and Drug Addiction
This study sample is a highly drug-experienced group with all respondents using several drugs on a regular basis. Most had already tried other drugs before experimenting with GHB, though one respondent felt that GHB was his "gateway" to experimenting with "harder drugs." It is not clear if this a particular risk of GHB or if it is similar to other substances, with which initial use of one illegal substance erodes the psychological barrier to try other nonsocially-sanctioned substances.
The majority of subjects reported behaviors consistent with GHB abuse or dependence, such as continued use despite negative consequences, compulsive use, lack of control with inability to stop using, and withdrawal effects of increased anxiety, depression, and mood lability. One respondent plans to use GHB to self-medicate his underlying depressed mood. Though most subjects did not report enough symptoms to meet the full DSM-IV TR criteria for substance dependence (GHB dependence is coded in the DSM-IV-TR as "Sedative, Hypnotic, or Anxiolytic Dependence," 304.10; APA 1994), this diagnosis was not directly and fully assessed. Three respondents subjectively felt that they had problematic use of the drug, though none of them sought medical assistance or drug counseling.
GHB and Sex
Subject responses shed further light on the use of GHB as a date-rape drug, with one person losing consciousness to find someone was having unprotected intercourse with him and several others stating that they had sex with people they ordinarily would not consider as sexual partners. If GHB were used as a date-rape drug, the victim would not necessarily need to lose consciousness to participate in sexual activity with a sexual predator--the hypersexual effect of the drug could act like a "love potion" that would sway an otherwise unwilling person to have sex.
Risk of HIV and other STD transmission
GHB could potentially increase risk of transmission of HIV, as well as other STIs. Most GHB users felt that they would be less likely to take protective precautions, and two said that this was the first time they had ever had sex without condoms. GHB users who fall unconscious are unable to make any judgment about safety precautions.
Potential problems with this study include the small sample size, which lacks statistical power to estimate the prevalence of the issues identified. Because of the recruitment methods, there was a strong selection bias toward men, though anecdotal reports by some study participants strongly suggest a significant number of females who use GHB. Drug effect, appeal, usage patterns, and abuse potential among women could differ substantially from the predominantly male population surveyed.
The investigators suggest a larger scale study with a broader recruitment method to obtain prevalence data. Formal addiction scales would allow a better assessment of the prevalence and the potential for addiction to GHB. Urine toxicology screens would validate subjects' self-reports of drug use. Monetary compensation for participation may also attract younger and lower-income adults who may have been underrepresented in this study.
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Steven J. Lee, M.D., Assistant Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY
Petros Levounis, M.D., M.A., Director, The Addiction Institute of New York, New York, NY; Chief, Division of Addiction Psychiatry, St. Luke's and Roosevelt Hospitals, New York, NY; Assistant Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY
Please address correspondence and reprint requests to Steven J. Lee, M.D.,130 West 19th Street, New York, NY 10011; email: Steven10011 C hotmail.com
TABLE 1 Description of the 17 Study Participants Interview Number Age Gender Occupation Settings 1 32 M Investment Clubs, Advisor parties, sex 2 31 M Unemployed No data 3 40 M Massage No data Therapist 4 50 M Footwear Clubs, designer parties, sex 5 24 M College Bars, clubs administrator small social gatherings 6 32 M Editor for HIV Clubs, publication parties, sex 7 25 M Student, Sex receptionist 8 22 M Student, With friends receptionist privately 9 29 M Publicist No data 10 24 M Physical Friend's Therapist home 11 22 F Student Parties, music industry scene 12 33 M Human Res. Clubs, consultant beach 13 27 M Unemployed Friend's home, beach 14 31 M Human Res. Home with manager boyfriend 15 32 M Psycho- Circuit therapist parties, small gatherings sex 16 33 M Biochemist Discos, bars, beach, alone at home 17 42 M Medical Home, Doctor clubs, beach Interview Quantity Safer Sex Number Source (Per Dose) Sex on GHB on GHB 1 Internet 3 grams Yes Only time unsafe was on GHB 2 No Data 2.5 tbs No N/A 3 Dealers 1/2 tsp Yes Have had powder, unsafe sex 1-2 tsp on GHB liquid 4 Friend Unknown No N/A 5 Friend 2-4 cc No N/A 6 Friend 1/2 vial Yes Same 7 Sex partner Unknown Yes Same 8 Father of 1 tsp to Yes Don't know girlfriend 1 Tbs 9 Dealer Varied-- Yes Less in clubs different or local bottles had dealer different effects 10 Friend's 1/2 capful No N/A gnest 11 Dealers 2-3 capfuls Yes Same 12 Friend 2-3 tsp Yes Less 13 Dealer 2-3 capfuls Yes Less 14 Friend 2 oz Yes Was not safe when used GHB 15 Friends 2-3 glass Yes Same vials 16 Internet, 2-3 grams Yes Less * health food stores in the past 17 Friend 1 Tbs No N/A N/A = Not Applicable * "I wouldn't haue unsafe sex, but I passed out during sex and the other person was not using a condom." TABLE 2 Positive Effects From GHB Number of Subjects Reporting Effect the Effect Sexual Effects Enhanced Sexual Experience/Increased Libido 11 Decreased Sexual Inhibitions 8 Elevated Mood Euphoria 7 Feeling Light 2 Dancing More Fun 1 Dream-Like 1 Giggliness 1 Anxiolytic Effects Disinhibition 5 Sedation/Calm 5 Pleasant Mood 3 Increased Confidence 2 Decreased Self-Consciousness 2 Feeling Powerful/Stronger 2 Social Interactions Increased Social Bonding/Closeness 4 Increased Speech/Expressiveness 3 Improved Health Weight Loss, Better Appearance, Toned Muscles 2 Increased Alertness (Early Effect) 2 General Improved Health 1 Cleanliness 1 Diminished Acne 1 Special Senses Enhanced Senses (Vision, Hearing Touch) 4 Tingling Sensation 2 Miscellaneous More Openness to Spiritual Messages 1 Numbness 1 TABLE 3 Negative Effects From GHB Number of Subjects Reporting Effect the Effect CNS Depression Oversedation/Sleepiness 12 Somnolence 3 Loss of consciousness 3 Mental Cloudiness, Confusion 4 Poor Judgment 4 Difficulty Speaking 3 Motor Incoordination (One Fell, Two Could Not Stand) 8 Dizziness 5 Disinhibition 3 Slowed Respirations 2 Slurred Speech 2 Twitching/Tremor 2 Impaired Memory 1 Slowed Heart Rate 1 Coma 1 * Death (Sleeping In A Fire) 1 * Seizure 1 * Increased Appetite 2 Sexual Effects Hypersexuality ("Oversexed") 1 Dependence on GHB for Sex 1 Miscellaneous Sleep Disruption (1-3 Hour Sleep Intervals) 3 Bad Taste 2 Bluny Vision 2 Crash/WD with Fatigue, Low Mood 2 Nausea/Vomiting 7 Feeling Warm/Overheated/Sweating 2 Auditory and Visual Hallucinations (with LSD) 1 Crossed Eyes 1 Delayed Orgasms 1 Emotional Reactivity (Crying More Easily) 1 Headaches 1 Palpitations 1 Esophageal Erosion 1 * * Effects experienced by friends of subjects while they were using GHB TABLE 4 The GHB Experience: Direct Quotations from GHB Users Sensation 1. It's incredible ... you feel slightly drunk, very sensual. It's like you're drunk on G, but not sloppy drunk. Very sexually disinhibited. Sometimes it's embarrassing and increases erections. It makes me feel very horny. 2. After taking it, I feel an overwhelming need for sex. 3. It put me in a good mood. I felt euphoric, like when Ecstasy is kicking in. 4. It was a little like alcohol, heroin, and Ecstasy. I felt warm and a little drowsy. It's NOT as extreme as heroin. It makes you really relaxed, gets rid of your paranoia. 5. I didn't enjoy it. I did it because I had so much of it and wanted to get rid of it. I don't think it's addictive. Cognition 1. I would lose my train of thought, like "What did I just say?" I would daydream things and then start talking in the daydream, and then I would realize I'm talking out loud. It was like falling asleep and going into a dream and going into REM. Judgment 1. A potential problem is that when I use GHB, if I want to have sex with someone, I'll do things I don't think are good, like have sex with someone who is dating my friend. 2. The one time I had sex without a condom, it was while I was on GHB. If there are condoms around, it wouldn't keep me from using condoms, but if there were no condoms ... 3. I had sex on it with a woman I got very attached to. She wasn't the type that I normally would have gotten so attached to. I think the GHB made me very emotional. It definitely increased the length of time I had sex. Physical Symptoms 1. It really messed up my motor skills, I'd bump into things. I felt dizzy, clumsy, and I'd fall. 2. Sometimes I get palpitations. Once I took too much and was vomiting. Sometimes I felt hot, and I sweated a lot. Withdrawal 1. When I wake up, I feel completely refreshed. In comparison to the other drugs that are supposed to be "clean," GHB really is clean. 2. After I do GHB, when I try to sleep, my sleep is fitful, I can't stay asleep, and I can only sleep in 20-minute intervals. The next day I feel sleep-deprived. 3. After I tried to stop taking GHB, I became depressed and cried. The depression started high and then gradually got better over a month.
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|Author:||Lee, Steven J.; Levounis, Petros|
|Publication:||Journal of Psychoactive Drugs|
|Date:||Sep 1, 2008|
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