Research Paper
Going knock—Recurrent comatose GHB intoxication in the Netherlands & Flanders (Belgium)

https://doi.org/10.1016/j.drugpo.2018.06.010Get rights and content

Highlights

  • GHB overdose is a growing concern in the Netherlands.

  • Those most experienced with GHB seem most at risk while stacking doses and using alone are important risk factors for GHB coma.

  • Collective use in leisure contexts seems to offer a level of protection against GHB overdose.

  • Recurrent GHB coma is more common in provincial communities and a minority of daily consumers deliberately induces overdose during the night.

  • Stabilizing heavy consumption patterns and reducing overdose and other harms should be prioritized in responding to heavy GHB consumption.

Abstract

Background

Gamma-hydroxybutyrate (GHB) overdose is an important concern in the Netherlands and Flanders, Belgium and accounts for most overdoses reported by emergency services. Few stu dies have focused on GHB overdose. Appropriate public health responses have yet to be developed. We report an explorative survey of people who use GHB and their experience with GHB overdose, aiming to identify risk and protective factors associated with comatose intoxication after GHB ingestion.

Methods

We conducted a cross-sectional survey of GHB consumers from different GHB consumption contexts. Between May and October 2014, 146 respondents were recruited in both the urban Randstad and in smaller towns in the Netherlands and Flanders, using a variety of sampling methods. Descriptive statistics were used to describe demographic, social economic, drug use, environmental variables and the experience of overdose and GHB induced coma in the resulting convenience sample. Multivariate CHAID (Chi-quadrat automatic interaction detector) was used in exploring interactions with overdose.

Results

All study respondents were poly drug consumers. We identified several factors associated with coma. The strongest relationship was found between coma and the lifetime number of GHB consumption episodes. Using alone, the number of doses per consumption episode (stacking) and the living region were strongly associated with GHB overdose as well. In the Netherlands, heavy, high risk GHB consumption is primarily found among poorly educated young adolescents in economically less privileged provincial communities.

Conclusions

We found extremely high rates of comatose intoxication after GHB use and the strongest association with GHB overdose concerned the lifetime number of GHB consumption episodes. Poly-drug consumption appears to be the norm in our entire sample, but does not necessarily distinguish heavy or high risk consumption from more recreational use. Using in the company of friends may offer some level of protection against GHB overdose. Overdose prevention, stabilizing heavy and harmful drug consumption patterns and reducing the harms associated therewith should become an important priority in the Dutch response to GHB.

Introduction

Overdose is a principal cause of death among people who use illicit drugs (Centers for Disease Control and Prevention, 2017; Davoli et al., 2007; Mathers et al., 2013), primarily affecting people who use opioids in their most productive years (Australian Bureau of Statistics, 2017; European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2017); Hedegaard, Warner, & Minino, 2017; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2017). Most of these preventable deaths are attributed to opioids, illegal or prescribed, but a substantial part of reported overdose deaths concerns or includes benzodiazepines or other non-opioid drugs. Often several substances are implicated (Centers for Disease Control and Prevention, 2017; European Monitoring Centre on Drugs and Drug Addiction, 2015).

Belgium, The Czech Republic, the Netherlands and the United Kingdom, as well as the USA have recently seen increases in the use of Gamma-hydroxybutyrate or GHB (European Monitoring Centre for Drugs and Drug Addiction, 2011; Palamar, Martins, Su, & Ompad, 2015; Wu, Schlenger, & Galvin, 2006). Compared to opioids, few lethal overdoses are associated with GHB, but non-lethal overdose, referred to among regular consumers as “going knock”(out), is reportedly very common (Chin, Kreutzer, & Dyer, 1992; Degenhardt & Dunn, 2008; Duff, 2005b; Korf, Nabben, Leenders, & Benschop, 2002).

GHB is a comparatively cheap liquid drug, used orally and easily synthesized without laboratory equipment by mixing sodium hydroxide and lukewarm water into Gamma Butyrolactone or GBL, its legal precursor (Brunt & Schrooten, 2014; Hearne, Alves, Van Hout, & Grund, 2017). Consumers attribute a range of positive effects to GHB, including increases in energy, euphoria, disinhibition, relaxation, self-confidence, sociability, sensuality and sexual arousal (Camacho, Matthews, Murray, & Dimsdale, 2009; Degenhardt, Darke, & Dillon, 2002; Korf et al., 2002; Sumnall, Woolfall, Edwards, Cole, & Beynon, 2008). Shortly after ingestion, people may however, experience drowsiness, dizziness, shallow breathing, slow heart rate, low blood pressure, nausea or vomiting (especially when combined with alcohol) (Chin et al., 1992; Korf et al., 2002; Korf, Nabben, Benschop, Ribbink, & van Amsterdam, 2014; Li, Stokes, & Woeckener, 1998; Schep, Knudsen, Slaughter, Vale, & Mégarbane, 2012; Thai, Dyer, Benowitz, & Haller, 2006). GHB consumers may quickly slide into heavy sedation and profound coma, with resultant loss of bowel/bladder control, headaches, amnesia, convulsions (when combined with stimulants in particular), (Chin et al., 1992; Li et al., 1998; Thai et al., 2006) and, finally, bradycardia and cardiac arrest (Schep et al., 2012). Symptoms are compounded when GHB is used in combination with depressants such as alcohol or benzodiazepines (Corkery et al., 2015; Zvosec, Smith, Porrata, Strobl, & Dyer, 2011). An antidote, such as naloxone for opioid overdose, is unlikely to be available anytime soon (Degenhardt, Darke, & Dillon, 2003).

Recurrent GHB overdose may cause serious neurotoxic harms at the level of memory and cognitive functioning similar to binge drinking or high dose ketamine use (van Amsterdam, Brunt, McMaster, & Niesink, 2012). Regular intake of GHB can quickly lead to dependence and severe withdrawal symptoms (Galloway et al., 1997), causing anxiety, paranoia, hallucinations, fever, tremor, fast heart rate and abnormal eye movements for weeks (Perez, Chu, & Bania, 2006; van Noorden, van Dongen, & Zitman, 2009), with sometimes life-threatening complications (Veerman, Dijkstra, & Liefting-Kluft, 2010). Globally, there were around 400 deaths associated with GHB described in the clinical literature in 2010 (Knudsen, Greter, & Verdicchio, 2008; Zvosec & Smith et al., 2010; Zvosec et al., 2011). As with opioids, GHB associated death usually coincides with ingestion of other drugs, such as alcohol, depressants and/or stimulants (Aromatario, Bottoni, Santoni, & Ciallella, 2012; Corkery et al., 2015; Thai et al., 2006; Wisselink & Mol, 2013; Wisselink, Kuijpers, & Mol, 2014). The actual role of GHB in GHB-related deaths is hard to establish. The drug is rapidly metabolized (half-life: 22–53 min), may be formed spontaneously post-mortem and is detectable in bodily fluids for a short period of five to twelve hours only (Kintz, Villain, Cirimele, & Ludes, 2004; Verstraete, 2004), complicating timely collection of post-mortem specimens, potentially resulting in underreporting (van Laar et al., 2014).

In 2009, an estimated 144,000 Dutch people, aged 15–64 years, had ever used GHB, or 1.3%. 22,000 people used GHB in the last month (van Laar et al., 2014); Belgian population estimates are not available. In a 2013 web survey, 21.8% of regular nightlife participants aged 15–35 years in the Netherlands had ever used GHB and 5.1% did so in the last year (Goossens, Frijns, van Hasselt, & van Laar, 2014). Among Flemish visitors of clubs, dance events and “(mainstream) (rock) festivals,” lifetime and last year GHB consumption were 6.8% and 3,2% in 2011 (Brunt & Schrooten, 2014) and 10.0% and 3.3% in 2012 (Wetenschappelijk Instituut Volksgezondheid, 2013). But that same year, visitors of peer information and support stalls (e.g. at festivals) reported 22.3%–22.8% lifetime and 8.3%–10.6% last year GHB consumption (Brunt & Schrooten, 2014). GHB use is particularly high in the Netherlands compared to other European countries or Australia, but more recently rising prevalence of GHB use is observed in both regions (Brennan & Van Hout, 2014; Degenhardt & Dunn, 2008; Horyniak et al., 2014).

In the Netherlands, heavy (Rehm et al., 2013) or high risk (Thanki & Vicente, 2013) GHB consumption is largely concentrated in 'hotbeds' of problematic GHB-consumption in Noord-Brabant, Flevoland, Twenterand and Friesland (marked in purple in Fig. 1.) (Wisselink & Mol, 2013). Between 2007 and 2012, addiction services in the Netherlands were confronted with over a twelvefold increase in treatment demand from people with primary GHB problems (from 60 to 761) (Wisselink & Mol, 2013). After 2012, GHB treatment demand levelled off with 837 people in 2015, representing 1% of people in addiction care (Wisselink, Kuijpers, & Mol, 2016). In early 2015 GHB treatment researchers estimated the number of people dependent on GHB in the Netherlands between 2000 and 3000 (Harmen Beurmanjer, personal communication), but the actual number remains unclear in the Netherlands. 60% of those requesting treatment in 2013 with a primary diagnosis of GHB dependence reported secondary drug use, amphetamines and cocaine in particular (20%) (Wisselink et al., 2014). In Belgium, GHB use and treatment episodes are primarily reported in Flanders, the northern, Dutch speaking part of the country. In Flanders, 78 treatment episodes were registered in 2011 and 65 in 2012; over 60% of treatment participants also used amphetamine (Wetenschappelijk Instituut Volksgezondheid, 2012, 2013). In all of Belgium, 475 treatment registrations (representing 1% of people in treatment) mentioned GHB in 2015, 'but it is unclear whether this is the primary reason for seeking treatment (Wetenschappelijk Instituut Volksgezondheid, 2016).

GHB accounts for the largest portion of non-fatal overdoses reported by Dutch emergency services (Vogels, Croes, & Van der Pol, 2013). Of all drug related incidents involving a combination of drugs reported by emergency rooms, ambulance services, police medics and first aid stands at (dance-)events, GHB combined with XTC was most commonly cited. 84% of GHB treatment entrants in the Netherlands had ever experienced loss of consciousness after taking GHB, 43% had been admitted to an emergency medical department (between 1 and 12 times) and 20% had ever been treated in an intensive care unit (Dijkstra, de Weert-van Oene, Verbrugge, & de Jong, 2013). In 2012, GHB was mentioned in thirteen ‘cause of death’ certificates, registered by Statistics Netherlands, an increase over the previous years and the Netherlands Forensic Institute (NFI) reported GHB as the primary cause of death in two cases of post-mortem drug testing in 2012 and in seven cases in 2013 (van Laar et al., 2014).

Section snippets

Methodology

Prompted by these concerns and the relatively high rates of GHB consumption in the Netherlands, we conducted a multi-method study on GHB overdose, exploring socio-demographic, drug use and other personal characteristics of people at risk of GHB overdose, as well as environmental factors in GHB use that may aggravate or alleviate the risk of overdose (Zinberg, 1984). The primary aim of our study was to inform the development of tailored drug policy responses. Improved understanding of the

Social demographics

Over one-fourth (28%) of the respondents were female and the mean age was 28 years, ranging from 15 to 53 years. Flemish respondents were somewhat older (31.5) than those living in (30) or outside (26) the Dutch Randstad. 41% of the Dutch respondents lived in the Randstad and 59% outside of the metropolitan area. 38% of the respondents was not in employment, education or training at the time of interview (Table 1).

Substance use

98% of the respondents took GHB in the last year and 64% did so in the last

Discussion

Presenting findings from a survey of 146 GHB consumers, this is the first EU study to focus on the relations between GHB overdose and drug use, personal and environmental factors, providing an initial basis for indexing the experiences with GHB overdose in its diversity and for informing the development of harm reduction, prevention and treatment interventions. Our study did not aim to estimate the population prevalence of GHB coma but to improve our understanding of the risk and protective

Study limitations

As other studies of hard to enumerate populations, our study relied on self-reported data from a non-random sample. Comparison with previous studies and Dutch national treatment data suggests that our sample may represent a larger spectrum of GHB use patterns, including both recreational and many heavy consumers of the drug. As most respondents were Dutch, we do not know in how far our results apply to other populations of people who use GHB, Belgium or elsewhere.

Conclusions

We report extremely high rates of comatose intoxication after GHB use. In our study the strongest association with GHB overdose concerned the lifetime number of GHB consumption episodes. Using in the company of friends offers some level of protection against GHB overdose. Using alone and stacking of doses increased the risk for GHB overdose.

In the Netherlands, these high risk consumption patterns are more common among poorly educated young adolescents in economically less privileged provincial

Conflicting interests

None of the authors have financial/personal interest or beliefs that could affect his/her objectivity on the research presented.

Acknowledgements

This study is part of the ‘Overdose prevention among hard-to-reach users of non-opioid substances’ project of the Mainline foundation, funded by the European Commission (JUST/2013/DPIP/AG/4795) and the Dutch Mental Health Foundation (Fonds Psychische Gezondheid)HH/2013 6791.

We like to thank the study respondents who shared intimate details on their drug consumption and life with us. Important contributions at various points in this study were made by Alex van Dongen, Novadic-Kentron, Vucht; Ton

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