Management of GHB withdrawal

Heavy or regular (eg daily) use of GHB (or precursors) can lead to dependence. As GHB has a short half-life, people who use it very regularly may be taking multiple daily doses (some every few hours). Symptoms of GHB withdrawal in a dependent person can start within 1 to 4 hours of stopping. Advise patients not to attempt to reduce or stop their GHB use without medical advice because it is difficult to make even small dose adjustments without risking unplanned withdrawal.

Common symptoms of GHB withdrawal include anxiety, agitation, sweating, tremor, tachycardia, hypertension, hyperthermia, cravings and insomnia. Severe withdrawal can cause myoclonus, bradycardia, autonomic instability, perceptual disturbance, auditory or visual hallucinations, confusion, acute delirium, seizures, rhabdomyolysis and renal impairmentPhan, 2020Tay, 2022.

Factors that predict severe GHB withdrawal includeFreeman, 2022NSW Health, 2022Tay, 2022:

• frequent dosing (eg less than 4 hourly), including waking at night to dose
• higher doses (eg more than 15 mL GHB in 24 hours)
• previous severe withdrawal
• no days without use in the previous 6 weeks
• concurrent use of a stimulant (eg metamfetamine); this increases seizure risk on withdrawal from GHBPhan, 2020.

Patients planning managed withdrawal who are at risk of severe withdrawal or those with significant concurrent medical or mental health problems should be managed in hospital. Severe GHB withdrawal may require treatment in an intensive care unit. See Withdrawal management in disorders of substance use for considerations in ensuring safety in choice of environment, prescribing and the supply of medications for substance withdrawal. Seek specialist advice regarding any concerns about evaluating these factors.

Benzodiazepines are the primary treatment for GHB withdrawal. Dosages depend on the severity of withdrawal.