Experiences of Gamma Hydroxybutyrate

8/9/2019 Experiences of Gamma Hydroxybutyrate

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EXPERIENCES OF GAMMA HYDROXYBUTYRATE (GHB) INGESTION: AFOCUS GROUP STUDY

Judith C. Barker ,1 Shana L. Harris,1 and Jo E. Dyer 2

Author information ► Copyriht and Li!ense information ►

"he pu#$isher%s fina$ edited &ersion of this arti!$e is a&ai$a#$e at J 'sy!hoa!ti&e Drus

See other arti!$es in '(C that !ite the pu#$ished arti!$e.

Abstract

)o to*

INTRODUCTION

Until recently, gamma hydroxybutyrate (GHB) and its chemical analogs, butanediol and gamma

butyrolactone, were readily available and cheap to purchase through Internet sales and in

nutrition stores. abeled as dietary supplements, they claimed to enhance muscle growth, aid

sleep, and improve sexual per!ormance ("nead # Gibson $%%&). GHB was ' approved in

$%%$ as a therapeutic agent !or cataplexy. *he analogs are available !or a range o! legitimate

commercial uses, !or example, as industrial solvents, paint strippers, and !lavoring agents.

*hroughout the last decade, however, various state and national drug monitoring systems,

emergency departments, health care pro!essionals, drug counseling services, and law

en!orcement agencies noticed a precipitate rise in patients presenting !or medical care a!ter

overdose or chronic use o! GHB (+ompton et al. $%%& "nead # Gibson $%%& -vosec # "mith

$%%& "porer et al. $%%yer # Haller $%%/ 0iotto et al $%%/ -vosec et al. $%%/ +hin et al.

/112). 3esponding to escalating evidence o! abuse, GHB was legislated a "chedule I controlled

substance in $%%%, leaving a provision !or approved drug products in "chedule III.

GHB is a naturally occurring substance in the body. 4hysiologic activity at endogenous levels

remains unclear and levels achieved with exogenous administration have activity at GHB and

GB5B receptors ("nead # Gibson $%%&). 4rominent e!!ects seen a!ter GHB ingestion begin

with euphoria, sedation, memory loss, nausea, and vomiting, and escalate with dose to produce

agitation, myoclonus, bradycardia, respiratory depression, and coma. number o! deaths have

been attributed to GHB ingestion or a!ter co5ingestion o! other illegal substances or alcohol

(yer # Haller $%%/ -vosec et al. $%%/), death occurring !rom accident, in6ury, and respiratory

compromise. 4eculiar to GHB is the time course7 an extremely !ast onset and short duration o!

e!!ects. 0edical response to overdose there!ore !ocuses on short5term airway maintenance and

support o! respiration rarely does intubation become necessary. GHB is rapidly metaboli8ed and

even pro!oundly comatose patients are responsive in 9:; hours. *he drug is eliminated below the

limit o! detection in blood or urine within /$ hours. *his short detection period is troublesome in

drug5!acilitated assault ("nead # Gibson $%%& "malley $%%) where GHB


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exploited !or ne!arious acts7 these uni=ue e!!ects are disinhibition, anterograde amnesia, and !ast

onset o! incapacitation. In contrast to acute overdose, prolonged administration allows central

nervous system adaptation to sedative e!!ects resulting in an abstinence syndrome upon

discontinuation or rapid reduction in chronic dosing. *he GHB abstinence syndrome presents

with symptoms o! stimulation7 anxiety, insomnia, tremor, agitation, and hallucinations, and may progress to li!e5threatening delirium and sei8ures (-vosec # "mith $%%& yer # Haller $%%/).

>hile some indications show that GHB use in the United "tates is dropping (nderson et al.

$%%;), in other parts o! the world, such as ustralia, ?ngland, and ?urope, the use o! GHB,

especially by youth, continues unabated or is even increasing (u!! $%%; egenhardt, ar@e #

illon $%% $%%$ >instoc@, Gri!!iths # "tewart $%%/ Iten, et al. $%%% >eir $%%%). Because

consumption o! GHB is o!ten said to ta@e place at dance5music clubs or Araves which attract

youth and young adults en mass ('endrich, >islar, Cohnson # Hubbell $%% 0axwell

$%%& Gahlinger $%%9 >instoc@ et al. $%%/), and is noted as being in wide use at gay male

Dcircuit parties< (4alamar # Hal@itis $%%; +amarcho, 0athews # imsdale $%%9 0ansergh et

al. $%%/ 0attison et al $%%/), the Eational Institute o! rug buse has categori8ed GHB as a

Dclub drug.<

Until very recently, the ma6ority o! the published literature on GHB consisted o! clinical case

reports mainly !rom emergency departments, animal studies, and investigations !rom the /1;%s

into its potential !or use as an anesthetic. argely absent are pharmaco@inetic studies o! GHB,

either alone or a!ter co5ingestion with alcohol or other substances. *he impact o! GHB on basic

cognitive and motor !unctions has also been poorly investigated to date. >hile comments about

the various behaviors observed in human users o! this drug are o!ten included in case studies or

reviews ("nead # Gibson $%%&), this aspect o! GHB use has only 6ust begun to be systematicallyinvestigated or detailed. ?specially absent in the literature are reports o! user


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'ocus groups F a method o! systematic =ualitative research based on interview techni=ues F

are especially use!ul when exploring new topics or developing a deeper understanding o! the

processes behind speci!ic behaviors (Bloor et al. $%%/ 0organ /11; "tewart # "hamdasani

/11% rueger /122). small number o! sub6ects (usually /%) are selected !or their particular

@nowledge or relevance to the phenomenon under consideration and then as@ed, in asconversational and open5ended a !ashion as possible, to describe their experiences, @nowledge or

views on the research topics. main aim is to uncover the degree o! consensus in the opinions

and experiences o! the sub6ects as well as the range o! opinion. In this study, users o! the illicit

drug gammahydroxybutyrate comprised the population o! relevance, and their belie!s,

experiences and practices with respect to GHB were the primary topics o! conversation in the

!ocus groups.

'lyers and a web site advertising all components o! the 'orge pro6ect were the main tools used to

recruit participants. *hough it was expected that most respondents would be !rom the city o! "an

'rancisco, outreach via !lyers was carried out with the aim at generating a more geographicallywidespread sample incorporating those living within an approximate ;% mile radius o! "an

'rancisco. Be!ore being re!erred to the !ocus group researchers, a brie! telephone screening

=uestionnaire was used to establish respondent eligibility !or the study, i.e., that the person

claimed to have personally used GHB at least once within the previous six months and could

accurately describe the physical !orm o! GHB. pproximately one5third o! !ocus group

participants noted that they either already had completed or intended to complete the structured

telephone survey as well as participate in a !ocus group.

*he !ocus groups aimed to recruit a total o! 9& people with personal experience o! the drug

having consumed it at least once in the previous /$ months. 4articipants were to be adults, with a

lower age limit set at /2 years. Eo upper age limit was set although it was expected that most

sub6ects would be % or under, consistent with the literature on many other illicit drugs.

+omments !rom health providers and others @nowledgeable about this substance suggested that

user experiences would vary by gender, sexual orientation, and whether or not a person was a

novice or ight user. Hence, recruitment aimed at soliciting a total sample o! at least one5third

!emale respondents, at least one5third who were ight or novice users, and at least one5third who

were Heavy or dependent users. "exual orientation was not a !ormal recruitment criterion but

was monitored with the intent to solicit at least one5third non5heterosexuals.

4rior to commencing sub6ect recruitment, all its components o! the 'orge study received ethical

approval !rom the institutional review board o! the University o! +ali!ornia, "an 'rancisco as

well as a +erti!icate o! +on!identiality !rom the Eational Institutes o! Health. 'ocus group

participants provided signed consent and were given an honorarium to compensate !or their

travel costs, time and disruptions o! routine.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R16


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ll !ocus groups were audio5taped !ollowed by verbatim transcription o! all utterances. *he same

moderator (C+B) ran all the groups assisted by a co5!acilitator who managed the audio5taping,

too@ written notes, ensured completion o! necessary paperwor@ and oversaw the provision o!

snac@s. *ranscripts were chec@ed !or accuracy and completeness by both the moderator and the

co5!acilitator, through comparison with the original audiotapes.

+onversation was guided by a primary set o! open5ended =uestions posed in the same order to

each group, with each =uestion being !ollowed5up as appropriate with probing =uestions eliciting

!urther commentary and details. iscussion between the participants was encouraged so that

diverse experiences and viewpoints would be revealed. 'ocal =uestions were chosen to elicit

GHB users< experiences and insight into issues that are at present poorly documented or are

di!!icult to handle in other !ormats (e.g., =uestionnaires). ?!!orts were made to ensure that each

participant was able to recount !ully his or her experience with GHB and to express the !ull range

o! their experiences rather than simply recalling their usual or desired experience. t the end o!

each session, participants were as@ed to answer two short =uestionnaires, one on socio5demographics and one on their GHB use practices (both surveys being derived !rom those used

in the parent 'orge study (yer, nderson, im, Bar@er # Blanc $%% 5 in press). ltogether

these =uestionnaires too@ a total o! /% minutes to complete, and were derived !rom and

compatible with those used in the telephone survey component o! the 'orge study.

!ter a lead5o!! =uestion about the street names these users give to GHB 5 a =uestion designed to

establish rapport and encourage conversation among participants 5 the primary =uestions !ocused

on the !ollowing topics7

/. nature o! the sub6ects< Dhigh.<

$. bene!its believed to derive !rom use o! GHB

. perception or re!utation o! GHB as a dangerous or ris@y substance

9. reactions, complications or unintended e!!ects o! GHB

&. comparison o! GHB to ?cstasy (methylenedimethylamphetamine or 00), alcohol,

and other (illegal) substances

;. medical, social, economic, legal, or other problems GHB may have caused participants.

4articipants were also as@ed to describe their !irst encounters with GHB and their use tra6ectory

therea!ter. 4robing =uestions, derived !rom diverse hints in the extant literature, concentrated on

understanding GHB


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)o to*

RESULTS

Recr!t"e#t

3ecruitment occurred through interested persons using in!ormation on !lyers or the 'orge

website to contact the main 'orge study telephone number. 3esearchers screened contacts !or

eligibility !or inclusion in the study and re!erred eligible sub6ects to the !ocus group researchers.

?ligible participants had to be ?nglish5spea@ing, at least /2 years o! age, able to answer correctly

=uestions about the physical appearance o! GHB, and sel!5report having used the substance at

least once. small proportion (/&J) o! !ocus group participants was recruited via word5o!5

mouth re!erral by other !ocus group respondents or through personal contact with study sta!!.

total o! 2$ eligible people expressed interest in attending a group. Kverall, ;%J o! these people

actually attended a !ocus group // people (/J o! the ;$ scheduled) simply did not show up attheir scheduled event. Knly one person withdrew, not wanting to set a date to attend a!ter

expressing initial interest. Eineteen people (/ o! whom were male) were simply unable to be

contacted7 nine because o! no replies to telephone calls despite at least !ive attempts at various

times o! day or day o! wee@, or unreturned responses to discreet messages seven had provided

the wrong contact in!ormation, moved out o! state, or had a contact number disconnected. Kne

person proved to be ineligible. nalyses o! all potential sub6ects showed no systematic

di!!erences, by gender, re!erral source, or geographic location (6udged by area code o! contact

telephone number), between those who did participate and those who were Ano5shows, or those

lost to !urther contact. .

F$cs Gr$%s

Between 0arch and ecember $%%9, /% !ocus groups were held F six groups comprising only

male participants, !our comprising only !emales F with a total o! &/ participants. Groups ranged

in si8e !rom three to nine participants, with a median si8e o! 9 to &. ll group meetings lasted

between / hour 9& minutes and $ hours, and too@ place in a private meeting room in a university

building. *he employment status o! the respondents was re!lected in the scheduling o! groups.

ll male participants attended groups beginning at 9pm on >ednesdays whereas all !emale

participants said their 6ob responsibilities precluded wee@day attendance, hence, all !emale

groups were held at //am on "aturdays. 4articipants were recruited !rom geographically

dispersed sites7 two5thirds (;J) lived in "an 'rancisco city, /2J came !rom Ka@land and other

immediate ?ast Bay locations, and with the remaining /&J coming !rom other locations in the

greater "an 'rancisco Bay rea, including a !ew people !rom as !ar away as "acramento.

*he goals set !or sample composition were generally well met. K! the total o! &/ people, women

comprised 9%J (nL$/), and ;/J (nL/) o! the total sample sel!5reported as heterosexual.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/


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Kverall, one5third (;J) were ight users, having ingested GHB !ive or !ewer times in their

li!etime. Kne !ourth ($9J) said they had used the drug more than &% times and were there!ore

classed in this study as Heavy users. "everal Heavy users also described themselves as

dependent or addicted to the substance.

S$c!$&De"$'ra%!c Caracter!st!cs $ Res%$#*e#ts

"ocio5demographic characteristics o! the total sample are presented in *able /. lthough diverse

in some ways, participants collectively are best described as white, urban, and well5educated

people, with stable employment and moderately high income. 4articipants were somewhat older

than expected (on average, /./ years M .; years), and encompassed a broad age range (/2 to &$

years). *he ma6ority (%J) o! respondents was unmarried, though relatively !ew lived alone.

0ost (12J) were childless. Kverall, three5!ourths o! the sample (9J) sel!5reported as being in

excellent or very good health.

*able /3?"4KE?E* ?0KG34HI+" (EL&/)

nalysis revealed only one signi!icant di!!erence among respondents with respect to any socio5

demographic characteristic. >hile signi!icantly more !emale (2/J) than male (9J) respondents

were wor@ing (N $ L;.%1, d! L/, p%.%/), overall there was no signi!icant di!!erence in annual

income by gender. Eearly one5third ($2J) o! the total sample reported an annual income o! over

O;%,%%%. 0ore than hal! the sample had completed college, with one5!i!th ($$J) having

completed post5graduate or pro!essional degrees. 0ost participants were engaged in managerial,

scienti!ic or technical occupations, one5!ourth ($9J) were artists or musicians or had other 6obs

in the entertainment industry.

Re%$rte* Hab!ts $ Use

'ocus group participants reported their consumption habits and experience o! GHB both verbally

and in writing. 3esults !rom the written responses to the short =uestionnaire on drug use habits

are provided in *able $. 'or the purposes o! this study, participants were classi!ied, according to

their li!etime experience with using GHB, in the !ollowing manner7 a ight user sel!5reported

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/table/T2/


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Secrec,

ll participants were aware o! the illicit nature o! this substance, and limited the @nowledge o!

their use o! GHB to a small, select group o! close !riends or partners, many o! whom also used

drugs. Rery !ew !amily members were aware that participants used this substance although three

!emales reported that their mothers @new. 0ost other participants, however, said they activelydenied using drugs when parents or other !amily members as@ed.

dditionally, names such as AGina were intentionally used to obscure the meaning o! a

conversation when in the presence o! people who did not @now about their drug use. 'or

example, i! participants were on the telephone with their source or arranging to be at an event

where drugs were going to be available !or purchase or consumption, they would not re!er to

GHB directly, but would instead as@ i! AGina was going to be at the party.

A'e at F!rst Use

In contrast to many other substances (e.g., alcohol, nicotine, and other club drugs), average ageat !irst use o! GHB among these respondents was surprisingly high7 $;.2 M .$ years, with a

range !rom /:&% years. 4eople reported having used GHB !or a mean o! 9. M $.& years, with a

range o! /:// years. 3elatively !ew people either @new about or used pre5cursor substances or

analogs o! GHB, and there!ore most had not switched between products.

C$sts

0ost but not all respondents were aware that !ive years ago GHB was reclassi!ied as a controlled

substance and that there had been success!ul law en!orcement e!!orts since that date to halt sales

via the Internet. *his has resulted in reduced availability o! GHB and sharply increased cost.+ompared to some other commonly used party drugs, such as ?cstasy, GHB is expensive.

In general, men displayed @nowledge o! the availability and cost o! GHB and changes over time

said they had purchased it at some time and had on some occasions @ept a supply o! it at their

residence. 0ost women, however, indicated that they themselves had never bought the drug

were o!ten unaware o! its availability or cost did not @eep a supply, and tended to use GHB

more intermittently, mainly at social gatherings when it was supplied by others.

Internet connections remain important to GHB users, not 6ust because the availability o! this

substance through the web has started to increase again, but because it provides @ey access to

sources o! in!ormation about the drug, its e!!ects, and dangers. Kne website in particular, ?rowid,

was singled out as a trusted and important source o! reliable and authoritative @nowledge and has

been accessed by many 'orge study participants. 0any people reported reading testimonials and

see@ing in!ormation on the web be!ore ingesting GHB !or the !irst time.

*hree o! the % male respondents and one o! the $/ !emale participants @new how easy the

substance was to ma@e and could provide a recipe !or doing so at home. Knly one person F a


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sel!5identi!ied GHB addict and drug dealer F claimed to have actually made GHB himsel! and

to have sold it, while the others spo@e o! having !riends who either made or sold the substance.

T!"!#' a#* L$cat!$# $ Use

+onsistent with the in!ormation imparted during discussion, in the =uestionnaire responses most

(2;J) participants reported ta@ing GHB in!re=uently 5 less than one day a wee@ mainly in the

evening on wee@ends and at parties or social gatherings. modest proportion (about one5third)

said they ta@e GHB when at or going to dance5music clubs or Draves,< as they !ind it energi8ing

and gives them stamina to dance all night. 'or several reasons, however, most participants said

they did not use GHB at public events. *hese respondents pre!erred to consume GHB at private

parties in residences, o!ten during the Dchill out< period a!ter dances. n emphatic reason !or this

pre!erence, stated by several respondents, was the more assured presence o! people whom

respondents @new well and trusted to loo@ a!ter them i! an adverse reaction occurred. nother

reason related to the users< accounts o! decreased control o! limbs or coordination o! movements

as well as !eeling tired, lethargic, mellow and content as well as disinhibited. *he third reason

was an extension o! this disinhibition7 participants< description o! GHB as a power!ul aphrodisiac

inducing sexual activity, something they wished not to underta@e in public locales.

Se-a. Res%$#ses

*he in!luence o! GHB on sex was a popular theme throughout the !ocus group discussions. Both

male and !emale participants recalled increased !eelings, sometimes =uite intense, connected to

many aspects o! sexuality, such as sexual desire, arousal, and activity. 3eports o! these e!!ects

did not di!!er by sexual orientation

G, for me, just like turns me into a perfect slut, I think, loving up the whole room. Everybody is

looking really good.

[Male, ! years old, "eavy user#

G feels to me like it has the $ualities of teaching you how to open up to people and have less

inhibitions naturally and also se%ually, you can open up, it&s to me the best. It is the most perfect

drug for se%ual interaction, the best se%ual function, the best se%ual function, the best.

['emale, () years old, Moderate user#

>hereas women commonly spo@e o! the sensual and emotional dimension induced by GHB,men tended to discuss GHB more in the terms o! enhanced tactile sensations and intensity o!

sexual arousal. "ome men wryly noted that while sexual desire was increased greatly, their

ability to per!orm or success!ully complete sexual acts was greatly diminished, a phenomenon

some re!erred to as Ahaving a whis@y dic@ as happens a!ter consuming too much alcohol.

"imilarly, some women noted that while sex under the in!luence o! GHB might have been great,


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they could not always remember precisely what occurred on those occasions and so chose to no

longer engage in sex a!ter ingesting the drug.

Both male and !emale participants commented that they @new GHB use was prevalent in the gay

male community, but no one suggested that the experience o! the high or the ways o! using GHB

was in any way connected with sexual orientation. Both the gay men and the bisexual !emales in

the !ocus groups described experiences, belie!s, and practices around GHB that were

indistinguishable !rom people who sel!5reported as heterosexual.

*he possibility o! sexual ris@5ta@ing as a conse=uence o! GHB ingestion was barely

ac@nowledged. Kne gay male respondent very directly noted that he had decided to =uit using

GHB a!ter the second time because when sober later he recalled that he had engaged in sex with

a partner whom he had 6ust met and without using a condom, practices he would not usually

underta@e and that he !elt were very ris@y. "everal women noted the possibility o! heightened

sexual ris@5ta@ing but only indirectly. Indirectly because they claimed, !irst, that they would not

engage in activity outside their usual practices or !antasies, and, second, that GHB unleashed the

restraints on their desires but did not change their !undamental behaviors.

Date Ra%e

*here was a general recognition among both male and !emale participants o! GHB


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undetectable colorless substance slipped into their drin@ and being ta@en advantage o! while

under its in!luence. "ome women said that date rape or threats thereo! had occurred to !riends

a!ter they ingested GHB, but were somewhat uncertain o! the extent to which the substance was

a ma6or !actor in the situation.

D$s!#'

lmost all sub6ects (1;J) consumed GHB in li=uid !orm, one cap!ul at a time, with the cap

holding about &ml (/ teaspoon) o! !luid. Kne person reported snorting GHB and one in6ected it.

*he ma6ority reported the main e!!ects o! the drug beginning within % minutes o! ingestion and

waning considerably, i! not completely, by 9 hours a!ter consumption. !ter !our hours, euphoric

and care!ree !eelings tended to be replaced by hunger and !atigue. *hus, a ma6ority (;%J) o!

sub6ects ta@e GHB twice or more on any one occasion in order to produce or maintain a Ahigh

that lasts eight hours or longer.

E-%er!e#ces $ te GHB /H!'0Kverall, the description o! the experience o! a GHB5induced Dhigh was remar@ably uni!orm,

with only slight variations between male and !emale users, or between ight, 0oderate, and

Heavy users. 4articipants generally stressed the euphoric and relaxing nature o! the high while

also emphasi8ing the loss o! inhibition and increased sexual response that GHB induced. 0ost

respondents emphasi8ed that they !elt GHB enhanced their mood and sociability but le!t

unimpaired and unchanged their decision:ma@ing and thin@ing abilities. 0any noted they also

!elt silly or giggly as well as tal@ative during the !irst several hours a!ter ingestion. >hile a !ew

people described occasions on which they had experienced hallucinations, both visual and

auditory, and involuntary limb movements, these were not common aspects o! the GHB Dhigh,<and tended to be experienced by Heavy users o! the drug rather than ight or 0oderate users.

"ome participants also discussed their experience as cognitively disorienting7

It&s very dissociative. /ou&re definitely not totally present in your body and I agree with that

[previous comment noting this effect#. 0ust being able to talk to people. I felt+it&s funny, I felt

pro1social but I also felt very introverted because I was having a hard time speaking. I was just

kind of sitting there laughing now and then, and just kind of being comfortable being around

people, but not really wanting to talk.

['emale, !2 years old, Moderate user# I almost felt like disabled, like wanting to move, but my body wouldn&t move, like heavy1ish and

la3y. *ike I wanted to do something, but I just couldn&t get up.

[Male, !4 years old, *ight user#

E"$t!$#a.!t,


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espite a very high degree o! consensus and repeated, assertive verbal ac@nowledgments during

the !ocus group conversations that it was very easy to overdose on GHB, !ew respondents

chec@ed the strength o! the product they were ingesting or ad6usted dosage. >hile a !ew people

told us that with a new bottle or source o! GHB they will ingest a smaller than usual amount and

6udge the strength by the time to produce e!!ects and the nature o! those, most people made nosuch comment. 'or those who did chec@ in this !ashion, they o!ten re5dosed with the same or

slightly reduced amount until the desired Dhigh< occurs i! they experienced little e!!ect within the

!irst %:;% minutes.

0any participants stressed the need to control ris@s by ensuring that GHB is ta@en in a context

whereby each user is sociali8ed into how properly to use the drug. "everal people gave

descriptions similar to the one =uoted below, descriptions o! what many considered the most

appropriate scenario !or introduction to GHB7

8he first time I took it I was coached, told e%actly what I was going [to e%perience# 9 I mean,

the person that introduced me to it was very like, okay, this is how you&re going to feel, what to

e%pect, don&t do this, don&t do this.

[Male, () years old, Moderate user#

"ome disclosed that their circle o! !riends or drug5consuming communities ta@e deliberate and

certain measures to avoid ris@y or dangerous situations, as one woman explained7

*ike if we are deciding to do G that night, we have a law in our, like, tribe. 6t a party we write

down the dosage and time so if you do forget+and you&ll forget + and then a half hour later you

think you can take another cap and then that&s too much.

['emale, !2 years old, Moderate user#C$&!#'est!$#

Eot only did people not o!ten chec@ the strength, a large proportion (2%J) reported having co5

ingested GHB with another substance at least once, although some claimed to be unaware o! this

mixing until later, particularly i! the other substance was alcohol. Kther illicit substances most

o!ten deliberately co5ingested with GHB were amphetamines, ?cstasy and mari6uana (see *able

$). 0ost people report mixing GHB with 6ust one other substance although almost hal! the

sample (9;J) reported having mixed it, on at least one occasion, with two or more co5ingestants.

*he aim o! mixing substances was to produce a high that was individually tailored to a person


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and !alling over or sitting down with a blan@ stare or !acial expression, Aacting spacey) (see

also ohrs, 0ann # Greenberg $%%9).

3arely were any ris@s !rom mixing substances overtly or extensively discussed. *hese were

metaphorically recogni8ed, however, through the sardonic names given to some mixtures !or

example, A?G7 a mixture o! ?cstasy, etamine and GHB. etamine is widely @nown on the

streets as A"pecial F yet another moc@ing pun, this time re!erring to a well5@nown brand o!

brea@!ast cereal.

GHB a#* A.c$$.

0ixing GHB with other (predominantly illegal) substances appeared to be more deliberate acts

than was the co5ingestion o! GHB with alcohol : the one ris@y act o! co5ingestion that users

openly and voci!erously discussed. 0ost participants were adamant about not ever using GHB

with alcohol. >hile some people mentioned unpleasant reactions to the mixture o! GHB and

alcohol, such as nausea and vomiting, others tal@ed about potentially more serious conse=uences,such as coma or death. *hese possible outcomes are a widespread piece o! street @nowledge7

Everything I&ve ever read or heard about G"5 and alcohol indicates that it is a recipe for going

into a coma.

[Male, ( years old, Moderate user#

If you drink [alcohol# with it, it&s a whole other ballgame. If you drink a bunch of boo3e with it,

even like a couple of beers, it&s going to change the effects of it without that+ 6nd again, I&m

sure it&s hella fun, but you&re going to get knocked out. I mean, at that level, you don&t come

down off of it, you pass out and wake up the ne%t day.

[Male, !: years old, Moderate user#

t the same time, several participants admitted that they or their !riends and ac=uaintances have,

nonetheless, mixed GHB with alcohol. *hese occasions tended to be when GHB was ingested !or

the !irst time outside the context o! a speci!ic group or site at which the drug is care!ully

introduced. "ome recounted occasions when GHB was unwittingly ingested a!ter having already

consumed alcohol, o!ten because they were provided !luids (e.g., orange 6uice or water) that

unbe@nownst to them had been spi@ed with GHB.

*o the ama8ement, even consternation, o! others in the group, one respondent reporteddeliberately and unconcernedly imbibing alcohol and GHB together on a regular basis. *his

respondent was !ar !rom being a typical GHB user, however, as she reported a history o! having

used practically every illegal substance as it became available or !ashionable over the last three

decades.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R15


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lthough there was a strong discourse about the ris@s run by mixing GHB and alcohol, the

villain in this pair was not claimed to be GHB but alcohol. In the rhetoric o! many !ocus group

respondents, alcohol was a much more dangerous drug than GHB. *hese people alleged that

alcohol has !ar greater mortality and morbidity than GHB, in both short and long term. nd also,

that alcohol is much more addictive with considerably worse and more wide ranging physicaland social e!!ects. couple o! respondents even acerbically commented that, in star@ contrast to

the case with alcohol, no one had ever gone out and beaten up their wi!e or children because they

were drun@ on GHB, or had staggered around the streets incoherently yelling, cursing and raging

at all who pass by.

React!$#s

In general, participants did not always view reactions to or undesired e!!ects o! GHB as

unpleasant or unexpected, even though many such experiencesSse=uelae are pointed to in the

medical literature as evidence o! overdose. "ome people had a high tolerance !or these side

e!!ects, seeing them as necessary ad6uncts to achieving the desired e!!ects, o! any drug not 6ust

GHB. 'or instance, A!alling out or AG5napping was accepted by many as part o! the experience

o! using GHB. I! dealt with appropriately, they were not matters o! great concern. *hese adverse

reactions were reported as usually waning completely by 9 hours post5ingestion.

'or a !ew respondents, undesired reactions were su!!iciently unpleasant and aversive enough to

limit their consumption o! GHB or to ma@e them stop using it entirely. 'our respondents

commented they had stopped using GHB because they did not li@e the vomiting, the Aweird

sensations running up and down my arms, and the episodes o! memory loss the drug induced.

Kther respondents said they =uit or cut5bac@ their GHB use when other drugs became available

that better produced their sought5a!ter e!!ects, !or example, pre!erring etamine or Ashrooms

(mushrooms) to GHB because o! their greater psychedelic propensities.

I used to think that it re$uired immediate medical attention once they went into a coma when I

first, that night that I first took it. 7hereas now I + it&s been shown to me that as long as you just

let them sleep and put them in a position so that they don&t choke on their own spit + or

whatever, that they will wake up pretty much without incident.

[Male, (; years old, Moderate user#

*he appropriateness o! responses to potentially dangerous reactions, li@e G5napping, dependsvery much on who one is. Users and medical pro!essionals tend to have =uite di!!erent responses

to and evaluations o! the appropriateness o!, !or example, giving crystal meth to a person

beginning to succumb to the e!!ects o! too much GHB, or to the advice simply to let a person

who is beyond a momentary AG nap but actually comatose, to sleep it o!!.

A"#es!a


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"everal participants discussed having episodes o! anterograde loss o! memory a!ter ingesting

GHB. 0ild to moderate episodes were the most commonly articulated experiences during which

people could still hear and see but were slow to comprehend or respond. 0emory loss was

sometimes o! very short duration. !ew participants, however, recounted similar yet more severe

amnesic experiences.

I woke up a couple of times and said, "ow did I get here< I don&t remember what just

happened + 5ut I didn&t ever ended up in a hospital.

[Male, () years old, "eavy user#

I took some G"5, I was high, I was really high and I went to this building [where the dance was

that night + while waiting to use the restroom# I was pacing back and forth. 7ell, at some point

I hit the cement wall, opened my eyes. "it the cement wall and opened my eyes. "it the cement

wall hard + I&m like two miles down from where the actual building was. =o while I was pacing,

somehow I fell asleep and I walked and I do not remember how I walked out of that gate and I

kept going straight until I hit this cement wall and opened my eyes.

[Male, (2 years old, "eavy user#L$ss $ M$t$r S1!..s

oss o! control F usually a partial loss not complete F o! gross motor s@ills was !re=uently

cited as a reason why many respondents did not li@e to use GHB while out, especially when out

at dance clubs. 4eople spo@e o! this as !eeling Awea@ or A!atigued, or wanting to sit down or lie

down, to not move around. "ome Heavy users o! GHB also spo@e o! occasionally experiencing

their limbs 6er@ing or ma@ing similar involuntary movements. lthough a modest proportion o!

people (about one5!ourth) !elt GHB energi8ed them and so li@ed to use it while dancing, a muchgreater proportion o! respondents said !eelings o! invigoration tended to come about the next

day. 3ather than !eeling hung5over the next morning, GHB le!t them !eeling normal and

re!reshed, energetic. Hangovers, which they associated with consumption o! drugs such as

alcohol or ?cstasy, were described as comprising nausea, dehydration, depressed mood,

withdrawal !rom social interaction, and !atigueSlassitude.

I think people think of it [using G"5#, at least I know I sort of look at it on the same level as

having a drink. -ften times it affects me for a shorter period of time and I don&t have any

hangover the ne%t day, it doesn&t make me feel crappy+ get great sleep.

['emale, !) years old, Moderate user#

7hen you take a proper dose of G you get a better feeling than if you were to get drunk [on

alcohol# anyway. If you get drunk you have a lack of judgment, a hangover the ne%t day. It&s to

me like having a few drinks and getting drunk is more disassociative than taking G because, like

+ your judgment is more impaired and all that stuff to do the ne%t morning, feeling like crap.

I&m sure, granted, you can take too high a dosage of G or something and maybe go the same


17/25

way, but taking just enough you&d probably get the same euphoria as drinking. /our judgment

isn&t as impaired and you&re not typically falling over things.

[Male, (! years old, Moderate >ser#

Kne speci!ic circumstance where there was clear ac@nowledgement o! danger !rom GHB wasdriving. "peci!ically, the decrease in motor s@ill and increase in amnesia or loss o! consciousness

induced by GHB was considered stress!ul, unsa!e and a ma6or impediment to !unctioning. >hile

the ma6ority o! !ocus group participants expressed ama8ement and disbelie! that anyone would

even consider driving while under the in!luence o! GHB, a !ew people said they had done so, an

action that in hindsight horri!ied them. *hese people vividly recounted instances o! driving under

the in!luence o! GHB, instances that eventually convinced them not to get behind the wheel a!ter

ingesting this drug.

It&s not cool actually. /our eyes get shaky and for me it was hard to judge speeds and distances

very well. I mean, I could obviously, if I got close enough, but I was doing a lot of going real fast and slowing down. It&s nerve racking. I never went on the freeway. I can&t imagine trying to go

on like some cra3y freeway like that. It would be insane.

[Male, !: years old, Moderate user#

It was like suspended animation. I was barely conscious. I was able to just drive, not drive well,

not stay between the lines. It was horrible and I mean like actually I crashed, you know I

crashed into a concrete barrier doing 4)) miles an hour and came out with two bruises [shakes

head in wonder#. I mean, I barely had control. 7ent over 4;) miles [in distance# each time

without remembering it. I ended up in another state [?evada# at one time and I was, like, I didn&t

even know where I was.

['emale, (! years old, "eavy user#Eects $ L$#'&ter" Use

In=uiry into possible long5term e!!ects o! GHB ingestion revealed that this is not a topic widely

discussed within this particular drug5consuming community. common opinion vigorously

expressed by most ight and some 0oderate users was that GHB is not an addictive substance,

that a user cannot become dependent. !ew 0oderate users, however, noted that they had

noticed that their use had increased over time !rom occasional to more !re=uent, and thus were

beginning to reconsider whether dependence was possible.

hand!ul o! respondents (;J) reported using GHB daily. ll o! these Heavy users

ac@nowledged the potential o! becoming addicted to GHB, but only a two admitted to actually

being dependent. t the time o! the !ocus groups, two people, one man and one woman, were

undergoing drug rehabilitation in a supervised therapeutic community setting !or addiction, one

!or addiction to GHB, the other !or dependence on several other drugs. third man was


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19/25

to and evaluations o! gammahydroxybutyrate (GHB) and its place in the repertoire o! illegal

substances available on the street and consumed on a regular basis.

Ingestion o! GHB is ac@nowledged to be an illegal activity and so awareness o! a person


20/25

immediate ris@s o! using GHB with alcohol (e.g., going into a deep coma) outweighed long5term

ris@s, !or example, o! engaging in sexually5ris@y practices while under the in!luence o! GHB

with possible contraction o! sexually5transmitted diseases. nother example concerns driving

a!ter ingesting GHB (Bar@er # arsoho $%% : in press)

3espondents recogni8ed a high possibility o! overdose due to the narrow therapeutic range and

steep dose5response5curve o! GHB (see also 4alamar # Hal@itis $%%; >hite et al . $%%;). 0ost

interesting in this regard is the deliberate sociali8ation to the drug that seems to occur.

"ociali8ation consisted o! care!ul explanation to novice users by more experienced users o! how

and when to use GHB, what its e!!ects are, and what substances to avoid mixing it with.

0onitoring activities also occurred among some groups o! !riends !or example, at some private

parties, present company would designate an individual to stay sober and @eep trac@ o! others<

ingestion o! GHB and other drugs, and its impact, to ensure that overdose did not happen and or

adverse e!!ects were noticed and handled promptly. >hile most (;$J) said they did something to

chec@ the strength o! the GHB they were consuming in order to limit the potential dangers, asi8eable minority o! respondents too@ no such action. 0ore than one5third o! respondents (2J)

said they did not chec@ the strength be!ore using GHB by, !or example, reducing the initial dose

si8e in order to gauge their response.

dverse reactions, such as episodes o! vomiting, amnesia, loss o! motor control or AG napping,

were not categori8ed by !ocus group participants as evidence o! overdose. 3ather, they are seen

as common and !or the most part tolerable side e!!ects o! the drug. 'or some people, however,

these were su!!iciently unwanted to curtail or stop their use o! this substance. 'or other people,

such reactions were 6ust the price to be paid !or experiencing the desired pleasurable states o!

euphoria, sociability, mellowness, and increased sexual desire and sensitivity to sound and touch.

>ith rare exceptions, GHB !atalities occur in the pre5hospital setting !or reasons such as

aspiration, positional asphyxia and traumatic accident or in6ury secondary to abrupt loss o!

consciousness. Kver the past decade, however, during which time GHB has come to be a widely

available and consumed drug, users appear to have developed and disseminated a set o!

procedures aimed at prevention and non5pro!essional management o! overdose. n e!!ective

street @nowledge has developed and been widely disseminated among users about not consuming

GHB with alcohol, a combination @nown to have a high potential !or inducing coma or death

(*hai, yer, Benowit8 # Haller, $%%; *hai, yer, Cacob # Haller $%%). ?!!icacy cannot be so

con!idently ascribed to users< strategies !or dealing with other signs o! serious adverse reaction

or overdose, such as coma or AG naps that extend over more than a !ew minutes or that result

!rom co5ingestion o! GHB and other substances. 3ather than see@ing pro!essional medical help,

it is apparently becoming a more common response among users to put a person in the Arescue

position to minimi8e potential !or asphyxiation and allow him or her to sleep it o!!. nother

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R23http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R31http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R23http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R31http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/#R29


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the wide range o! experiences o! GHB. *here!ore, clinical practice can bene!it greatly !rom

insights into the experience o! GHB ingestion provided by users themselves.

)o to*

Ac1#$2.e*'"e#ts

'unding !or this study was provided by EI 3%/ /91& (C.?. yer, 4harm , 4rincipal

Investigator). >e than@ isa *hai !or assistance with data collection, Gillian ?arnest !or help

with =uantitative data analysis, and Ilene B. nderson, 4harm , "usan T. im, 4harm # 4aul

. Blanc, 0, +o5Investigators in the 'orge "tudy, !or their help!ul comments and associated

research underta@ings. >e also than@ the !ocus group participants !or sharing with us their views

and experiences o! this substance

)o to*

Reere#ces

/. nderson IB, im "T, yer C?, Bur@hardt +B, I@noian C+, >alsh 0C, Blanc 4. *rends

in Gamma Hydroxybutyrate (GHB) and 3elated rug Intoxication7 /111:$%%. nnals

o! ?mergency 0edicine. $%%;9($)7/:2. ?pub ec $2. V40+ !ree articleW V4ub0edW

$. Bar@er C+, arsoho H. Ha8ardous use o! GHB 7 riving under the in!luence. "ubstance

Use and 0isuse $%% in press.

. Bloor 0, 'ran@land C, *homas 0, 3obson . 'ocus Groups in "ocial 3esearch. ondon7"age 4ublications $%%/.

9. +hin 3, "porer , +ullison B, yer C?, >u *. *he clinical course o! gamma

hydroxybutyrate. nnals o! ?mergency 0edicine. /112/7/;:$$. V4ub0edW

&. +amarcho , 0athews "+, imsdale C?. Use o! GHB5compounds by HIR5positive

individuals.merican Cournal on ddictions. $%%9/7/$%:/$. V4ub0edW

;. +ompton >0, *homas T', +onway 4, +olliver C. evelopments in the epidemiology

o! drug use and drug use disorders. merican Cournal o! 4sychiatry. $%%&/;$(2)7/919: /&%$. V4ub0edW

. egenhardt , ar@e ", illon 4. *he prevalence and correlates o! gamma5

hydroxybutyrate (GHB) overdose among ustralian users. ddiction. $%%127/11:

$%9. V4ub0edW

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2246009/http://www.ncbi.nlm.nih.gov/pubmed/16431231http://www.ncbi.nlm.nih.gov/pubmed/9624311http://www.ncbi.nlm.nih.gov/pubmed/15204663http://www.ncbi.nlm.nih.gov/pubmed/16055770http://www.ncbi.nlm.nih.gov/pubmed/12534425http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257870/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2246009/http://www.ncbi.nlm.nih.gov/pubmed/16431231http://www.ncbi.nlm.nih.gov/pubmed/9624311http://www.ncbi.nlm.nih.gov/pubmed/15204663http://www.ncbi.nlm.nih.gov/pubmed/16055770http://www.ncbi.nlm.nih.gov/pubmed/12534425


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2. egenhardt , ar@e ", illon 4. GHB use among ustralians7 +haracteristics, use

patterns and associated harm. rug and lcohol ependence. $%%$;721:19. V4ub0edW

1. u!! +. D+harging< and DBlowing Kut


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$%. 0organ . 'ocus Groups as Xualitative 3esearch. *housand Ka@s, +7 "age

4ublications /11;.

$/. 0attison 0, 3oss 0>, >ol!son *, 'ran@lin . "an iego HIR Eeurobehavioral

3esearch +enter Group. +ircuit party attendance, club drug use and unsa!e sex in gay

men. Cournal o! "ubstance buse. $%%//7//1:/$;. V4ub0edW

$$. 0iotto , ara@6ian C, Basch C, 0urray ", -ogg C, 3awson 3. Gamma5hydroxybutyric

acid7 4atterns o! use, e!!ects and withdrawal. merican Cournal on

ddictions. $%%//%7$$:$9/.V4ub0edW

$. 4alamar CC, Hal@itis 4E. =ualitative analysis o! GHB use among gay men7 3easons !or

use despite potential adverse outcomes. International Cournal o! rug

4olicy. $%%;/7$:$2.V40+ !ree articleW V4ub0edW

$9. "malley ". D*he 4er!ect +rime


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Documents

Experiences of Gamma Hydroxybutyrate