49 - References

References

Addictions and substance misuse CHAPTER 4 References

1. Kamal RM, et al. Pharmacological treatment in gamma-­hydroxybutyrate (GHB) and gamma-­butyrolactone (GBL) dependence: detoxification and relapse prevention. CNS Drugs 2017; 31:51–64.
2. Bell J, et al. Gamma-­butyrolactone (GBL) dependence and withdrawal. Addiction 2011; 106:442–447.
3. Abdulrahim D, et al. Textbook of Clinical Management of Club Drugs and Novel Psychoactive Substances: NEPTUNE Clinical Guidance. Cambridge: Cambridge University Press; 2022.
4. LeTourneau JL, et al. Baclofen and gamma-­hydroxybutyrate withdrawal. Neurocrit Care 2008; 8:430–433.
5. Siefried KJ, et al. Inpatient GHB withdrawal management in an inner-­city hospital in Sydney, Australia: a retrospective medical record review. Psychopharmacology (Berl) 2023; 240:127–135.
6. Floyd CN, et al. Baclofen in gamma-­hydroxybutyrate withdrawal: patterns of use and online availability. Eur J Clin Pharmacol 2018; 74:349–356.
7. Liao PC, et al. Clinical management of gamma-­hydroxybutyrate (GHB) withdrawal delirium with CIWA-­Ar protocol. J Formos Med Assoc 2018; 117:1124–1127.
8. Habibian S, et al. Successful management of gamma-­hydroxybutyrate (GHB) withdrawal using baclofen as a standalone therapy: a case report. J Addict Med 2019; 13:415–417.
9. Dijkstra BA, et al. Detoxification with titration and tapering in gamma-­hydroxybutyrate (GHB) dependent patients: the Dutch GHB monitor project. Drug Alcohol Depend 2017; 170:164–173.
10. Beurmanjer H, et al. Tapering with pharmaceutical GHB or benzodiazepines for detoxification in GHB-­dependent patients: a matched-­ subject observational study of treatment-­as-­usual in Belgium and the Netherlands. CNS Drugs 2020; 34:651–659.
11. National Poisons Information Service. 2024; https://www.npis.org.
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13. Freeman G, et al. Phenobarbital to manage severe gamma-­hydroxybutyrate withdrawal: a case series. Drug Alcohol Rev 2023; 42:27–32. Pre-­withdrawal ■ ■Discuss treatment plan with the patient and person who will be supporting them ■ ■Encourage patient to keep a week-­long diary of GBL use including dose frequency and quantity ■ ■Encourage patient to cease ‘on-­top’ drug use such as mephedrone and crystal methamphetamine before elective withdrawal ■ ■Start baclofen 10mg PO tds 3–7 days before target withdrawal date ■ ■Encourage patients to reduce GBL dose as much as tolerable either by reducing each dose by 0.1mL every 1–2 days or increasing the time period between doses Withdrawal ■ ■On day 1 of planned ambulatory withdrawal, ask patient to attend having used no GBL for a minimum of 2 hours, and advise them to dispose of their remaining supplies of GBL ■ ■Advise patients they will need to stay at the clinic for up to 4 hours on day 1, that they cannot drive motor vehicles during withdrawal, and should not drink alcohol or take other sedatives during withdrawal ■ ■Increase baclofen to 20mg PO tds ■ ■Initiate benzodiazepine treatment once signs and symptoms of withdrawal develop – tachycardia, sweaty palms, fine tremor and anxiety. Start diazepam 20mg, review after 2 hours and monitor for anxiety/sedation/respiratory depression. Repeat up to 20mg PO diazepam if indicated ■ ■Once 6 hours have passed since last GBL usage the patient may be given up to a further 40mg diazepam, and then seen daily on the following 2 days ■ ■At each daily visit, review diazepam dosage and titrate to symptoms. Diazepam is seldom needed beyond 7 days. Typical initial daily doses of diazepam are around 40–60mg/day Post-­withdrawal ■ ■Continue baclofen 20mg PO tds following benzodiazepine withdrawal, reducing over 4–6 weeks. One of the few trials in this area successfully used 45–60mg a day for 3 months for relapse prevention11 ■ ■After withdrawal, persisting anxiety and insomnia are common, and there is a high risk of relapse. Before initiating elective withdrawal management, a plan should be in place to monitor and support patients for a minimum of 4 weeks to minimise risk of relapse GBL, gamma-­butyrolactone; PO, by mouth; tds, three times a day.