Successful use of the CIWA-Ar scale for gamma-butyrolactone withdrawal

Background: Gamma-butyrolactone (GBL) is a prodrug for Gamma-hydroxybutyrate (GHB) and is available as an industrial solvent. GHB and its prodrugs are abused for their sedative and euphoric effects and by body builders for claimed anabolic effects. Regular users of GHB can develop tolerance and dependence, developing a continuous pattern of dosing every 1–2 hours. Chronic heavy GHB abusers can experience severe withdrawal, while many GHB users may experience some symptoms upon discontinuation. GHB withdrawal is rapid occurring within 1–6 hours after the last dose and can last up to 2 weeks. Treatment is usually with benzodiazepines. Large doses may be required and symptoms can be difficult to control. Case report: A 22 year old male was admitted after an overdose including 30ml of GBL. He was a regular user of GBL ingesting up to 50ml a day for 2 years (3–5mL every 2 hours). Symptoms of agitation, clammy skin, excessive thirst, vomiting, and tachycardia were present around 12 hours post overdose. Diazepam 20mg was started every 4 hours to control withdrawal symptoms. The patient became increasingly anxious with tremor and hallucinations uncontrolled by diazepam therapy. It was decided to start him on the CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol) scale as for alcohol withdrawal. The patient scored moderate to high on CIWA-Ar because of anxiety and hallucinations so diazepam was administered accordingly every ninety minutes. Four days post ingestion the patient ceased scoring on CIWA-Ar and diazepam was decreased to 2–5mg for mild agitation. After an uneventful recovery the patient was discharged 6 days post ingestion. Conclusion: GHB withdrawal can be very difficult to manage and there are frequent reports of patients resistant to high-dose benzodiazepines, requiring other sedatives such as quetiapine or phenobarbital. This case shows increasing the frequency of dosing based on symptoms as in the CIWA-Ar scale may be of benefit in severe GHB withdrawal appearing resistant to benzodiazepines. This is the first report in our knowledge of someone successfully treated with CIWA-Ar scale for GHB withdrawal. This or a modified version could prove an effective management protocol for these patients.