Gamma-hydroxybutyrate

INTRODUCTION

Gamma hydroxybutyric acid (GHB) is a naturally occurring small chain fatty acid (1) that has been described as a possible neurotransmitter (2-4). Since about 1990, GHB has been abused on the street; names include "Liquid Ecstasy," "Soap," "Easy Lay," and "Georgia Home Boy." GHB and its precursors, gamma butyrolactone and 1,4 butanediol, have been involved in poisonings, overdoses, date rapes, and deaths (5, 6). GHB emergency room visits increased from 55 in 1994 to 2.973 in 1999 (7, 8). In 1999, GHB accounted for 32% of illicit drug-related poison center calls in Boston (7, 9). These products, obtainable over the Internet and sometimes still sold in health food stores, are also available at some gyms, raves, nightclubs, college campuses, and are particularly popular among gay men. The products are commonly mixed with alcohol, have a short duration of action, and are not easily detectable on routine hospital toxicology screens (7).

GHB is a popular recreational drug used by young adults (10-12). It appears to have a high abuse potential because it produces euphoria, hallucinogenic effects, relaxation, tolerance, and severe withdrawal symptoms (14, 15). In the United States, GHB compounds have been marketed illicitly to body builders as a growth hormone stimulant to build muscular mass. They have also been promoted as a replacement for L-tryptophan to improve sleep (16, 17). Two GHB precursors, gamma-butyrolactone and 1,4 butenadiol also have been marketed to improve athletic performance, enhance sexual activity, and release growth hormone (18). Dietary supplements containing these precursors are widely available through the Internet under different names such as Serenity, Growth Hormone Release Extract (GHRE), Thunder Nectar, and Revitalize Plus among others (19, 20). This article describes the pattern of use and knowledge about GHB compounds among college students, who are frequently the "cutting edge" of new patterns of drug abuse.

METHODS

A survey was distributed in the student health clinic of a large university from July 2002 until January 2003. Anonymous surveys were placed for distribution at patient registration areas. Students were asked to complete only one questionnaire, even if they made multiple visits to the student health clinic during the period of study. Students who answered the survey placed them in a secured box. The investigators collected the surveys from the boxes on a weekly basis. During that period, a total of 18,744 students attended the clinic; 37% were male and 63% were female. Their age distribution was as follows: 13,339 patients between ages of ages 18-25, 4,812 patients between ages of 26-35, and 988 patients older than 35.

The participants were asked about the use of the following compounds: Serenity, Revitalize-Plus. Growth Hormone Release Extract (GHRE), Somato-Pro, Enliven, NRG-3, Thunder Nectar, White Belt Cleaner, GBL, Butenadiol, and GHB. They were also asked about their amount of use over the last 6 months, as well as their knowledge of GHB compounds' addictive potential, GHB legal status, and effects experienced when using any of these compounds. The study was approved by the University of California, San Diego Human Subjects Protection Program.

RESULTS

A total of 215 students answered the survey. The mean age of the participants was 22.8 (S.D. 3.5) years and their average level of education was 16.5 (S.D. 2.5) years. Among the respondents, 90 were male (41.9%) and 125 (58.1%) were female. There was no difference between men and women in terms of age or years of education. The participants described their sexual orientation as follows: 163 (75.8%) heterosexual, 32 (14.9%) homosexual, l0 (4.7%) bisexual; 10 students (4.7%) did not indicate their sexual orientation. Respondents were asked if they recognized the previously mentioned GHB-related compounds. The most commonly recognized compound was GHB (53%), followed by GHRE (46%). The most commonly used compounds were GHRE (28.8%) and GHB (19%). GHRE users reported consumption 23 times per month, while GHB users reported use 1-2 times per month.

The respondents reported frequent effects from using GHB-compounds, including euphoria (n = 41), increased energy (n = 51), weight loss (n = 59), and dizziness (n = 13). Other reported effects were irritability (n = 3), a decreased need for sleep (n = 3), and social problems associated with the use of GHB (n = 1).

Regarding the use of GHRE, there was a significant difference between males and females (chi square] = 49.0 df = 1 p<0.001). A total of 59 women reported using GHRE, compared to only 3 men. Fifty-seven of the GHRE users reported their sexual orientation as heterosexual, 3 as bisexual, and 2 as homosexual. Ninety-six percent of GHRE users (57/62) reported weight loss as an effect--and among the 59 women, 55 reported weight loss as a reason for using GHRE. Increased energy was reported by 23 out of the 59 women who used GHRE and the 3 men. Figure 1A summarizes the results.

[FIGURE 1 OMITTED]

Consistent with previous reports (21), GHB tended to be used preferentially by gay and bisexual individuals ([chi square] = 7.2 df= 1 p = 0.07). Eighty-eight percent of GHB users (36/41) reported euphoria as a common effect from the compound. Only 2 GHB users reported weight loss. Twenty-three men and 2 women reported increased energy associated with the use of GHB. Increased energy was reported more often by gay/bisexual participants than heterosexuals ([chi square] = 79.9 df = 3 p < 0.01). Figure 1B summarizes these results.

Participants answered questions about their general knowledge of GHB-compounds. Among the 215 participants, 43 thought GHB was addictive, 18 thought that Serenity was addictive, and 11 thought that Thunder-Nectar was addictive. Only 40 of the 215 participants knew that GHB was illegal and only 6 knew that GHB has addictive potential (Table 1).

DISCUSSION

College students frequently experiment with addictive substances (22). Our results showed that college students are using GHB compounds for a variety of reasons. Interestingly, the reported effects varied according to gender and sexual orientation. Female participants reported ease in losing weight and increased energy when using GHRE. On the other hand, homosexual participants reported increased euphoria but not weight loss when using GHB.

GHB is a known substance of abuse and continues to pose serious risks for users (23). Our data show that college students have limited knowledge about the wide variety of GHB compounds and their illegal and addictive nature. Future studies are needed to specifically address the possible misuse of GHB among a representative sample of college students.

Our preliminary study has several limitations. The sample of participants is small considering the number of people who attended the clinic during the period of the study, although the gender and age demographics of the sample reflect that of the clinic. Distribution of the survey was limited to the student health clinic, and as the clinic saw approximately 35% of the student body during the time of the survey, this sample would not appear too nonrepresentative of the population as a whole. The same patient may have responded to more than one survey, although participants were requested to complete the form only once. There may have been selection bias by respondents who completed the survey. Based on our results, it is important to conduct larger epidemiological studies to clarify the patterns of use of GHB and its compounds on college campuses.

Clinicians and health workers should educate patients about this new compound as it appears that the general knowledge about GHB is quite limited. It will be important to foster open communication and continued education on college campuses to prevent serious consequences associated with the misuse of GHB. Given the different reasons that different groups use these drugs, targeted education programs may be more appropriate than blanket ones.

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Alvaro Camacho, M.D., (1) Scott C. Matthews, M.D., (1) Brian Murray, M.D., (2) and Joel E. Dimsdale, M.D. (1)

(1) Department of Psychiatry, University of California, San Diego, California, USA

(2) Student Health and Wellness Center, University of California, San Diego, California, USA

The authors thank Ronalee Mizoguchi, R.Ph. for her assistance in preparing this manuscript.

Address correspondence to Joel E. Dimsdale, M.D., Department of Psychiatry, UCSD, 9500 Gilman Dr., La Jolla, CA 92093-0804, USA; Fax: (619) 543-5462; E-mail: jdimsdale@ucsd.edu

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