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Am Fam Physician. 1998;57(9):2078-2081

to the editor: Gamma-hydroxy butyrate is an increasingly popular illicit drug used by body builders for its alleged anabolic effects and by recreational drug users for its effects on the central nervous system. When purchased as a powder, it may be called Somatomax PM or sodium oxybate. Gamma-hydroxy butyrate also has a number of street names, including “liquid ecstasy,” “grievous bodily harm,” “GBH,” and “liquid X.” At selected body building gyms, night clubs and “rave” halls, gamma-hydroxy butyrate is sold pre-mixed in small glass jars. At high doses, its sedative effect and ability to produce muscle relaxation and hypotonia, along with its amnestic effect, have been exploited in the practice known as “date rape.” The onset of action is usually within 15 minutes, and effects resolve within eight hours.

Gamma-hydroxy butyrate is a four-carbon fatty acid endogenous metabolite of gamma amino butyric acid, a central nervous system depressant. It is present in the brain at about one thousandth of the concentration of its parent compound. Gamma-hydroxy butyrate increases the level of dopamine in the brain and produces its effects by unknown mechanisms.1 At higher doses (above 30 mg per kg, or about two capfuls of powder), it may produce loss of strength, a trance-like state and amnesia.

Street lore and eyewitness accounts of gamma-hydroxy butyrate ingestion describe a lag period, after which the user becomes limp and drops to the floor. Ingesting more than three capfuls or mixing gamma-hydroxy butyrate with alcohol or other intoxicants may cause recurrent vomiting and central nervous system depression, which may lead to stupor or coma. Respiratory depression has been reported.1

Some experts believe that daily ingestion of doses of about two or more capfuls (30 to 50 mg per kg) can lead to addiction. The craving has been described by those using it to be somewhat similar to that of cocaine.

During the 12-month period ending September 1996, poison control centers in New York, Dallas and Galveston, Tex., received reports of 69 acute poisonings and one death attributed to ingestion of gamma-hydroxy butyrate.2 Appropriate warnings have been printed in various medical journals, including state medical journals.35 There are now 14 documented fatalities caused by gamma-hydroxy butyrate, often in association with sublethal doses of alcohol (personal communication, Dr. James Tollinei).

Two states (Rhode Island and Georgia) have classified gamma-hydroxy butyrate as a Schedule I drug (no proven clinical use and high potential for abuse), and several other states are considering similar action.

The drug can not be detected with standard urinalyses used to test for drugs of abuse, because it requires gas chromatography for detection.6 Gamma-hydroxy butyrate should be added to the list of illicit drugs that can cause syncope and coma. Ingestion should be considered in body builders who present to the emergency department with such symptoms. No known antidote to gamma-hydroxy butyrate intoxication exists. Naloxone (Narcan, Talwin) has been tried but without success.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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