Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

172 III. SUBSTANCES OF ABUSEIn the 1970s, GHB was available commercially as a sleep aid. It has somedemonstrated therapeutic efficacy, particularly in the treatment of narcolepsy(Lammers et al., 1993; Mamelak, Scharf, & Woods, 1986; Scrima, Hartman,Johnson, Thomas, & Hiller, 1990). In 1990, after reports indicated that GHBmight have contributed to the hospitalization of several California youth, theFDA banned it. GHB has an extremely small therapeutic index, and as little asdouble the euphorigenic dose may cause serious central nervous system (CNS)depression. In recent years, it has been associated with numerous incidents ofrespiratory depression and coma. Increasing numbers of deaths have beenlinked to GHB (Li, Stokes, & Woeckner, 1998).The legal status of GHB is complicated. Recently, GHB, under the brandname Xyrem, was classified as a Schedule III controlled substance, but with specialregulations. The company that makes and markets the medication hasdeveloped a rigorous system that makes Xyrem available to patients from a singlespecialty pharmacy. Both physicians and patients must receive an educationprogram from the manufacturer, Orphan Medical, before obtaining Xyrem.Orphan Medical has worked closely with the FDA, the Drug EnforcementAdministration (DEA), and law enforcement agencies to develop strict distributionand risk-management controls designed to restrict access to Xyrem tothe intended patient population (Tunnicliff & Raess, 2002). Illicit use ofXyrem is subject to penalties reserved for Schedule I drugs.Most of the GHB sold in the United States is of the bootleg variety, manufacturedby nonprofessionals. In fact, it is relatively easy to manufacture, andInternet sites devoted to explaining the process can be found readily, althoughthey are sometimes cleverly concealed.Physiological EffectsGHB is ingested orally, absorbed rapidly, and reaches peak plasma concentrationsin 20–60 minutes (Vickers, 1969). The typical recreational dosage is0.75–1.5 g; higher dosages result in increased effects. The high lasts for no morethan 3 hours and reportedly has few lasting effects. Repeated use of the drug canprolong its effects.Users of the drug report that GHB induces a pleasant state of relaxation andtranquility. Frequently reported effects are placidity, mild euphoria, and anenhanced tendency to verbalize. GHB, like MDMA, has also been described as asensual drug. Its effects have been likened to alcohol, another GABA-like drug(McCabe, Layne, Sayler, Slusher, & Bessman, 1971). Users report a feeling ofmild numbing and pleasant disinhibition. This effect may account for the reportsthat GHB enhances the experience of sex. The dose–response curve for GHB isexceedingly steep. The LD 50is estimated at perhaps only five times the intoxicatingdosage (Vickers, 1969). Furthermore, the drug has synergistic effects withalcohol and probably other drugs as well. Therefore, small increases in the