What is GHB and why does it lead to so many overdoses? Sorting fact from fiction

Last weekend 22 people were hospitalized after overdosing at a dance event in Melbourne. According to a spokesperson for Ambulance Victoria, paramedics transported more than 30 people from a number of events across the city in that one evening, stating that it was it was "highest number of overdoses" they had seen "for some time". So what was the drug that caused all this chaos and is it a drug that parents should be overly concerned about?

The drug was believed to be GHB or gamma-hydroxybutyrate. This is certainly not a new drug and has been causing significant problems on the Australian dance/nightclub scene for over 20 years. The media rarely deals with drug stories particularly well, but this one they keep getting wrong and, as a result, there is a great deal of misinformation out there about the substance, what it is, how it is used and its harms.

Some of the statements made in the media last weekend included the following:

• GHB is a new drug
• the overdoses were due to a 'bad batch' of GHB
• the overdoses were caused by a 'derivative' of GHB - GBL
• GHB is also known as 'fantasy', 'liquid E', 'liquid ecstasy' or 'coma in a bottle'
• it is a odourless, tasteless and clear liquid that is undetectable
• GHB is a 'date-rape' drug often used in drink spiking

Some of these statements are just wrong (as already stated, GHB is certainly not a new drug), while others have some basis in truth. As with any drug issue, there is no 'black and white', instead there are lots of 'shades of grey' ... So, let's try and clear things up a little ...

Without a doubt, this drug singlehandedly changed the face of the dance/nightclub scene not only in Australia but around the world. Prior to G (how the drug is often referred to by users) being introduced to the scene, it was rare to ever see ambulances being called to nightclubs or dance events. Drug-related fatalities were extremely rare and although many people became unwell after using drugs at a dance festival or nightclub, for the most part, on-site medical staff could usually look after them without too many problems. That all changed when this liquid drug (the only drug bought and used in that form) started to be used by those on the dance scene. Suddenly people were passing out on dancefloors, their respiratory systems seemingly shutting down. If they were breathing it was only barely and then, to make matters worse, some of them would start to fit and convulse. We had no idea what was happening and some paramedics who arrived on the scene administered Narcan, believing they were seeing a heroin overdose. I remember working at one event in the late 90s where the medical team called almost 30 ambulances across a 3-hour period, often with the ambulance transporting 2 patients at a time!

GHB is a naturally-occurring neurotransmitter, as well as an illegal drug. GHB molecules exist in all of us and they are involved in the everyday functioning of the brain. One of the great problems with identifying if someone has died as a result of GHB is that the coroner has a difficult time in determining whether the GHB they find in the body was there to begin with or the person used the drug. It was first synthesized in the early 1960s and has been used in the treatment of schizophrenia, as an anaesthetic and even an aid to childbirth. For many years it could be bought over-the-counter in some parts of Europe and by prescription in others. 

When the drug first came onto the Australian scene back in the 90s (the first 'mass overdose' was outside a Gold Coast nightclub in 1996), users were actually using true GHB. This usually came in the form of a salty clear liquid but after the Gold Coast incident, governments across the country quickly made the drug illegal and we started to see another substance substituted - GBL or gamma butyrolactone. In fact, from what information we do have on the G available on the street, much of it is GBL and has been for some time.

Gamma butyrolactone (GBL), often used in products such as paint thinner, varnish and woodstripping products is mixed with other more easily obtainable substances to make GHB.  However, if GBL is taken into the body on its own, it metabolises into GHB, creating the same effects as GHB (although it can take a little longer to take effect, often leading to users thinking they haven't taken enough and then taking more and subsequently overdosing). It is an important solvent used in industry and, although it carries the same legal consequences as GHB if caught with it, it is easier to obtain (usually by contract burglaries or diversion from particular industries) and is also far more likely to be imported into the country illegally (there were 33 GHB detections by Customs in 2014-15, 133 GBL in the same time period). Although GHB is definitely preferred by users, it is more likely to be GBL they are being sold (why would dealers bother 'converting' the GBL if they don't need to?) ...

GHB/GBL is a powerful depressant and is highly 'dose-dependent', i.e., the difference between a 'pleasurable' effect and finding yourself in hospital on life-support is minimal. Take too much (and we are talking a usual dose for an adult man being around 2-2.5mls) and the user loses consciousness and their respiratory system may start to shut down. Why so many people overdose on it is because the 'high' they get from this drug is intense and when that feeling starts to subside (usually after about 40 to 90 mins), not surprisingly, they want to feel like that again. Mistakenly believing that the drug has worn off, they take another dose, not realising that they still have a reasonable amount in their system and subsequently overdose. It is rare (although not impossible) for users to overdose on their first dose (most tend to be young women who know little about the drug, who take a similar dose to the males they are with). Typically you see ambulances called to events when G users start to take their second and third doses (doses are usually spaced at least 2 hours apart) and this explains the 'waves' of overdoses that are usually reported.

When GHB first appeared on the scene, it was thought that using it with alcohol appeared to be the major cause of fatal overdose. When mixed with other drugs that slow the central nervous system, including alcohol and sleeping pills, the depressant effects of GHB are increased. This continues to be an issue and is the greatest concern of paramedics and emergency department workers who have to deal with this issue.

GHB/GBL is usually referred to by users as 'G'. When the Gold Coast incident occurred in the late 90s the term 'fantasy' was used by the media but I have never heard a regular user of the drug use that word. 'Liquid ecstasy' or 'liquid E' were certainly street terms used by dealers in the early 2000s to market the drug, particularly to young people, after GHB started to get negative publicity but it is important to remember that this drug is not related to ecstasy in any way. Goodness knows where the term 'coma in a bottle' comes from (maybe paramedics or law enforcement have referred to it in that way for obvious reasons) and I can guarantee you that no user of the drug would call it that - but it makes a great headline and, no doubt, we'll see it repeated many times.

When GBL (a liquid product) is converted into GHB it forms white crystals (as shown) that are then diluted into a liquid. This product is then sold to users by the millilitre. Most regular users purchase the drug in larger quantities (10, 20 or 50ml lots, some even by the litre!) and then take measured doses to events in small vials or bottles. Soy-fish containers (shown below) are particularly popular due to their size and the plastic they are made from, making them difficult to detect if users are searched or patted-down by security or law enforcement.

The term 'bad batch' was used by a number of media outlets, once again implying that there are 'good batches'. We see the media, as well as police, often use this to describe ecstasy when we see a cluster of overdoses or a death - it is not helpful and it is often based on no hard data. If we keep warning people about potential 'bad batches' when we actually don't know what really happened and we run the risk of being seen as the 'boy who cried wolf'. G is always a potentially risky drug and although it is true that due to the dilution process described above when converting GBL to GHB, some 'batches' may be considerably more concentrated than others, the overdoses are more likely to be due to a naïve group of users than anything else. GHB overdoses occur every weekend, in almost every city across the country, they are not unusual. Yes, the number was highly unusual but it's important not to throw around terms like 'bad batches' without any toxicological information ...  

Neither GHB or GBL (or any of the other substances such as that can be substituted for G) are odourless and tasteless and undetectable. Certainly GHB was originally available as a clear liquid but due to be it mistaken for water in a few well-publicised cases, manufacturers and dealers usually add food colouring to the mix. The colour was also used as a marketing tool. True GHB is often coloured blue and for a time was sold as 'blue nitro'. GBL used in industry is also usually coloured - most often a green or brown colour. None of these products are odourless and tasteless. Any user will tell you that at the very least G has a salty taste and, at worst, a particularly nasty chemical taste. It is certainly not undetectable, with users usually putting it into a sugary drink to avoid the unpleasant taste. It would appear that the taste is the easiest way to work out whether you have true GHB or GBL. GHB is usually a salt and will have a salty taste and smell (often described as similar to diluted sea water), whereas the solvent GBL is just that, a solvent. It has a very distinctive chemical taste and smell and is certainly not undetectable.

When GHB overdoses occur, the 'date-rape' death of an Australian woman on a cruise in 2002 and the drug's apparent use in drink spiking is also usually raised by the media in their reports. That was once again the case last weekend. Drink spiking is an area that people have very strong opinions on, particularly if they or someone they know believes they have been a victim of this crime. Although research shows that alcohol is most likely to be used in drink spiking crimes, many victims and their families, for a variety of reasons, refuse to accept that this is their case in their instance.

A number of drugs (including Rohypnol) are put forward as possible drugs that could be used but research has shown over and over again that, although routinely checked for, these drugs are rarely identified when someone is tested after an alleged spiking. The reason why GHB is often put forward as a likely drug to be used by perpetrators of this crime is due to the difficulty in identifying the drug in the system, i.e., if nothing else is found, it must be GHB.

There are, however, a number of issues with GHB being used in drink spiking. Firstly, it is a particularly dangerous drug to drop into someone's alcoholic drink or if the potential victim has been drinking. As appears to have been the case with the woman on the cruise, the mix can be lethal. Remember, this drug is highly dose-dependent. The spiker would have to be extremely careful with the dose they used and also have a general awareness of how much alcohol has already been consumed. But more importantly, as already discussed, anyone who has ever taken G knows that it is hardly tasteless and odourless – at the very least it is salty, at worst, extremely chemical tasting. This is hardly a drug you would not notice, unless you were pretty intoxicated. Could it be used in drink spiking? Absolutely! Is it likely to be used by perpetrators of this crime? Highly doubtful ...

We are going to continue to see issues with GHB/GBL - it has been around for over 20 years and won't be going anywhere, anytime soon. It is a particularly risky drug due to it being so dose-dependent and will continue to cause great problems for nightclub owners and promoters of dance events (who I can tell you, absolutely hate the drug!). The strain it puts on the ambulance service and emergency departments can be frightening. It does seem to have a bit of a resurgence in recent times however and that could be due to a number of factors:

• it is relatively cheap - nowhere as cheap as it once was (it was once $1 per ml!), but certainly in terms of 'bang for the buck', users see the cost as well worth it
• the quality is consistent - G really came into its own during a period when the quality of ecstasy was at an all time low. MDMA was difficult to find and people started to call ecstasy 'pills' - you didn't know what you were getting. G would always provide the required effect
• users believe that it is not one of the drugs that can be detected by drug detection dogs - little information is publicly available on what substances the dogs are trained to detect but ecstasy/MDMA and amphetamines are regularly found

As far as I am concerned, it is the drug dog issue, combined, of course, with the fact that users enjoy the effects of the drug, that have ensured its growing popularity amongst a particular subset of partygoers. There is absolutely no evidence that drug detection dogs have had any impact on reducing illicit drug use but we do know that this law enforcement strategy has changed how some people take their drugs. I believe that they have also contributed to some users changing the drugs they use, causing them to start using potentially more risky drugs such as GHB.