Harmen Beurmanjer

100 Chapter 7 Considerations for treatment planning and organisation of care for patients with GUD The negative effects of acute GHB intoxication, withdrawal symptoms and risk for adverse events combined with limited illness insight, high anxiety levels, and cognitive impairment place clinicians for a dilemma; where and how to start with the treatment of GUD? On the one hand, we want patients quitting GHB as fast as possible in order to start both the physical and mental recovery, as well as lifting the negative effects of GHB intoxication on cognition. On the other hand, if we start detoxification with limited preparation, there’s a good chance that many patients are not fully aware what’s happening and will likely quit treatment during or soon after detoxification, given that they might feel overwhelmed being sober again with the return of stress, anxiety and the full realisation what has happened. Subsequent drop-out from treatment often leads to a fast relapse (25% within the first week)(Dijkstra et al., 2017), which results in a negative treatment experience and requires patients to start the same cycle over and over again. Looking at the severity of the problems in many domains in patients with GUD as observed in chapter 1-3, it is clear that many patients need extensive treatment and support in order to recover. Given the high drop-out rates, the main focus for improving treatment outcome in patients with GUD should be preventing drop-out, and increasing the period of sobriety. When the latter proves too difficult in the short run a different treatment approach should be undertaken, aimed at reducing harm and improving autonomy in the patient, as suggested by Koekkoek and colleagues(Koekkoek et al., 2011). In order to improve treatment delivery by health professionals, it is important that they have a good understanding of GUD and its accompanying behaviour. This will allow them to anticipate on the needs of patients during treatment. It is recommended that staff working with patients with GUD receives training and education regarding GUD. As a first step to achieve this, a guideline for the treatment of patients GUD (Joosten et al., 2020) was composed, based on the results of several recent studies, including this thesis. Methodological considerations The current thesis should be viewed in the light of several strengths and weaknesses. A major strength is the use of multiple methods to study the topic. We applied literature review, qualitative and quantitative designs, as well as cohort studies and clinical trials. We present the first model for the development of GUD and measured cognitive impairments in patients with GUD seeking treatment. Furthermore, we published the first comparative study into GHB detoxification comparing pharmaceutical GHB and benzodiazepines, and tested baclofen to prevent relapse for the first time. However, several limitations should also be considered during the interpretation of the current results. From the current literature (chapter 2) it becomes clear that there is