Harmen Beurmanjer

30 Chapter 2 Discussion This review aimed to create an overview of different GHB-using populations as described in the literature, in order to inform adequate policy responses. Overall, the included studies show young males to be overrepresented among people using GHB, and a high level of co-use of substances across different populations of people using GHB. The identified GHB-using populations can be roughly categorized by increasing severity level of GHB use as recreational use of GHB without adverse effects; recreational use of GHB with adverse effects, and people with GUD. Sexual minorities, mainly gay and bisexual men, using GHB might represent a specific subpopulation with a distinct GHB use pattern. A previous study distinguish three groups with increasing severity of GHB use: people with modest GHB experience (up to 50 times), considerable GHB experience (50 to 200 times) and abundant GHB experience (more than 200 times) (Grund, van Gaalen, & de Bruin, 2015). Where the first group tends to avoid passing out due to GHB overdose, the latter sees GHB-induced comas to be an unavoidable part of their GHB use. Despite the severity people using GHB generally experience a low level of concern with respect to those comas (Beurmanjer et al., 2019). The current synthesis of studies shows a classification based on the negative consequences instead of the amount of GHB. The negative consequences do have a relation with amount of use, but also with co-substance use and the reason to use GHB. The percentage of GHBrelated accidents, leading to potentially life-threatening situations and hospitalization (European Monitoring Centre for Drugs & Drug Addiction, 2017), is high compared to other drugs and this should be the focus of policy interventions. First, policy interventions should aim at preventing the transition from recreational substance use to GHB as most are experienced recreational substance users prior to starting GHB use. The Ecstasy and Related Drugs Reporting System (EDRS) is a good example that successfully tracked the increase of GHB use in Australia and could be of use to identify transitions to GHB use (Dunn, Topp, & Degenhardt, 2009). When people use GHB regularly, intervention programs should aim at reducing the level of GHB use and preventing GHB use-related harm (Phan, Arunogiri, & Lubman, 2020). As health issues and safety reasons are the main reasons for quitting GHB, besides legal issues (Anderson et al., 2010), prevention programs should focus on education about these risks. Furthermore, people using GHB often perceive overdose situations and comas as harmless (Beurmanjer et al., 2019; Palamar & Halkitis, 2006). Education about the potential lethal and long-term cognitive consequences of GHB use might contribute to reducing GHB use and GHB-related harm. Second, specific targeted intervention strategies might be required for prevention of transition to GUD. Specifically, people using GHB for non-recreational reasons (e.g. to cope with psychosocial problems) and/or those who are unemployedmight be at risk. However, it is a major challenge to reach out to these at-risk populations, since GHB use is often