Harmen Beurmanjer

73 Tapering GHB or BZDs for Detoxification in GHB-Dependent Patients 5 Discussion This study compared BZD and GHB tapering in GUD patients. In line with the hypotheses GHB tapering was associated with a milder withdrawal syndrome and fewer adverse events (including delirium) during detoxification, compared to BZD treatment. Contrary to our hypothesis, no differences in craving scores between the two groups were found. These findings suggest that taperingwithpharmaceutical GHBmight bemore comfortable and safer than detoxification with BZD in patients with GUD. The difference in reported adverse events, in particular delirium, is highly relevant from a clinical perspective. In the GHB group one in forty patients developed delirium, in comparison to one in five in the BZD group. BZD might not sufficiently counteract GHB withdrawal symptoms in all patients (Craig et al., 2000; Neu, Sofin, & Danker-Hopfe, 2018; Strand, Petersen, Nielsen, & Boegevig, 2017; M. S. van Noorden et al., 2015). The current findings are in line with several case studies on detoxification of GUD patients, where delirium was common in BZD tapering, despite very high BZD doses (Craig et al., 2000; Kamal et al., 2017; Rosenberg, Deerfield, & Baruch, 2003). This difference might be explained by the different working mechanism of BZD´s and GHB. Where BZD’s primarily affect GABA-A receptors (Lorenz-Guertin et al., 2019), GHB binds to GABA-B and GHB receptors( Laborit, 1964). Withdrawal symptoms of GHB, probably mediated through GABA-B and GHB receptors, might thus not be sufficiently suppressed through BZD acting through GABA-A. Furthermore, BZD use has been associated with the development delirium in some cases (Zaal et al., 2015). This might have further contributed to the increased risk of delirium in the BZD group. In the present study withdrawal symptoms were more severe in patients treated with BZD from the start of detoxification, compared to patients treated with pharmaceutical GHB. This might be related to differences in the titration procedure between the two conditions. Where initiation of BZD administration was based on increased blood pressure and/or heart rate (symptom triggered), pharmaceutical GHB administration was initiated two hours after the last ingestion of street GHB, and then continued every two hours in a fixed schedule. Furthermore, patients might develop withdrawal symptoms before their blood pressure and/or heartrate increase. Therefore, patients treated with pharmaceutical GHB might have experienced fewer withdrawal symptoms from the start of detoxification than patients treated with BZD. Therefore, differences in titration procedure between the conditions might also have contributed to the differences in withdrawal severity that we observed. Another important difference between BZD and GHB detoxification is the duration of the detoxification. Tapering with BZD’s took on average seven days and tapering with GHB eleven. GHB detoxification thus seems more gradual, and might therefore be associated with fewer withdrawal symptoms and adverse events, including delirium, as compared to BZD tapering. The observed increased withdrawal severity and risk for delirium in the BZD