Harmen Beurmanjer

74 Chapter 5 group might thus also be related to more rapid detoxification with BZD tapering, compared to GHB tapering. Since the vast majority of patients receiving BZD tapering did not experience any adverse events and had on average a shorter detoxification period, it could be argued that pharmaceutical GHB tapering could also be done in seven days. However, this will likely increase withdrawal severity and possibly also the risk of adverse events like delirium. Some additional considerations regarding both treatment options as assessed in this study. First, tapering with GHB requires frequent administration of doses during the entire day and often also during the night. This is a demanding procedure for both the patient and staff. However, prevention of delirium and other adverse events of GHB withdrawal clearly outweighs the burden for patients and staff. Second, the length of admission in the GHB tapering group was shorter than reported in other publications on the Dutch GHB sample (Beurmanjer H, Verbrugge CAG, Schrijen S & DeJong CAJ, 2016; Dijkstra et al., 2017). The discrepancy in length of stay between this study and past GHB studies with the Dutch sample is likely accounted by the matching process, as the Belgium sample used, on average, a lower GHB dose than commonly reported in the Netherlands (Dijkstra et al., 2017). Patients using higher doses of street GHB are more likely to experience severe withdrawal and adverse events like delirium during detoxification and BZDs are less effective in preventing delirium in this population. Given that our study participants use lower-than-average doses of street GHB prior to detoxification, the current findings may be an underestimation of the beneficial effects of pharmaceutical GHB compared to BZD in more severe GUD populations. Lastly, substitution of ´street´ GHB with pharmaceutical GHB means that patients have to continue to use a substance that they are trying to quit. It can be speculated that this continued use could reinforce GHB use and sustain the compulsive pattern of use (Kwako & Koob, 2017). However, no differences in craving levels were found between the two groups, indicating that patients in the GHB group did not experience a stronger need to use than patients in the BZD group. It would be interesting to study if type of detoxification influences relapse rates after detoxification in future longitudinal studies. While future studies would ideally use randomized controlled designs to replicate our findings, this might not be feasible in this patient population for several reasons. First, patients with GUD often come into treatment in acute situations requiring immediate care due to a fast-developing severe withdrawal syndrome. This complicates informed consent and randomization procedures. Second, the results from the current study in combination with existing literature point towards potentially high risks of complications during BZD tapering in patients with GUD. This further complicates randomization to BZD versus GHB tapering from ethical point of view, as BZD tapering might be inferior to pharmaceutical GHB tapering. The current comparative study was mainly possible due to juridical restrictions of pharmaceutical GHB use in Belgium, offering the possibility of an observational non-randomized trial.