Harmen Beurmanjer

75 Tapering GHB or BZDs for Detoxification in GHB-Dependent Patients 5 Future research on GHB detoxification should also focus on optimisation of the duration of detoxification and study whether some patients could profit more from one method or the other. For instance, it is likely that in patients with relatively low levels of GHB use, BZD tapering might be sufficient to counteract GHB withdrawal, whereas in patients using high levels of GHB pharmaceutical GHB might be the preferred option. Cost-effectivity should also be taken into account, as pharmaceutical GHB is more expensive than BZD’s. Future studies should also focus on the GABA-B agonist baclofen as an alternative for BZD and/or GHB tapering in GUD (Beurmanjer, Kamal, de Jong, Dijkstra, & Schellekens, 2018; Lingford-Hughes et al., 2016). Since baclofen has a longer half-life than GHB and targets GABA-B receptors, it might effectively suppress GHB withdrawal. Moreover, baclofen tapering might allow patients to quit using GHB, preventing withdrawal, with only three to four daily dosages (Beurmanjer et al., 2018; Kamal, Loonen, Dijkstra, & De Jong, 2015). Furthermore, baclofen has been suggested to be effective in reducing relapse after detoxification( Beurmanjer et al., 2018; Kamal et al., 2015). Given its similarities to GHB, baclofen might also be a candidate for GHB substitution therapy. The current findings should be viewed in the light of some limitations of this study. Given the explorative, non-randomized, design of the study and the fact that each treatment was assessed in a different country and a different institution, there is a risk for selection bias and procedural confounding respectively. However, the two groups were matched and did not differ on key variables, such as level of GHB use, duration of GHB use, co morbid substance use, age, and gender. Both populations were Dutch speaking, and The Netherlands and (Flemish) Belgium are culturally bound together. This minimizes the risk of an effect of language and cultural differences between groups. It is also important to note that both groups received a similar treatment by experienced medical staff. No additional (psychotherapy) treatment was offered at both institutes during detoxification, ruling out the influence of one treatment being more extensive than the other. Yet, any confounding effect of selection bias or treatment institute cannot be fully ruled out. Another possible limitation is that delirium assessments were based on clinical observations, as reported in the discharge summaries written by the treating psychiatrist and in the treatment outcome forms. The use of a structured scale, such as the Delirium Observation Screening Scale (DOS), might have been more reliable (Schuurmans, Shor- tridge-Baggett, & Duursma, 2003). Conclusion In patients with GUD, detoxification with pharmaceutical GHB showed less severe withdrawal symptoms and less adverse events, specifically delirium, than detoxification with BZD’s. This supports earlier work that BZD’s might not always sufficiently dampen withdrawal in GUD. Based on the current findings tapering with pharmaceutical GHB could be considered for patients with GHB dependence during detoxification, as it has potentially less severe withdrawal and less complications than benzodiazepine tapering.