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mg/kg IV. If there is no response despite the suspicion of opiate intoxication, the
naloxone dose should be repeated (up to a total dose of 8 to 10 mg), depending on
effect and level of suspicion.

γ-Hydroxybutyrate, γ-Hydroxybutyrolactone, and 1,4Butanediol
Current Evidence
The related agents, γ-hydroxybutyrate (GHB), γ-hydroxybutyrolactone (GBL),
and 1,4-butanediol (1,4 BD), became popular substances of abuse among
teenagers and young adults in the late 1990s and early 2000s. These agents are
used for a variety of reasons, but primarily as euphoriants and aphrodisiacs at
parties or all-night dance clubs (“raves”). GHB has gained a particular notoriety
as a date-rape agent. This class also has a reputation in the body-builder
community as growth hormone stimulants and thus enhancers of muscle
development and fat loss. Medically, sodium oxybate (Xyrem) is available as a
schedule III substance used to treat cataplexy.
GHB is an endogenous compound with neurotransmitter and/or
neuromodulator function and interacts with dopamine, serotonin, GABA, and
endogenous opioid-based neural systems. GBL is actually a precursor to GHB
and is rapidly metabolized in vivo to GHB, thus the clinical effects of ingesting
either agent are nearly indistinguishable. 1,4 BD is also metabolized to GHB via
alcohol dehydrogenase.
Clinical Considerations
GHB, GBL, and 1,4 BD are CNS depressants that cause rapid onset of deep sleep
that can progress to coma and respiratory depression. Patients who have
overdosed may have transient seizure activity or myoclonus and are often
hypothermic and bradycardic. The coma is usually relatively short in duration, on
the order of 1 to 2 hours. During emergence, transient delirium and vomiting are
often observed. Depressed respiratory effort and airway-protective reflexes are
common in the more severe cases, although aspiration pneumonia has been a rare
complication. Many patients are surprisingly responsive to stimulus, and attempts
at laryngoscopy to effect endotracheal intubation in a seemingly deeply comatose

patient may result in an angry, combative patient who sits up and swears at the
endoscopist.
Most patients with acute overdose can be managed with the provision of
ambient oxygen, suctioning, and attention to the airway. A nasal trumpet is
helpful in some cases, and endotracheal intubation may be required. Atropine has