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Early Career in Drug Abuse with Preference for �-hydroxybutyrate Resulted in Mixed Drug Overdose Death


 
AW Jones1 and FC Kugelberg1,2

1Department of Clinical Pharmacology, Faculty of Health Sciences, Link�ping University, Link�ping, Sweden and 1,2 Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12,  Link�ping, Sweden,




Correspondence to:
 Professor AW Jones
e-mail  HYPERLINK "mailto:wayne.jones@liu.se" wayne.jones@liu.se
Abstract
�-hydroxybutyrate (GHB) is a depressant of the central nervous system (CNS) and is a highly dangerous recreational drug of abuse. GHB is commonly encountered in forensic investigations of living and deceased persons. Results are presented from the toxicological analysis of blood and/or urine in one person who was arrested 28 times for use of illicit drugs. Over a 13 y period, GHB was identified on 21 occasions, either in blood (6 times) or urine (15 times). Another favourite drug of abuse was amphetamine, which was identified 15 times. The man died of a mixed-drug overdose aged just 29 y mainly from GHB intoxication with 200 mg/L in blood and 4700 mg/L in urine. The much higher concentration of GHB in urine compared with blood suggests that the ante-mortem concentration of GHB in blood was considerable higher than 200 mg/L.

Key words; abuse, drugs, death, GHB, intoxication, poisoning.

Introduction
Among drugs of abuse the short-chain carboxylic acid �-hydroxybutyric acid (GHB) is particularly dangerous, owing to the narrow margin of safety between a recreational dose and a fatal overdose  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_1" \o "Zvosec, 2011 #219" 1, HYPERLINK \l "_ENREF_2" \o "Galicia, 2011 #318" 2). In the form of its sodium salt (sodium oxybate), GHB is also registered in some countries as a pharmaceutical product for treatment of narcolepsy (Xyrem�) or alcohol withdrawal (Alcover�)  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_3" \o "Fuller, 2004 #565" 3, HYPERLINK \l "_ENREF_4" \o "Skala, 2014 #482" 4). 

GHB first emerged as a recreational drug of abuse in Sweden in the early 1990s and although its popularity has fluctuated over the years, this central nervous system (CNS) depressant is commonly encountered in forensic investigations of living and deceased persons  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_5" \o "Jones, 2008 #233" 5, HYPERLINK \l "_ENREF_6" \o "Kugelberg, 2010 #226" 6).  The Swedish government added GHB to the list of scheduled drugs in 2000, and although this initially led to fewer instances of abuse, the effect was short lived. Two precursor drugs �-butyrolactone (GBL) and 1,4-butanediol (BD), which are not controlled substances, continued to be abused  ADDIN EN.CITE <EndNote><Cite><Author>Brunt</Author><Year>2014</Year><RecNum>293</RecNum><DisplayText>(7)</DisplayText><record><rec-number>293</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">293</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brunt, T. M.</author><author>van Amsterdam, J. G.</author><author>van den Brink, W.</author></authors></contributors><auth-address>Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Da Costakade 45, 3521 VS Utrecht, The Netherlands. TBrunt@trimbos.nl.</auth-address><titles><title>GHB, GBL and 1,4-BD Addiction</title><secondary-title>Curr Pharm Des</secondary-title><alt-title>Current pharmaceutical design</alt-title></titles><periodical><full-title>Curr Pharm Des</full-title><abbr-1>Current pharmaceutical design</abbr-1></periodical><alt-periodical><full-title>Curr Pharm Des</full-title><abbr-1>Current pharmaceutical design</abbr-1></alt-periodical><pages>4076-85</pages><volume>20</volume><number>25</number><dates><year>2014</year></dates><isbn>1873-4286 (Electronic)&#xD;1381-6128 (Linking)</isbn><accession-num>24001290</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/24001290</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Brunt, 2014 #293" 7). These organic solvents (GBL and BD) are relatively easy to obtain and available for purchase over the internet and after ingestion these substances are rapidly converted into GHB  ADDIN EN.CITE <EndNote><Cite><Author>Schep</Author><Year>2012</Year><RecNum>199</RecNum><DisplayText>(8)</DisplayText><record><rec-number>199</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">199</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schep, L. J.</author><author>Knudsen, K.</author><author>Slaughter, R. J.</author><author>Vale, J. A.</author><author>Megarbane, B.</author></authors></contributors><auth-address>National Poisons Centre, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. leo.schep@otago.ac.nz</auth-address><titles><title>The clinical toxicology of gamma-hydroxybutyrate, gamma-butyrolactone and 1,4-butanediol</title><secondary-title>Clin Toxicol (Phila)</secondary-title><alt-title>Clinical toxicology</alt-title></titles><periodical><full-title>Clin Toxicol (Phila)</full-title><abbr-1>Clinical toxicology</abbr-1></periodical><alt-periodical><full-title>Clin Toxicol (Phila)</full-title><abbr-1>Clinical toxicology</abbr-1></alt-periodical><pages>458-70</pages><volume>50</volume><number>6</number><keywords><keyword>4-Butyrolactone/pharmacokinetics/*poisoning</keyword><keyword>Antidotes/therapeutic use</keyword><keyword>Butylene Glycols/pharmacokinetics/*poisoning</keyword><keyword>Charcoal/therapeutic use</keyword><keyword>Humans</keyword><keyword>Sodium Oxybate/pharmacokinetics/*poisoning</keyword><keyword>Substance Withdrawal Syndrome</keyword><keyword>Therapeutic Irrigation</keyword><keyword>Tissue Distribution</keyword></keywords><dates><year>2012</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1556-9519 (Electronic)&#xD;1556-3650 (Linking)</isbn><accession-num>22746383</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/22746383</url></related-urls></urls><electronic-resource-num>10.3109/15563650.2012.702218</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_8" \o "Schep, 2012 #199" 8)

Forensic evidence of GHB intake is not always easy to obtain because of the drug�s short plasma elimination half-life of ~30 min  ADDIN EN.CITE <EndNote><Cite><Author>Brailsford</Author><Year>2012</Year><RecNum>203</RecNum><DisplayText>(9)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brailsford, A. D.</author><author>Cowan, D. A.</author><author>Kicman, A. T.</author></authors></contributors><auth-address>Department of Forensic Sciences and Drug Monitoring, Drug Control Centre, King&apos;s College London, London SE1 9NH, UK. alan.brailsford@kcl.ac.uk</auth-address><titles><title>Pharmacokinetic properties of gamma-hydroxybutyrate (GHB) in whole blood, serum, and urine</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>88-95</pages><volume>36</volume><number>2</number><keywords><keyword>4-Butyrolactone/blood/urine</keyword><keyword>Administration, Oral</keyword><keyword>Adult</keyword><keyword>Calibration</keyword><keyword>Female</keyword><keyword>Gas Chromatography-Mass Spectrometry/methods</keyword><keyword>Humans</keyword><keyword>Liquid-Liquid Extraction</keyword><keyword>Male</keyword><keyword>Quality Control</keyword><keyword>Reproducibility of Results</keyword><keyword>Retrospective Studies</keyword><keyword>Sodium Oxybate/*blood/*pharmacokinetics/*urine</keyword><keyword>Young Adult</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1945-2403 (Electronic)&#xD;0146-4760 (Linking)</isbn><accession-num>22337777</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/22337777</url></related-urls></urls><electronic-resource-num>10.1093/jat/bkr023</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_9" \o "Brailsford, 2012 #203" 9). The concentrations of GHB in blood and/or urine after recreational doses decrease below the currently used laboratory cut-off levels of 5-10 mg/L fairly rapidly  ADDIN EN.CITE <EndNote><Cite><Author>Andresen</Author><Year>2010</Year><RecNum>329</RecNum><DisplayText>(10)</DisplayText><record><rec-number>329</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">329</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Andresen, H.</author><author>Sprys, N.</author><author>Schmoldt, A.</author><author>Mueller, A.</author><author>Iwersen-Bergmann, S.</author></authors></contributors><auth-address>Department of Toxicology, Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Butenfeld 34, 22529 Hamburg, Germany. h.andresen@uke.uni-hamburg.de</auth-address><titles><title>Gamma-hydroxybutyrate in urine and serum: additional data supporting current cut-off recommendations</title><secondary-title>Forensic Sci Int</secondary-title><alt-title>Forensic science international</alt-title></titles><periodical><full-title>Forensic Sci Int</full-title><abbr-1>Forensic science international</abbr-1></periodical><alt-periodical><full-title>Forensic Sci Int</full-title><abbr-1>Forensic science international</abbr-1></alt-periodical><pages>93-9</pages><volume>200</volume><number>1-3</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Forensic Toxicology</keyword><keyword>Gas Chromatography-Mass Spectrometry</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Narcotics/*blood/*urine</keyword><keyword>Postmortem Changes</keyword><keyword>Reference Values</keyword><keyword>Sodium Oxybate/*blood/*urine</keyword></keywords><dates><year>2010</year><pub-dates><date>Jul 15</date></pub-dates></dates><isbn>1872-6283 (Electronic)&#xD;0379-0738 (Linking)</isbn><accession-num>20418032</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/20418032</url></related-urls></urls><electronic-resource-num>10.1016/j.forsciint.2010.03.035</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_10" \o "Andresen, 2010 #329" 10). Nevertheless, GHB is commonly identified in blood samples from impaired drivers and also in forensic autopsies involving drug intoxication deaths. 

Although much discussed as a potential date-rape drug, the evidence that victims were incapacitated by GHB is very limited, at least in part, because of the delays in obtaining body fluids for analysis  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_11" \o "Marinetti, 2010 #524" 11, HYPERLINK \l "_ENREF_12" \o "Jones, 2008 #460" 12).  The sampling of blood and urine in forensic investigations for analysis of GHB must be done expeditiously to ensure optimal analytical results. Analysis of GHB in hair strands offers a way to extend the window of detection for this drug of abuse after single exposure and has been used in date-rape cases  ADDIN EN.CITE <EndNote><Cite><Author>Goulle</Author><Year>2003</Year><RecNum>446</RecNum><DisplayText>(13)</DisplayText><record><rec-number>446</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">446</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Goulle, J. P.</author><author>Cheze, M.</author><author>Pepin, G.</author></authors></contributors><auth-address>Laboratoire de PharmacocInetique et de Toxicologie Cliniques, Hopital Jacques Monod, BP 24, 76083 Le Havre, France.</auth-address><titles><title>Determination of endogenous levels of GHB in human hair. Are there possibilities for the identification of GHB administration through hair analysis in cases of drug-facilitated sexual assault?</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>574-80</pages><volume>27</volume><number>8</number><keywords><keyword>Dose-Response Relationship, Drug</keyword><keyword>Female</keyword><keyword>Gas Chromatography-Mass Spectrometry/methods</keyword><keyword>Hair/*chemistry</keyword><keyword>Hair Color</keyword><keyword>Humans</keyword><keyword>Hydroxybutyrates/administration &amp; dosage/adverse effects/*metabolism</keyword><keyword>Male</keyword><keyword>*Rape</keyword><keyword>Reproducibility of Results</keyword><keyword>Substance Abuse Detection/*methods</keyword></keywords><dates><year>2003</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>0146-4760 (Print)&#xD;0146-4760 (Linking)</isbn><accession-num>14670136</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/14670136</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_13" \o "Goulle, 2003 #446" 13). 

Methods
In our laboratory, the analysis of GHB in blood and urine is done by conversion to �-butyro-lactone (GBL) and analysis of the latter by gas chromatography (GC) with a flame ionization detector (FID). This GC-FID-GBL method was recently reviewed and considered reliable for use in forensic toxicology  ADDIN EN.CITE <EndNote><Cite><Author>Ingels</Author><Year>2014</Year><RecNum>283</RecNum><DisplayText>(14)</DisplayText><record><rec-number>283</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">283</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ingels, A. S.</author><author>Wille, S. M.</author><author>Samyn, N.</author><author>Lambert, W. E.</author><author>Stove, C. P.</author></authors></contributors><auth-address>Laboratory of Toxicology, Faculty of Pharmaceutical Sciences, Ghent University, Harelbekestraat 72, 9000, Ghent, Belgium.</auth-address><titles><title>Screening and confirmation methods for GHB determination in biological fluids</title><secondary-title>Anal Bioanal Chem</secondary-title><alt-title>Analytical and bioanalytical chemistry</alt-title></titles><periodical><full-title>Anal Bioanal Chem</full-title><abbr-1>Analytical and bioanalytical chemistry</abbr-1></periodical><alt-periodical><full-title>Anal Bioanal Chem</full-title><abbr-1>Analytical and bioanalytical chemistry</abbr-1></alt-periodical><pages>3553-77</pages><volume>406</volume><number>15</number><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1618-2650 (Electronic)</isbn><accession-num>24500753</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/24500753</url></related-urls></urls><electronic-resource-num>10.1007/s00216-013-7586-6</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_14" \o "Ingels, 2014 #283" 14). The analytical cut-off concentrations used to report positive GHB results was 5 mg/L in blood from living cases and 30 mg/L in autopsy cases  ADDIN EN.CITE <EndNote><Cite><Author>Jones</Author><Year>2007</Year><RecNum>191</RecNum><DisplayText>(15)</DisplayText><record><rec-number>191</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">191</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jones, A. W.</author><author>Holmgren, A.</author><author>Kugelberg, F. C.</author></authors></contributors><auth-address>Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, SE-581 33 Linkoping, Sweden. wayne.jones@RMV.SE</auth-address><titles><title>Gamma-hydroxybutyrate concentrations in the blood of impaired drivers, users of illicit drugs, and medical examiner cases</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>566-72</pages><volume>31</volume><number>9</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Automobile Driving</keyword><keyword>Female</keyword><keyword>Forensic Medicine</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Sodium Oxybate/*blood</keyword><keyword>Street Drugs/*blood</keyword><keyword>Substance Abuse Detection</keyword></keywords><dates><year>2007</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>0146-4760 (Print)&#xD;0146-4760 (Linking)</isbn><accession-num>18093415</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/18093415</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_15" \o "Jones, 2007 #191" 15). The corresponding cut-off concentrations for analysis of GHB in urine were 10 mg/L in living cases and 20 mg/L in autopsy cases.  All results from toxicological analysis were entered into a forensic database (TOXBASE), which was used to retrieve information necessary for preparation of this article of a chronic abuser of GHB leading to premature death. 

Case report
This example of GHB abuse includes a time-line of illicit drug abuse (Table 1) in one male person, who was repeatedly arrested by the police over a period of 13 years. This person was first arrested aged just 16 y, although toxicology results were negative. When re-arrested a few years later GHB was identified in blood at a concentration of 78 mg/L and re-arrests for illicit drug use occurred a total of 28 times and the man died of a mixed drug overdose aged 29 y, with GHB one of the drug identified at autopsy. 

A search of TOXBASE showed the man was registered 29 times over a 13 year period with GHB identified on 21 occasions, either in blood (6 times) or urine (15 times). Another favourite drug of abuse was amphetamine (15 occasions), although this stimulant was not present in blood at the time of death.

Table 1 here

The autopsy report and death certificate gave cause of death as �mixed-drug intoxication� and both GHB and amitriptyline were at high concentrations and no doubt contributed to toxic response. The GHB concentration in blood was 200 mg/L although in urine it was considerably higher at 4700 mg/L. The much higher concentration of GHB in urine compared with blood suggests that considerable time had elapsed after intake of GHB until death and that the concentration in blood had decreased through metabolism, with no metabolism occurring in the bladder. 

The high concentration of GHB in urine (4700 mg/L) gives convincing evidence that the concentration in blood was much higher than 200 mg/L (autopsy report) some time before death occurred. However, it would be speculative to estimate this concentration from the concentration in urine, because the GHB urine/blood relationship, to our knowledge, has not been determined by controlled dosing studies. However, the serum/blood distribution ratio of GHB was recently reported as 1.35:1  ADDIN EN.CITE <EndNote><Cite><Author>Brailsford</Author><Year>2012</Year><RecNum>203</RecNum><DisplayText>(9)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brailsford, A. D.</author><author>Cowan, D. A.</author><author>Kicman, A. T.</author></authors></contributors><auth-address>Department of Forensic Sciences and Drug Monitoring, Drug Control Centre, King&apos;s College London, London SE1 9NH, UK. alan.brailsford@kcl.ac.uk</auth-address><titles><title>Pharmacokinetic properties of gamma-hydroxybutyrate (GHB) in whole blood, serum, and urine</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>88-95</pages><volume>36</volume><number>2</number><keywords><keyword>4-Butyrolactone/blood/urine</keyword><keyword>Administration, Oral</keyword><keyword>Adult</keyword><keyword>Calibration</keyword><keyword>Female</keyword><keyword>Gas Chromatography-Mass Spectrometry/methods</keyword><keyword>Humans</keyword><keyword>Liquid-Liquid Extraction</keyword><keyword>Male</keyword><keyword>Quality Control</keyword><keyword>Reproducibility of Results</keyword><keyword>Retrospective Studies</keyword><keyword>Sodium Oxybate/*blood/*pharmacokinetics/*urine</keyword><keyword>Young Adult</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1945-2403 (Electronic)&#xD;0146-4760 (Linking)</isbn><accession-num>22337777</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/22337777</url></related-urls></urls><electronic-resource-num>10.1093/jat/bkr023</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_9" \o "Brailsford, 2012 #203" 9). GHB is completely miscible with water and does not bind to plasma proteins, so the urine-to-blood distribution ratio of GHB for freshly produced urine is probably similar to the serum/blood ratio.  

The most important co-ingested drug in terms of potential toxicity is the antidepressant amitriptyline and its metabolite nortriptyline  ADDIN EN.CITE <EndNote><Cite><Author>Reis</Author><Year>2007</Year><RecNum>572</RecNum><DisplayText>(16)</DisplayText><record><rec-number>572</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">572</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Reis, M.</author><author>Aamo, T.</author><author>Ahlner, J.</author><author>Druid, H.</author></authors></contributors><auth-address>Department of Clinical Pharmacology, Linkoping University, Sweden.</auth-address><titles><title>Reference concentrations of antidepressants. A compilation of postmortem and therapeutic levels</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>254-64</pages><volume>31</volume><number>5</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antidepressive Agents/*blood/*poisoning</keyword><keyword>Cause of Death</keyword><keyword>Child</keyword><keyword>Ethanol/blood</keyword><keyword>Female</keyword><keyword>Femoral Vein</keyword><keyword>Forensic Toxicology/*methods</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Postmortem Changes</keyword><keyword>Reference Values</keyword><keyword>Sex Factors</keyword></keywords><dates><year>2007</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0146-4760 (Print)&#xD;0146-4760 (Linking)</isbn><accession-num>17579969</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/17579969</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_16" \o "Reis, 2007 #572" 16). In a series of N = 233 forensic autopsies in which amitriptyline was identified in blood, the median concentration was 0.40 mg/L and the 97.5th percentile concentration was 3.96 mg/L  ADDIN EN.CITE <EndNote><Cite><Author>Jones</Author><Year>2009</Year><RecNum>573</RecNum><DisplayText>(17)</DisplayText><record><rec-number>573</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">573</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jones, A. W.</author><author>Holmgren, A.</author></authors></contributors><auth-address>Department of Forensic Toxicology, Artillerigatan 12, 58758 Linkoping, Sweden. wayne.jones@rmv.se</auth-address><titles><title>Concentration distributions of the drugs most frequently identified in post-mortem femoral blood representing all causes of death</title><secondary-title>Med Sci Law</secondary-title><alt-title>Medicine, science, and the law</alt-title></titles><periodical><full-title>Med Sci Law</full-title><abbr-1>Medicine, science, and the law</abbr-1></periodical><alt-periodical><full-title>Med Sci Law</full-title><abbr-1>Medicine, science, and the law</abbr-1></alt-periodical><pages>257-73</pages><volume>49</volume><number>4</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Central Nervous System Depressants/*blood</keyword><keyword>Child</keyword><keyword>Chromatography, Gas</keyword><keyword>Ethanol/*blood</keyword><keyword>Female</keyword><keyword>*Forensic Toxicology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pharmaceutical Preparations/*blood</keyword><keyword>Street Drugs/*blood</keyword><keyword>Sweden</keyword><keyword>Young Adult</keyword></keywords><dates><year>2009</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0025-8024 (Print)&#xD;0025-8024 (Linking)</isbn><accession-num>20025102</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/20025102</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_17" \o "Jones, 2009 #573" 17). The blood concentration of amitriptyline (5 mg/L) in this overdose death is definitely at a dangerously high level. The concentrations of other drugs identified, diazepam, tramadol, paracetamol and ethanol were fairly low and insignificant.   

Discussion
GHB is a depressant of the CNS and exerts its effects via the GABA-B receptor complex as well as a purported specific GHB receptor  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_18" \o "Bay, 2014 #292" 18, HYPERLINK \l "_ENREF_19" \o "Tyacke, 2010 #449" 19). Co-ingestion of other depressants, such as ethanol, enhances the effects of GHB thus increasing the risk of overdosing, toxicity and death  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_20" \o "Knudsen, 2010 #220" 20). 

Compared with other illicit recreational drugs, GHB is relatively cheap to buy and although listed as a scheduled drug since 2000 the precursors (GBL and BD) are not controlled substances. This case report suggests that people become addicted to GHB and after regular use develop tolerance and physical dependence. Abrupt cessation of GHB intake leads to agitation, confusion, delirium, and hallucinations  ADDIN EN.CITE <EndNote><Cite><Author>Tarabar</Author><Year>2004</Year><RecNum>348</RecNum><DisplayText>(21)</DisplayText><record><rec-number>348</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">348</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tarabar, A. F.</author><author>Nelson, L. S.</author></authors></contributors><auth-address>New York City Poison Control Center, New York, New York, USA. asim.tarabar@yale.edu</auth-address><titles><title>The gamma-hydroxybutyrate withdrawal syndrome</title><secondary-title>Toxicol Rev</secondary-title><alt-title>Toxicological reviews</alt-title></titles><periodical><full-title>Toxicol Rev</full-title><abbr-1>Toxicological reviews</abbr-1></periodical><alt-periodical><full-title>Toxicol Rev</full-title><abbr-1>Toxicological reviews</abbr-1></alt-periodical><pages>45-9</pages><volume>23</volume><number>1</number><keywords><keyword>4-Butyrolactone/adverse effects</keyword><keyword>Humans</keyword><keyword>Sodium Oxybate/*adverse effects/pharmacokinetics/therapeutic use</keyword><keyword>Substance Withdrawal Syndrome/drug therapy/*physiopathology</keyword><keyword>Substance-Related Disorders/physiopathology</keyword></keywords><dates><year>2004</year></dates><isbn>1176-2551 (Print)&#xD;1176-2551 (Linking)</isbn><accession-num>15298492</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/15298492</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_21" \o "Tarabar, 2004 #348" 21) and this requires treatment with benzodiazepines  ADDIN EN.CITE <EndNote><Cite><Author>McDonough</Author><Year>2004</Year><RecNum>514</RecNum><DisplayText>(22)</DisplayText><record><rec-number>514</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">514</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McDonough, M.</author><author>Kennedy, N.</author><author>Glasper, A.</author><author>Bearn, J.</author></authors></contributors><auth-address>Addictions Directorate, South London and Maudsley Trust and Institute of Psychiatry, King&apos;s College, London SE5 8AF, UK. mmcdonough@stpatsmail.com</auth-address><titles><title>Clinical features and management of gamma-hydroxybutyrate (GHB) withdrawal: a review</title><secondary-title>Drug Alcohol Depend</secondary-title><alt-title>Drug and alcohol dependence</alt-title></titles><periodical><full-title>Drug Alcohol Depend</full-title><abbr-1>Drug and alcohol dependence</abbr-1></periodical><alt-periodical><full-title>Drug Alcohol Depend</full-title><abbr-1>Drug and alcohol dependence</abbr-1></alt-periodical><pages>3-9</pages><volume>75</volume><number>1</number><keywords><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Sodium Oxybate/*adverse effects</keyword><keyword>Substance Withdrawal Syndrome/physiopathology/*therapy</keyword><keyword>Substance-Related Disorders/physiopathology/*therapy</keyword></keywords><dates><year>2004</year><pub-dates><date>Jul 15</date></pub-dates></dates><isbn>0376-8716 (Print)&#xD;0376-8716 (Linking)</isbn><accession-num>15225884</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/15225884</url></related-urls></urls><electronic-resource-num>10.1016/j.drugalcdep.2004.01.012</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_22" \o "McDonough, 2004 #514" 22). 

Comparing concentrations of GHB in both blood and urine provides usefulness information in post-mortem toxicology when the results are interpreted  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_6" \o "Kugelberg, 2010 #226" 6).  The GHB concentrations in bladder urine reflect the concentration in blood during the time period that the urine was being produced in the kidney and stored in the bladder  ADDIN EN.CITE <EndNote><Cite><Author>Jones</Author><Year>2006</Year><RecNum>569</RecNum><DisplayText>(23)</DisplayText><record><rec-number>569</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">569</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jones, A. W.</author></authors></contributors><auth-address>Department of Forensic Chemistry and Genetics, National Board of Forensic Medicine, and University Hospital, Linkoping, Sweden. wayne.jones@rmv.se</auth-address><titles><title>Urine as a biological specimen for forensic analysis of alcohol and variability in the urine-to-blood relationship</title><secondary-title>Toxicol Rev</secondary-title></titles><periodical><full-title>Toxicol Rev</full-title><abbr-1>Toxicological reviews</abbr-1></periodical><pages>15-35</pages><volume>25</volume><number>1</number><keywords><keyword>Area Under Curve</keyword><keyword>Automobile Driving</keyword><keyword>Ethanol/*blood/*urine</keyword><keyword>*Forensic Medicine</keyword><keyword>Humans</keyword><keyword>Metabolic Clearance Rate</keyword><keyword>Substance Abuse Detection/*methods</keyword><keyword>Urinalysis</keyword></keywords><dates><year>2006</year></dates><accession-num>16856767</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16856767 </url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_23" \o "Jones, 2006 #569" 23). The urine/blood ratio of GHB for a freshly voided specimen is expected to be about 1.3-1.4:1 based on differences in water content and lack of binding to plasma proteins  ADDIN EN.CITE <EndNote><Cite><Author>Brailsford</Author><Year>2012</Year><RecNum>203</RecNum><DisplayText>(9)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brailsford, A. D.</author><author>Cowan, D. A.</author><author>Kicman, A. T.</author></authors></contributors><auth-address>Department of Forensic Sciences and Drug Monitoring, Drug Control Centre, King&apos;s College London, London SE1 9NH, UK. alan.brailsford@kcl.ac.uk</auth-address><titles><title>Pharmacokinetic properties of gamma-hydroxybutyrate (GHB) in whole blood, serum, and urine</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>88-95</pages><volume>36</volume><number>2</number><keywords><keyword>4-Butyrolactone/blood/urine</keyword><keyword>Administration, Oral</keyword><keyword>Adult</keyword><keyword>Calibration</keyword><keyword>Female</keyword><keyword>Gas Chromatography-Mass Spectrometry/methods</keyword><keyword>Humans</keyword><keyword>Liquid-Liquid Extraction</keyword><keyword>Male</keyword><keyword>Quality Control</keyword><keyword>Reproducibility of Results</keyword><keyword>Retrospective Studies</keyword><keyword>Sodium Oxybate/*blood/*pharmacokinetics/*urine</keyword><keyword>Young Adult</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1945-2403 (Electronic)&#xD;0146-4760 (Linking)</isbn><accession-num>22337777</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/22337777</url></related-urls></urls><electronic-resource-num>10.1093/jat/bkr023</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_9" \o "Brailsford, 2012 #203" 9). The much higher urine/blood concentration ratio in these post-mortem specimens verifies that the ante-mortem GHB concentration in blood was a lot higher than 200 mg/L. This follows from the short plasma elimination half-life of GHB determined to be in the range 0.5-1 h  ADDIN EN.CITE <EndNote><Cite><Author>Brailsford</Author><Year>2012</Year><RecNum>203</RecNum><DisplayText>(9)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brailsford, A. D.</author><author>Cowan, D. A.</author><author>Kicman, A. T.</author></authors></contributors><auth-address>Department of Forensic Sciences and Drug Monitoring, Drug Control Centre, King&apos;s College London, London SE1 9NH, UK. alan.brailsford@kcl.ac.uk</auth-address><titles><title>Pharmacokinetic properties of gamma-hydroxybutyrate (GHB) in whole blood, serum, and urine</title><secondary-title>J Anal Toxicol</secondary-title><alt-title>Journal of analytical toxicology</alt-title></titles><periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></periodical><alt-periodical><full-title>J Anal Toxicol</full-title><abbr-1>Journal of analytical toxicology</abbr-1></alt-periodical><pages>88-95</pages><volume>36</volume><number>2</number><keywords><keyword>4-Butyrolactone/blood/urine</keyword><keyword>Administration, Oral</keyword><keyword>Adult</keyword><keyword>Calibration</keyword><keyword>Female</keyword><keyword>Gas Chromatography-Mass Spectrometry/methods</keyword><keyword>Humans</keyword><keyword>Liquid-Liquid Extraction</keyword><keyword>Male</keyword><keyword>Quality Control</keyword><keyword>Reproducibility of Results</keyword><keyword>Retrospective Studies</keyword><keyword>Sodium Oxybate/*blood/*pharmacokinetics/*urine</keyword><keyword>Young Adult</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1945-2403 (Electronic)&#xD;0146-4760 (Linking)</isbn><accession-num>22337777</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/22337777</url></related-urls></urls><electronic-resource-num>10.1093/jat/bkr023</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_9" \o "Brailsford, 2012 #203" 9). 

Besides information in this toxicology database, which is restricted to arrests made for taking illicit drugs, the person in question had probably on other occasions over the 13 y period abused drugs. The cause of death was attributed to a mixed drug intoxication involving GHB and amitriptyline, although the question of whether the overdose was accidental or intentional was left open. 


Declaration

There was no external funding applied for or received to prepare this manuscript and the authors do not consider conflicts of interest exist that hinder publication of this case report in an international journal. Table 1
Toxicological results from analysis of blood and urine in one person arrested 28 times for abuse of illicit drugs. The last registration in our database was autopsy after a mixed-drug overdose aged 29 y.

OffenceAge (y)DateGHB in blood (mg/L)GHB in urine (mg/L)Other drugs in blood (mg/L)Other drugs in urine (mg/L)116Sept 1994n.a.an.a.n.a.None 222Feb  200078n.a.Negativen.a.322Feb  2000260n.a.n.a.n.a.422Mar  2000n.a.370n.a.Carboxy-THC (0.02)523Dec 2001Negativen.a.Amphetamine (0.3)n.a.624Sept 200275n.a.Negativen.a.724Nov 2002140n.a.Amphetamine (0.05)n.a.826Feb  2005n.a.1300n.a.None 927Jan  2006160n.a.Negativen.a.1028Mar 200673n.a.Nordiazepam (0.1)n.a.1128May 2006n.a.2900n.a.Amphetamine (95)1228June 2006n.a.2100n.a.Amphetamine (0.3)1328June 2006n.a.n.a.n.a.Amphetamine (3.0)1428June 2006n.a.940n.a.Amphetamine (2.0)1528July 2006n.a.750n.a.Amphetamine (88)1628July 2006n.a.n.a.n.a.Amphetamine (2.0)1728July 2006n.a.310n.a.None 1828July 2006n.a.1700n.a.Carboxy-THC (0.09)1928Aug 2006n.a.580n.a.Amphetamine (6.0), Methamphetamine (16.0)2028Jan  2007n.a.n.a.Negativen.a.2128Jan  2007n.a.n.a.n.a.None 2229Mar 2007n.a.2100n.a.Amphetamine (0.9)2329Mar,2007n.a.1500n.a.Amphetamine (99)2429Apr  2007n.a.Negativen.a.Amphetamine (0.6)2529May, 2007n.a.690n.a.Amphetamine (0.8), carboxy-THC (0.06)2629June, 2007n.a.690n.a.Amphetamine (>100)2729July  2007n.a.870n.a.Amphetamine (7.0)2829July  2007n.a.320n.a.n.a.Autopsy29July  20072004700Ethanol (170), amitriptyline (5), nortriptyline (0.3), diazepam (0.1), paracetamol (1.0), tramadol (0.2)Ethanol (240)
an.a. = not analysed or not available. 

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�ְ��[�ڲ����v�D������x8y�ybz{����������������������������0���^��`�0�gd�z�$a$gd�z�gdS�18. 	Bay, T., Eghorn, L.F., Klein, A.B., Wellendorph, P. (2014) GHB receptor targets in the CNS: focus on high-affinity binding sites. Biochem Pharmacol 87: 220-228.
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{�{�{�{�{�{�{�{�{�{�{�{�{�{�{�{�{����������������$a$gdS�gd�z����0�^��`�0�gd�z�,1�h��. ��A!��"��#��$��%��������D<EndNote><Cite><Author>Zvosec</Author><Year>2011</Year><RecNum>219</RecNum><DisplayText>(1,2)</DisplayText><record><rec-number>219</rec-number><foreign-keys><key app="EN" db-id="2szrz5a0wd9pxre0zwqx9p092vst0edddaze">219</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zvosec, D. L.</author><author>Smith, S. W.</author><author>Porrata, T.</author><author>Strobl, A. Q.</author><author>Dyer, J. 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