Introduction: Gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL) are psychoactive substances commonly associated with men who have sex with men (MSM) and sexualized substance use contexts. Large-scale studies exploring broader sociodemographic characteristics and substance use behaviors among GHB/GBL users remain scarce. Methods: A convenience sample was recruited online through nightlife contexts to complete an anonymous online-questionnaire with a one-year follow-up. The survey assessed sociodemographic data, use of GHB/GBL and other psychoactive substances, GHB/GBL-related adverse events, and lifetime psychiatric diagnosis. Participants were categorized as occasional or frequent users based on the past 12 months. Results: Among 2196 participants, 47.4% reported GHB/GBL use within the past year; among these, 72.9% were occasional users (< 1x/week), and 27.1% frequent users (≥ 1x/week). At one-year follow-up, 10.9% of the sample was retained. The majority of users were male, with 40% of frequent users and 42% of occasional users identifying as homosexual. Frequent users reported more negative events associated with use (e.g., unconsciousness and overdose) and screened more often for problematic use (CAGE-AID). GHB/GBL use frequency was positively associated with methamphetamine, research chemical, and benzodiazepine use, and negatively associated with alcohol use. Conclusions: This study provides insight into GHB use in a diverse sample and confirms higher levels of adverse effects and problematic use patterns among frequent users. Findings highlight the need for prevention and harm reduction strategies that go beyond MSM/chemsex contexts. Broader, inclusive public health approaches are essential to reduce risks and address the evolving landscape of GHB use.

BACKGROUND: Sedative overdoses, particularly involving opioids, γ-hydroxybutyrate (GHB), and benzodiazepines, are an increasing contributor to toxicology admissions and intensive care unit (ICU) utilisation in Australia. While pharmacological mechanisms are well characterised, identifying which patients will deteriorate remains challenging. Existing risk stratification tools, such as the Glasgow Coma Scale (GCS), lack toxicology-specific nuance and may not adequately account for early physiological derangement, highlighting the need for improved, patient-centred risk assessment. AIMS: To evaluate clinical and exposure-related features associated with ICU admission, endotracheal intubation, and in-hospital complications following sedative overdose. METHODS: This retrospective cohort study included patients referred to a district toxicology service with suspected sedative overdose between November 2022 and November 2023. Data extracted from electronic medical records included demographics, ingestion characteristics, clinical course, and investigation results. Sedatives were defined by central nervous system depressant effects. Outcomes were ICU admission, endotracheal intubation, and in-hospital complications. Associations were examined using univariable analyses and multivariable logistic regression; venous pH was modelled separately using penalised logistic regression. RESULTS: A total of 374 patients were included. Common agents were benzodiazepines (32.1%), opioids (29.1%), and GHB (20.6%). In-hospital complications occurred in 35.8% of patients, ICU admission in 17.9%, and intubation in 13.6%. After adjustment, ICU admission was independently associated with lower venous pH and non-benzodiazepine GABA-ergic agent ingestion (e.g. pregabalin and Z-drugs) (adjusted OR 3.35, p = 0.04). Lower venous pH was consistently associated with all adverse outcomes. The model-estimated probability of intubation increased non-linearly with worsening acidaemia, rising from 8% at pH 7.35 to 66% at pH 7.20. In-hospital complications were independently associated with opioid ingestion (adjusted OR 3.81, p < 0.001) and lower GCS, while intubation was associated with lower GCS and lower venous pH. GHB ingestion was inversely associated with intubation. CONCLUSION: Lower GCS, reduced venous pH, and ingestion of high-risk sedative agents—particularly opioids and non-benzodiazepine GABA-ergic ingestion —were key features associated with clinical deterioration in sedative overdose. These findings support multifactorial, toxicology-specific risk stratification incorporating early physiological and pharmacological markers, with prospective validation required before clinical implementation.

Chemsex refers to the use of psychoactive substances, such as GHB, methamphetamine, and poppers, to enhance sexual experiences, predominantly among men who have sex with men and transgender individuals in LGBT+ communities. The practice is associated with increased risks, including sexually transmitted infections, substance dependence, overdose, and cardiac arrest. We present a fatal case of cardiac arrest following chemsex, where high levels of GHB and methamphetamine were detected. This highlights the severe health consequences and the need for targeted support and harm reduction strategies.

The British Association for Psychopharmacology guidelines for the management of substance dependence focus primarily on the pharmacological aspects of treatment. A group of international experts from a wide range of disciplines reviewed the current evidence in their field, considered the strength of the evidence and discussed the clinical implications at a consensus meeting. The guidelines focus on the pharmacological management of dependence on alcohol, benzodiazepines, 'z-drugs', γ-hydroxybutyrate (GHB), gabapentinoids, opioids, nicotine, cannabis and synthetic cannabinoids, cocaine, amphetamine and methamphetamine, dissociative drugs and their analogues. They are based on the available evidence and make recommendations to aid clinical decision making, as well as highlighting the gaps in the current evidence-base.

Chemsex is defined as the use of psychoactive substances - most commonly methamphetamine, synthetic cathinones, and Gamma-hydroxybutyrate/Gamma butyrolactone (GHB/GBL) - to enhance sexual activity primarily among gay, bisexual, and other men who have sex with men (GBM). It is associated with higher rates of sexually transmitted infections, HIV, and mental health conditions. However, despite substantial public health concerns regarding rising overdose deaths, the relationship between chemsex and overdose remains poorly studied. In this perspective, we synthesize the current evidence, identify critical knowledge gaps regarding the association between chemsex and overdose risk among GBM, and outline harm reduction and behavioral interventions. Assessing chemsex-related overdose deaths among GBM is challenging due to the limited documentation of sexual practices and sexual orientation in medical or legal records. Stigma further reduces disclosure, and chemsex involvement is rarely identifiable posthumously. Chemsex frequency and perceptions of harm also obscure problematic use. Effective pharmacologic treatments for stimulant dependence remain limited. In contrast, contingency management (CM) has been proven effective in reducing stimulant use, yet remains underutilized. Integrated harm reduction approaches are essential to mitigate the potential risks of chemsex. Key interventions include HIV testing, needle exchange, sexual health screenings, psychosocial interventions, and vaccinations. There is an urgent need for targeted research, improved data collection, and tailored harm reduction strategies to better understand and reduce overdose risk within chemsex contexts. Addressing these gaps is essential for reducing preventable deaths and improving health outcomes in this population.

Gamma-hydroxybutyrate (GHB) is a drug that acts as a central nervous system depressant and is commonly known to be used recreationally. We present the case of a 31-year-old male patient with a past medical history of hypertension (HTN), polysubstance abuse, and previous fentanyl overdose who was brought in an unconscious state to the emergency department (ED) after a suspected GHB overdose. Upon arrival at the ED, the patient was obtunded and therefore medically sedated and intubated for airway protection. His initial laboratory workup revealed a negative serum drug screen and positive urine drug screen for methamphetamines. Both urinalysis and respiratory panel were unremarkable. Several hours later, the patient regained consciousness, became agitated, and self-extubated. The patient's presentation of altered mental status, respiratory depression, and subsequent agitation was attributed to the GHB overdose; however, due to limitations on standard hospital drug screens, it was not detected on the initial work-up. This case aims to demonstrate the increase in the prevalence of GHB use and the importance of considering it in the differential diagnosis of suspected overdose patients. In addition, this case highlights the need for broader toxicology reports in hospital settings to improve the timely diagnosis and management of GHB-related overdoses.

Gamma-hydroxybutyrate (GHB) is a commonly used recreational substance. It has a narrow therapeutic index. The management of GHB overdose in the emergency department (ED) is labour and resource intensive. This study aims to provide a comprehensive analysis of GHB presentations at one of Victoria's largest tertiary hospitals.