Introduction

GHB was developed in the early 1960s as a human anaesthetic but medical
use was limited due to unwanted side effects. Its non-medical use as a sleep
aid and bodybuilding supplement in the 1980s, and as a recreational psychoactive
drug in the 1990s lead to growing concerns and GHB has been
scheduled in the United States and in some European Member States. This
report summarises the relevant data required by the Technical Annex C of
the Guidelines for the risk assessment of new synthetic drugs. In the absence
of systematic studies of illicit use of GHB, the sociological and criminological
evidence for this report is based on limited information collected from:

 the Reitox national focal points in the 15 EU Member States (1);
 Europol’s contribution to the risk assessment of GHB (2);
 EMEA’s contribution to the risk assessment of GHB (3);
 the Qualitative European Drugs Network (QED) (4);
 the literature (5);
 key European forensic scientists (6);
 key toxicologists in the United Kingdom (7);
 telephone interviews with key experts in the field of recreational drugs (8);
 the Internet (English-language searches) (9); and
 youth and mass media (English-language searches) (10).

Table 5 presents the topics covered in this annex by briefly indicating the
extent and type of evidence that is available. The numbers as in the list
above are used in the table to code the sources of information. Where information
is available, it is presented and examined under the main category
headings. In general, there is insufficient information, or too much overlap,
to address each of the subheadings in the text.

Social consequences for the user

The main social consequences of GHB for the user are linked to two different
factors: its pharmacological effects and its legal status.

Nausea, vomiting, and loss of physical control and consciousness sometimes
resulting from use of GHB may result in unpleasant or expensive consequences
ranging from social embarrassment to hospital admission and the
sort of invasive medical procedures, which are often used in cases of opiate
overdose, such as tracheal intubation. Home-made, ‘kitchen-sink’ GHB
products have been reported to have caused burns to mouth and lungs as a
result of large amounts of caustic soda.

Under the current laws in the European Union, the social consequences of
taking the drug or supplying friends is significantly greater in countries which
have placed GHB under drug control law, such as Denmark, France, Italy,
Ireland and Sweden, than in other countries without legal controls over use.
For example legal sanctions can result in dismissal from work, criminal
records distress and stigma for the users and their families.

Consequences on the social behaviour of the user

The described loss of physical control associated with the use of GHB has
obvious consequences on the social behaviour of users and presents a high
risk for driving, cycling or operating machinery. According to outreach workers
in the Netherlands:

[GHB] has a very negative effect on the atmosphere … people trying
to talk and not being able to … not a nice trend, not at all.

A particular consequence that has been linked with GHB by some media
and police reports is the potential for GHB to be used surreptitiously — by
adding it to other people’s drinks — for sexual purposes, including rape
(Sturman, 2000). Such reports are difficult to substantiate because GHB is
frequently taken, knowingly, in alcoholic drinks and together with other
drugs. Also, the majority of individuals who reported sexual assault to the
police also reported that they had been in the assailant’s company and had
consumed alcohol and/or other drugs prior to the assault. GHB-assisted sexual
assault cases had not been drawn to the attention of the drug outreach
workers interviewed and, in the United Kingdom, GHB has been detected in
only two alleged drug rape samples submitted to the forensic science services.
In the United States, successful convictions have been based on circumstantial
rather than laboratory analyses.

Other social consequences

Firstly, the ease with which GHB can be acquired, or manufactured, allows
more widespread entrepreneurial opportunity and consumer power than in
the illicit ‘ecstasy’ markets in the EU. This development can be linked to
developments in communication via the Internet. Secondly, the promotion
of GHB for health — anti-ageing and bodybuilding — through Internet sites
promotes the idea of illicit drugs being used for self-medication purposes
rather than hedonism. The representation of GHB for relaxation, sexual
enhancement and inducing sleep is strong and there appears to be a lobby
of users who wish to defend the right to use GHB for these purposes.

However, the size of this lobby is unknown and the vested interests of GHB
producers and distributors may play a part in its visibility on the Internet.

In view of the social and health risks relating to GHB, the widespread availability
of GHB and its precursors, and the ease with which it can be prepared
for consumption presents a number of implications for social institutions.
Responses by some social institutions are already evident in some Member
States.

Press and mainstream media

A recent American emergency room television series episode addressed the
issue of there being no effective intervention for treatment for an overdose of
GHB. In this episode, a doctor’s instructions regarding a patient brought in
who was known to have consumed GHB was to leave the patient in the
corridor to sleep it off.

Some types of media coverage are thought to inadvertently promote the use
of GHB. Careless coverage has been described in negative terms by drug
researchers, police and service providers. In particular, concerns have been
expressed about media coverage of GHB use in sexual assault. There is a
potential for such coverage to increase harm in the form of ‘copy-cat’ crime.
This is said to have occurred in Australia (Sturman, 2000). One example of
such coverage is in an article about GHB in the August 2000 issue of
Cosmopolitan (a women’s magazine with large international circulation figures).
The article was entitled ‘The new date rape drug’ and had a subtitle
‘From health pill to rapist’s tool’. One drug worker interviewed reported that
he actively discourages journalists from covering issues such as this in mainstream
magazines and newspapers.

Research institutions

Social research on illicit use of GHB is being initiated in some countries and
questions about the use of GHB have been inserted into a music magazine
survey and a gay magazine survey in the United Kingdom, and into a magazine
in Australia.

Information for drug outreach workers

Drug outreach workers are a key source of information for users. Compared
with other synthetic drugs and alcohol, the sleep dose response curve of
GHB and the unpredictable effects depending on what else has been con58
sumed have lead to the dissemination of targeted information. Both written
and verbal information highlight specific dangers about dose and about drug
and alcohol combinations to serve as a warning to users and potential users.
Information about contraindications for using GHB has also been provided.

Internet sources, which appear to be American, have advised people who
are going to use GHB to mark their hand with the letters ‘G’ or ‘GHB’ to
identify a reason for loss of consciousness, if it occurs. Admission to hospital
unconscious may lead to routine interventions for opiate overdoses, such as
intubation, and this can be very costly. By indicating that an overdose has
been caused by GHB, users have a better chance of avoiding high ambulance
and hospital fees.

Other advice to GHB users and ‘kitchen-sink’ producers has been to add
blue food colouring to GHB in order to help users identify it, and to prevent
both inadvertent use and/or deliberate use in drug-assisted assault.

Hospital personnel

Pharmacotoxicological information about GHB for hospital personnel may,
in some circumstances, help to prevent the adoption of unnecessary medical
procedures.

Community

In a number of urban areas, community drug and rape services have been
alerted about the use of GHB and provided with up-to-date information.
Advice to people who believe that they have been victims of drug-assisted sexual
assault is to provide a urine sample as early as possible (Sturman, 2000).

Workplace

Employees undergoing drug or alcohol treatment or screening may be particularly
vulnerable to the use of GHB in order to avoid detection.

Police

Police doctors are usually responsible for obtaining blood and urine samples
but, in the United Kingdom, some police forces have recently advised police
constables to obtain urine samples from people reporting as victims of sexual
assault as soon as possible in order to increase the possibility of identifying
the presence of GHB (Sturman, 2000).

Wholesale production and distribution (8)

Violence in connection with wholesale production and distribution

Member States did not provide data on violence in connection with the production,
trafficking and distribution of GHB.

Money laundering aspects

No reliable data are available on the volume of money laundering in relation
to the production, trafficking and distribution of GHB.

Involvement of (international) organised crime

Contributions of Member States’ law enforcement agencies

Austria, Greece, Italy and Luxembourg have reported that until now there
have been no seizures of GHB, nor is there any information on (large-scale)
production, trafficking and distribution of GHB or on the role of organised
crime in these activities.

In Belgium, seizures of GHB are increasing considerably and in particular
during summertime, where there was an increase in seizures of small quantities
of GHB in liquid form and, incidentally, in capsules. In Finland, 757
millilitres of GHB were seized in seven incidents in 1998. In 1999, the
Finnish forensic laboratories analysed samples of GHB relating to total
seizures of over 3 800 grams. Also, over 5 litres of the precursor GBL were
seized. In France, a ‘kitchen-type’ laboratory was discovered in the region of
Paris and 4 kilograms of GHB were seized in August 1998. In September
1998, 503 grams of GHB were seized and in September 1999 a ‘kitchentype’
laboratory was discovered in Bordeaux and 80 centilitres of GHB were
seized.

In Denmark there have been five seizures of GHB since June 1999. Germany
reports 11 incidents of seizures of small, insignificant quantities of GHB. The
limited number of seizures does not allow for an assessment of the level of
production, trafficking and distribution or the role of organised crime. In
Ireland, one seizure of GHB in liquid form (25 millilitres) was reported.

In the Netherlands there were a number of small seizures in 1999, totalling
76 capsules of GHB. Producers of GHB are thought to be involved in the
production of controlled drugs, with dealers possibly having links to ecstasy
producers. They are individuals with a criminal background or members of
small groups, rather than criminal networks. However, in January 1999, a
criminal organisation was dismantled that had been engaged for a number
of years in the production and trafficking of ‘designer drugs’, including GHB.
In Portugal, one seizure of 1 100 litres of the precursor GBL took place in
November 1999.

In Spain, 34 seizures took place in 1999, in Zaragozza (31) and Ibiza (three).
In Sweden, abuse of GHB is increasing and GHB and GBL have been found
in seizures of narcotic drugs and anabolic steroids. It is believed that GBL is
being imported into Sweden.

In the United Kingdom, London, the North-West, Midlands and South Wales
have been identified as the main areas of production and supply. There is
intelligence that the precursor, GBL, is being sourced from other Member
States, for example Belgium, to be used in GHB production. GHB is mainly
distributed through retail outlets, the Internet, via mail order and in gyms.
The disruption of overt supply has led to distribution patterns similar to illicit
drug networks. There is no current intelligence regarding international trafficking
of GHB into or from the United Kingdom. The high profit margins
and the comparatively limited penalties encourage the involvement of
organised criminal groups. There is evidence of criminals involved in controlled
drugs also being involved in the production and supply of GHB.

Conclusions

 No Member State has information on large-scale production, trafficking
and distribution of GHB. Seizures of GHB in the European Union are very
small when compared to seizures of ‘regular’ types of synthetic drugs such
as amphetamine, MDMA and MDA.

 Three Member States — France, the Netherlands and the United Kingdom
— have information on illicit production of GHB in their country.
Production in France seems to be incidental and limited to two kitchentype
facilities.

 Two Member States — the Netherlands and the United Kingdom — report
on the role of organised crime in the production, trafficking and distribution
of GHB. In both countries producers of GHB are thought to also be
involved in the production of controlled drugs, with dealers possibly having
links to ecstasy producers. They are individuals with a criminal background
or members of small groups, rather than criminal networks.

The retail market

The retail market appears to consist of both pharmaceutical grade GHB and
a wide range of home-made varieties serving a market historically predominated
by homosexual men but which is making inroads into the heterosexual
population, and in particular that of recreational drug users.

GHB is authorised only in three countries: in Italy for alcoholic craving and
in France and Germany as an anaesthetic (9). In France and Italy, the commercial
sales figures for GHB have decreased. In France they more than halved
(from 35 547 in 1988 to 12 456 in 1999) and in Germany no sales figures are
available but it is assumed that market sales are very low (EMEA, 2000).

In some countries such as the Netherlands and the United Kingdom, GHB
has been available for a number of years through retail outlets such as smart
shops, sex shops, gyms and through mail order (Stichting Adviesburo Drugs,
1990). GHB and GHB-making kits have been widely available through
Internet sales but, in 2000, concern about the drug’s safety and changes in
marketing authorisation have led to restricted advertising and sales. GHB kits
are no longer openly sold on the Internet and in August 2000, only two
English-language Internet sites openly marketing GHB were identified. GHB
sold in this way is generally in powder form in quantities ranging from 75 g
upwards and suppliers provide strong assurances of quality (assays above
99 % , measured using gas chromatography) and discretion with regard to
packaging, encrypted transactions, and guaranteed deliveries are assured.
One laboratory appeared to be based in the United States and offered worldwide
shipping. The other, a South African-based laboratory, excluded supply
to Australia, New Zealand, Norway, South Africa or the United States.

Although Internet sales of GHB have been curtailed, a number of bodybuilding,
anti-ageing and smart-drug web sites continue to advertise GHB
under other names such as gamma-OH, ProK, Genetika, Alcover, ReActive
and Renewtriant and Furanone Di-hydro. These GHB-type products are generally
advertised as dietary supplements providing therapeutic benefits for:
inducing sleep, mood enhancement, treatment of drug and alcohol addiction,
sexual enhancement, athletic performance and to combat ageing. The
sites that promote the use of GHB usually provide strong cautions with
regard to doses and contraindications.

A home-made, ‘kitchen-sink’ industry developed due to the fact that GHB is
easily manufactured and no special equipment is required for this process. A
book about GHB has been published and information about recipes, taste,
effects and where to purchase precursors is exchanged via the Internet in
many different languages (Ward, 2000). In February 2000, a web site dedicated
to GHB alone was established.

GHB dissolves easily and is generally colourless, odourless and relatively
tasteless. Therefore, it can be taken easily and unobtrusively in social settings
where alcoholic drinks are served. In recreational drug settings, GHB is most
frequently sold in liquid form in plastic opaque bottles or screw cap doses
and in Europe, GHB synonyms in these settings include ‘GBH’ and ‘liquid
ecstasy’, ‘happiness drops’ and ‘liquid loving’. Although GHB sometimes
appears in the same market place as ecstasy it is not likely to be purchased
as, or mistaken for, ecstasy because of its distinguishing physical appearance
and its effects, which are more similar to those produced by alcohol and
other sedatives than MDMA or other stimulant drugs. The United Kingdom
focal point reported that 30 ml bottles contain about 3 g of GHB and one of
these is typically sold for approximately EUR 15. In Spain and Sweden,
prices of GHB reported by the focal points are considerably lower than in
the United Kingdom but the defining units or price sources may be different.
For example, Internet or catalogue sales prices for bulk orders are lower than
‘street level’ sales prices.

A major technical difficulty facing control of the GHB retail market is that
the precursor gamma-butyrolactone (GBL) is used industrially and is commercially
available at low prices and the precursor can simply be recovered
from a GHB solution by adding acid to neutralise the sodium hydroxide. In
Sweden, in 1998 approximately 40 products containing GBL in substantial
amounts were identified and 11 of them were commercially available as
consumer products. The Swedish focal point reported that a dialogue with
major importers of GBL was planned in order to trace possible leaks to clandestine
production.

Social factors that increase the probability of harm

A major social factor that increases the probability of harm is linked to the
steep dose response curve of GHB (Elliott, 2000). Firstly, the variable and
unknown GHB content available on the illicit market makes it impossible for
individuals to assess their dose on the basis of past experience in the way
that they do with alcohol. Secondly, there exists a small, but significant,
minority of ‘innovators’ or ‘extreme’ users who take large quantities of drugs
and alcohol as part of their social lifestyle. This group may continue to use
GHB because of its availability, low price and other factors, even if more
accurate and reliable information about dose was available to them.

With regard to the potential wider dissemination of GHB use, it appears that
GHB may have a significant role in the recreational drug scene as a selfmedication
drug used to counteract some of the negative influences of stimulant
drugs such as sleeplessness and tension. Here the demand for GHB, or
a similar drug, is linked with the heavy or regular use of stimulants. The comparatively
low price of GHB also provides a cheap alternative to alcohol for
young people on low incomes. The similarities of GHB to alcohol both in
terms of oral administration and effects allows easy experimentation among
mainstream youth without any major value conflict. These factors, combined
with perceived lack of hangover effects, could lead to widespread dissemination
among young people. Socially excluded populations may be the
most vulnerable to widespread dissemination (EMCDDA, 2000). Mitigating
factors against widespread diffusion are the relatively low status of GHB due
to: its low price, its association with heavy alcohol use and its anti-socialising
effects. The relatively short-acting effects of GHB compared with drugs
such as MDMA also mitigate against the drug gaining widespread popularity
as does the high purity and low price of MDMA that is currently evident on
the market.

Finally, another social factor that increases the probability of harm is the role
of the media in promoting harm, if inadvertently. This relates particularly to
media coverage of GHB use for the purposes of sexual assault which could
promote a small, but significant, number of ‘copy-cat’ crimes.

(8) Europol’s contribution to the risk assessment.

(9) Classification for the supply of medicinal products for human use is regulated by Directive
92/26/EEC of 31 March 1992 and that Article 12 of Directive 75/319/EEC of 20 May 1975
regulated through the Committee for Proprietary Medicinal Products (CPMP) the suspensions,
withdrawal or variations to the terms of the marketing authorisation, in particular to
take account of the information collected in accordance with Pharmacovigilance.