Statistics from Altmetric.com
It seems inevitable that the marketing of recreational drugs, especially through the Internet, will keep one step ahead of attempts to control them. An illustrative tale centres on γ-hydroxybutyrate and its precursors (Deborah L Zvosec and colleagues. New England Journal of Medicine2001;344:87–94). Gamma-hydroxybutyrate is a metabolite of the inhibitory neurotransmitter, γ-aminobutyric acid (GABA) and, to some extent, may be reconverted back to GABA. In the 1980s it was promoted as a muscle builder and promoter of fat loss. Because it also induced euphoria and was said to enhance sexual performance it became popular, but toxic effects led to it being banned in the USA although it is said that it is still widely used at “raves”. Subsequently, two industrial solvents , 1,4-butanediol and γ-butyrolactone, both of which are converted to γ-hydroxybutyrate after ingestion, were marketed as dietary supplements (a 1994 US Act makes it legal to market non-food, non-drug, dietary supplements without proof of safety). Gamma-butyrolactone dietary supplements were subsequently recalled after FDA warnings but 1,4-butanediol was then promoted as a replacement. Further attempts at regulation have led to these compounds being advertised on the Internet as “non-toxic” solvents and cleaners. Proprietary and street names for the compounds include Rejuv@Nite, Liquid Gold, Zen, Thunder, Serenity, Easy Lay, Gamma Ram, Great Hormones at Bedtime, and Liquid Ecstasy. The toxic effects are similar to those of severe alcohol poisoning and include coma, respiratory depression, and death. Over a period of 6 or 7 months in 1999 nine episodes of acute poisoning with 1,4-butanediol affecting eight patients aged 22–51 were identified through three emergency departments in Minnesota, Texas, and Florida. Symptoms and signs included vomiting, aggressiveness, incontinence of urine and faeces, fluctuating conscious level, and respiratory depression. Two patients died. The US Drug Enforcement Administration has recorded 71 deaths from γ-hydroxybutyrate alone or in association with other drugs. Internet sites have tended to minimise the dangers and one apparently advised its readers that the side effects included “short-term, harmless coma”. The writers of this report conclude that 1,4 butanediol “is toxic, addictive, and potentially lethal. Ingestion . . . impairs one's ability to drive and it may be used to facilitate sexual assault”. Those who use or sell it will no doubt point out that all these things apply to alcohol.