1,4-butanediol (1,4-B) is a precursor of gamma hydroxybutyrate (GHB), a drug to which it is rapidly converted following ingestion. Thus, both anaesthetic euphoriants are referred to as ‘GHB’ and ‘Fantasy’. Both are leading causes of drug-induced coma, with 21 overdoses seen at Auckland Hospital in 1999, rising to 162 in 2002 (unpublished data derived from Auckland Hospital Emergency Department Overdose Database). Internationally, coingestion of alcohol and other drugs, comorbidity and/or use in high-risk settings have been common features in those fatalities that have been reported,1,2 as with non-medical use of other anaesthetics such as ketamine.3

Some have claimed that these drugs are safe if there is no coingestion or comorbidity, and that coma does not require emergency services.4,5 We describe the first confirmed fatality in New Zealand linked to the use of 1,4-B. This case demonstrates that death from 1,4-B can definitely occur when it is taken at home without coingestion or comorbidity. Advice that emergency services are not required in cases of coma is unsafe. There has now been a further death in Wellington that has been possibly linked with use of 1,4-B.

A healthy, 22-year-old male and his girlfriend both lost consciousness following ingestion of 15 ml of 1,4-B at a flat where others were present. He told his companions that he had taken too much, had a seizure and went to bed. He was found three hours later, not breathing, by friends. Neither he nor his girlfriend had ingested alcohol or any other drugs except 1,4-B. An ambulance was called and he was found to be in cardiac arrest. No initial bystander CPR had been administered. He was intubated, ventilated, resuscitated and defibrillated. Spontaneous circulation occurred after 30 minutes.

On arrival at the Emergency Department of Auckland Hospital, observations and biochemistry were typical of 1,4-B overdose (unpublished data, Auckland Hospital Emergency Department Overdose Database).1 The local analytical method used for biological samples measures only GHB. The blood level of GHB on admission was 220 mg/l. A chest X-ray indicated aspiration pneumonia. Brain death was confirmed the next day. The patient’s girlfriend recovered after six hours of ventilation.

1,4-B was detected in bottles, vomit and towels taken from the scene. Blood samples taken on admission were analysed for alcohol, most psychotropic medicines that affect the mind, and morphine, heroin, cocaine and amphetamines. Urine was analysed for alcohol and cannabis. There was no evidence for the use of any drugs except 1,4-B. Conclusions from the post-mortem examination were that death resulted from complications due to a 1,4-B overdose. Vomitus was inhaled resulting in pneumonia, shock, cardiac/respiratory arrest and brain damage.

Some promotional web sites and ‘user guides’ have stated that taking too much 1,4-B or GHB results in a deep sleep from which the person recovers in a few hours, and that there is no need to call emergency services unless the person has also used drugs such as alcohol.4,5 A pamphlet distributed in Auckland at the time of this death stated that ‘there have been instances where people have been inappropriately taken to an emergency room when their friends found them unconscious and unrousable, and assumed they were in danger. These individuals invariably woke up about three hours later, wondering where they were and why all these strange people were doing things to them. Unless other drugs or alcohol have been consumed with these substances, the only treatment necessary is to allow the sleeping person to wake up naturally.’4 This case illustrates that such advice can be dangerous. The case is also relevant to statements such as: ‘a significant part of the Government’s strategy to demonise GHB has been to encourage reporters and coroners to allege GHB as a cause of death...Of those twelve deaths, none were caused by any toxicity of GHB. They were either caused by pre-existing medical conditions (cirrhosis), other drugs, or traffic accidents.’6 The case reported here correctly attributes the death to taking 1,4-B.

Author information: Lynn Theron, Emergency Medicine Specialist, Emergency Department; Karl LR Jansen, Consultant Psychiatrist, Te Whetu Tawera; Adrian M Skinner, Emergency Medicine Registrar, Emergency Department, Auckland Hospital, Auckland

Correspondence: Dr Karl Jansen, Te Whetu Tawera, Auckland Hospital, PO Box 92024, Auckland. Fax: (09) 302 3058; email: K@BTInternet.com