Synthetic Drug Use and Limitations of Hospital Drug Screening: A Case of Gamma-Hydroxybutyrate Toxicity

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.