(NBC) (08/14/20)— It had been several years since professor Joseph Palamar had seen that unmistakable “caveman face,” the telltale sign of an imminent overdose of gamma-hydroxybutyric acid, or GHB.
Standing among throngs of concertgoers at a Brooklyn music venue last year, Palamar spotted the bulky man with the contorted face nearby. He was struggling to remain conscious.
“I’ve noticed that when people are meant to pass out and they keep forcing it, they make these very strange, primitive faces,” Palamar, an epidemiologist and associate professor of population health at New York University’s Grossman School of Medicine, told NBC News. “They look like they are in such euphoria it’s almost painful.”
Within minutes, the man succumbed, apparently to the suppressive effects of the drug, and collapsed to the floor. Security staff raced over and carried him away.
The ordeal reminded Palamar of New York’s sweaty nightclubs at the turn of the millennium, the same venues that had sparked his interest in studying drug use.
Back then, overdoses, particularly on GHB, were so common that some clubs hired private ambulances to avoid 911 calls and police scrutiny. One club allegedly hid unconscious patrons in a back room without medical assistance.
Despite these efforts, the clubs didn’t go unnoticed. After a rash of overdoses across the United States in the late ’90s, Congress scheduled GHB as a controlled substance in 2000. Exposures to GHB reported to poison control centers fell almost immediately.
But 20 years on, a new generation of recreational users — a disproportionate number of them gay and lesbian, according to researchers — has rediscovered the drug.
Recent indictments in a Texas federal court reveal that today’s networks for distributing GHB aren’t spread over local dealers but far-flung markets linking buyers to legal businesses with dubious motives.
Social media and the world’s largest online marketplace are also tangled in this web. This illicit network generates millions of dollars each year and has spurred a small but growing crisis, for which federal regulators and the medical community appear ill-equipped and unprepared.
Occurring naturally in the body, gamma-hydroxybutyric acid was first synthesized in a lab in the 1960s. Although its application in medicine has always been limited, GHB has had various recreational uses.
In the 1980s, health food stores marketed the compound as a dietary supplement. Then, in the ’90s, the drug found its way into American nightlife.
In small doses, mere milliliters, GHB produces feelings of relaxation and confusion and heightens sexual arousal, lending to its allure as a party drug. It can also cause amnesia and hallucinations.
While not particularly addictive, the drug has a steep dose-response relationship, meaning the difference between experiencing euphoria and losing consciousness is a matter of a few drops of the clear, viscous liquid.
It is this quality of GHB that gives it the nickname “the date-rape drug,” although the compound is rarely a factor in sexual assault.
Overdoses can result in coma and respiratory arrest, which to an unaccustomed observer may appear as if the affected person has only fallen asleep.
GHB overdoses surged in the United States during the 1990s. In 1995, the Drug Abuse Warning Network recorded 145 emergency department visits for GHB-related illness in a single year.
By 2000, this number was nearing 5,000. That same year, the American Association of Poison Control Centers logged some 2,000 exposures to GHB and its analogues as well as six deaths.
In reacting to the growing crisis, Congress passed the Hillory J. Farias and Samantha Reid Date-Rape Drug Prohibition Act of 2000, which authorized the attorney general to list GHB as a Schedule I controlled substance.
The law, named after two teenagers who allegedly died from GHB overdoses after unknowingly ingesting the drug, also targeted GHB analogues, or chemicals that are “substantially similar” to the illegal compound. Two of these — gamma-butyrolactone (GBL) and 1,4-butanediol (BDO) — were named in the act’s text.
Once ingested, GBL and BDO metabolize into GHB and have similar clinical effects. But unlike GHB, both chemicals have widespread use in industrial manufacturing, which prevents them from being regulated as controlled substances.
Under the Farias-Reid act, GBL became subjected to greater control by the Drug Enforcement Administration, while BDO was left unregulated.
Even so, under the new law, the sale and distribution of either GBL or BDO could result in criminal prosecution if the seller knew the buyer would consume the chemical.
After the federal government targeted GHB, reports of its use began to fall. By 2005, poison control centers in the U.S. only recorded some 550 exposures to GHB and one death.
During that same period, online retail grew to offer new avenues for buying and selling GHB and its analogues under the guise of legitimate business.
In 2002, in its first major action against the sale of GHB, codenamed Operation Webslinger, federal agents busted four drug-trafficking rings that had used the internet to connect with buyers.
One of these operations, a mother-son team in Missouri, was accused of setting up a limited liability company called Miracle Cleaning Products to deal BDO online.
Through their business, the duo could legally purchase the chemical in bulk from two U.S.-based suppliers and then distribute smaller quantities to their customers throughout the U.S.
When law enforcement finally arrested the family, federal agents recovered 2,200 gallons of BDO and seized $300,000 in cash.
Ultimately, the court sentenced the mother to 14 years in federal prison and the son to more than eight years.
Congress again took action by passing the Adam Walsh Child Protection and Safety Act in 2006.
In addition to establishing the national sex offender registry, the law made it illegal to use the internet to sell GHB or its analogues to any person without a legal prescription to use the drug or any business not authorized to handle the chemical.
Anyone convicted of using the internet to sell these compounds to unauthorized buyers could face a fine and 20 years imprisonment.
The new law also authorized the attorney general to develop regulations for record-keeping and reporting by anyone handling BDO. To date, the Department of Justice has not established these requirements.
A spokesperson for the U.S. Drug Enforcement Administration, which is part of the DOJ, told NBC News that it “has not promulgated any regulations that were authorized but not required by legislation,” adding that “1,4-butanediol is produced in large volumes for a multitude of legitimate industrial uses, none of which are intended for human consumption.”
Last month, federal agents raided Right Price Chemicals, a wholesaler in Texas, and arrested nine individuals who were accused of distributing BDO for human consumption beginning in 2015.
According to the DOJ, the defendants had used the internet to sell the compound to buyers in 48 states. Some of these buyers then dealt smaller quantities to other users.
In just four years, sales of BDO generated $4.5 million for Right Price Chemicals, according to the Department of Justice. Prosecutors also claim that the product caused at least two deaths.
A lawyer for one of the defendants told NBC News that Right Price Chemicals warned customers on its website and its products that BDO was not for human consumption.
“Simply because people misuse a product does not place criminal liability on the retailer of that product,” Ryan Gertz, the lawyer, said. “Right Price Chemicals is a legitimate business that maintained thorough records, paid taxes, employed experts to advise them about proper practices, and openly consulted with the government about its operations.”
The defendants in the case have pleaded not guilty and attest that they only distributed BDO for legitimate, legal purposes. If convicted, they face a minimum of 20 years, and up to life, in federal prison.
Right Price Chemicals is not the only business that has cashed in on BDO. Companies purportedly based in Europe, China, and India market the compound on English-language websites.
Stateside, companies have also found success by selling BDO on Amazon, the world’s largest online marketplace.
As of last week, two third-party sellers offered consumer-sized quantities of BDO on Amazon. Amazon removed these products after NBC News reached out to the company for comment.
In the interest of public health, NBC News has chosen not to name the companies or share their websites and social media accounts.
One of these sellers markets its products as an “organic reagent” and “heavy-duty cleaner” with multiple at-home uses, though the Drug Enforcement Administration maintains that 1,4-butanediol “has no household applications.”
On Amazon, the companies’ products were much pricier than traditional cleaning supplies. Whereas most heavy-duty cleaners on Amazon retail for about $15, BDO of a comparable size went for over $100.
Both sellers are legally registered in different Midwestern states as limited liability companies. The name of one suggests it is a chemical wholesaler, however, it only distributes 1,4-butanediol.
The other began as an all-natural soap company in 2015 but switched to selling BDO via its website and Amazon last year.
Prior to early August, buyers could also purchase BDO through the website of one of the sellers using cryptocurrencies, like Bitcoin.
One seller included a legal disclaimer on its Amazon product page stating that its BDO was not for human consumption.
Nevertheless, commenters on several blogs, including Reddit, have discussed purchasing BDO as a GHB substitute through Amazon.
NBC News attempted to contact multiple people who allegedly purchased BDO from one of the third-party sellers on Amazon. Only one agreed to speak on the condition of anonymity.
This buyer confirmed purchasing 1,4-butanediol on Amazon in order to ingest it and said the seller did not ask for justification when placing the order.
The buyer said that the day after consuming the BDO, they felt “absolutely terrible.” The compound, this individual said, caused them to feel fatigued, nauseous, and confused.
Shortly after NBC News began contacting these alleged buyers, the third-party seller removed images of BDO bottles and packaging labels from its Instagram account.
The company also removed its offering of BDO from its website and instead provided links directing customers to its product pages on the Amazon and Walmart marketplaces.
Amazon prohibits third-party sellers from using its marketplace to sell scheduled controlled substances, like GHB, and List I chemicals, like GBL. BDO is neither.
Still, Amazon specifies that its list of restricted products is “not all-inclusive” and the sale of “unsafe” products is strictly prohibited.
“Third party sellers are independent businesses and are required to follow our selling guidelines when selling in our store. Those who do not will be subject to action including potential removal of their account,” an Amazon spokesperson told NBC News. “The products in question are no longer available.”
Walmart also prohibits third-party sellers from selling controlled substances and “products that are subject to regulatory action or criminal enforcement.”
Like Amazon, Walmart removed 1,4-butanediol products from its website following NBC News’ request for comment.
In a statement, a Walmart spokesperson said: “We strive to make our third-party Marketplace a trusted destination for safe, high quality products. We require our third-party sellers to comply with all applicable laws and our prohibited products policy. We removed the product 1,4-butanediol from Marketplace and have taken steps to prevent sellers from listing similar items going forward.”
NBC News tried to contact both companies that formerly sold 1,4-butanediol on the Amazon and Walmart marketplaces. Neither responded.
One of the sellers, however, appears to have moved to another major online marketplace after being removed from Amazon and Walmart.com.
This marketplace, whose name NBC News will not publish in the interest of public safety, makes sellers’ purchase histories publicly available and shows the seller earned over $2,670 in just 48 hours this week from selling 35 units of BDO.
As the online market for GHB and its analogues has grown in recent years, researchers have seen an uptick in the drugs’ recreational use.
From 2016 to 2019, Palamar and Katherine Keyes, an epidemiologist at Columbia University, surveyed adults at electronic dance music parties in New York City to track relative changes in drug use.
In that three-year span, they found that the rate of GHB use increased from one in 100 to roughly one in 25, a relative increase of 300 percent.
But for certain demographic groups, the use of GHB is far more widespread. In another survey taken from 2016 to 2018, Palamar and a group of researchers at NYU and Rutgers University found that both gays and lesbians at electronic dance parties were at higher odds for GHB use than straight patrons.
According to the study, gay men were nearly 12 times more likely than heterosexual men to self-report GHB use within the past year. Lesbians were nearly seven times more likely than straight women.
While gays and lesbians reported comparable or higher rates of use across most surveyed drug types, the difference in GHB use between gay and straight attendees was by far the greatest.
It was in nightlife that Jon, who spoke on the condition of anonymity to protect his privacy, discovered GHB.
As a newcomer to New York City in 2013, Jon, like many young gay men, found a community in nightclubs where he began taking GHB with friends. At first, the drug was only a cheap weekend indulgence.
After drinking one glass of water mixed with GHB, “I wouldn’t need to drink for the rest of the night,” Jon said. “That’s a very attractive selling point.”
But the party didn’t always end on Monday. What had started as only a weekend exploit soon became a weekday occurrence and eventually a physical dependence on the drug.
For several years, no one — including Jon’s boyfriend at the time — knew of this dependence. Even when Jon acknowledged his problem to himself, he still didn’t reveal it to others.
“I wanted to detox without anyone knowing, because at that point I knew I was only doing it for maintenance,” he said. “I was only doing it to curb the withdrawals.”
These were often debilitating. If Jon didn’t ingest GHB on a regular basis, his body would begin to show symptoms akin to alcohol withdrawal. He would sweat and shake. His anxiety would soar to the point of confusion.
As a young person trying to make something of himself in New York, Jon needed to maintain his dependence on GHB. The alternative, abruptly stopping his GHB use, was to risk a coma and even death.
So, Jon continued to consume 1.25 milliliters of GHB every two hours for three and a half years.
When he finally sought help at a rehabilitation center last summer, Jon encountered a different problem altogether.
“They had never heard of the drug,” he said of the rehab’s staff. “They had no idea what it was. They didn’t know how to treat it. They didn’t know how to deal with it. Nothing.”
Ultimately, Jon’s doctors treated him with diazepam, which has been shown to be effective in treating GHB dependence. As of today, Jon has been in recovery for over a year.
The ignorance around GHB that Jon experienced in rehab is not unique to a single health care provider or institution. It pervades the entire society.
“It’s called ‘generational forgetting,’” said Palamar, using a term coined by the social psychologist Lloyd Johnston. “One generation could be fully aware of the potential adverse effects of a drug, but then the next generation just doesn’t know.”
This “forgetting” may also contribute to the apparent rise in GHB use among gays and lesbians.
“In the gay community, people don’t tend to go out for a very long period of their lives,” said Guy Smith, producer of the popular gay Pines Party on New York’s Fire Island. “A gay generation in nightlife is about 10 years, so the conversation that people have about a drug in any particular place will only last that long. There is no conventional wisdom.”
Like Palamar, Smith came of age in New York nightlife at the turn of the millennium when GHB overdoses spiked. In recent years, Smith said, use of the drug has started peaking again.
Spurring this rise are industries, like online retail and social media, which came of age in that same time frame and which therefore lack experience with the drug.
In such a lax environment, the front lines for addressing GHB abuse have shifted to unlikely places.
Several nightclubs and parties, including Guy Smith’s events, now enforce a zero-tolerance policy on GHB. The move is not without its naysayers, but Smith and Palamar stress that these policies save lives.
Both men witnessed GHB devastate New York nightlife when clubs ignored problematic drug use in the early 2000s.
Young opponents of zero-tolerance policies, Palamar said, were “not around when people were dropping like flies” and “not there with all the deaths.” And he hopes they never will be.
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