An Uncommon Case of Phenibut Toxicity in an Intensive Care Unit

Gamma-aminobutyric acid (GABA) agonists are used as exogenous neuromodulators for patients with chronic pain and refractory mental illness. Phenibut is a controlled GABA-B agonist, with an extensive use in Russia for psychiatric and perioperative patients.In recent times, its anxiolytic and nootropic properties are commercially marketed with an increased risk for recreational abuse. We present a case of a complicated admission of phenibut overdose in a 44-year-old Caucasian man and subsequent management in an intensive care unit (ICU). The drug was accessed over the Internet. The patient previously had multiple ICU admissions due to overdosing on this particular substance, with a fluctuating conscious state and a threatened airway that required intubation, ventilation, haemodynamic monitoring and vasoactive supports. His ongoing agitation over a course of several days mandated sedatives and hypnotics, and his admission was complicated by hypertensive crises and aspiration pneumonia. The clinical dilemma is yet to be addressed including the implications of this toxidrome and multi-organ dysfunction. The laboratory diagnosis (i.e. plasma phenibut level) are still investigational and needs more research. This report highlights the role of phenibut as an emerging psychotropic substance with a significant disease burden on the public health system. There is neither a consensus-based approach nor an antidote for this toxidrome, and its diagnosis often relies on accurate history alone. Long-term neurological sequelae and outcomes remain uncertain and more clinical surveillance and governance is needed in this particular area of toxicology and the nexus between e-commerce and substance abuse.