Search

Background: Increasing use of cannabis for medical and recreational purposes has augmented concerns about associated poisoning, and specifically pediatric and adolescent poisonings. Synthetic cannabinoids, often marketed as cannabis replacement, have recently emerged and knowledge and awareness of their toxic effects is growing. The objective of this study was to characterize and compare cannabinoid poisonings (medical and recreational cannabis, and synthetic cannabinoids) in Israel during the period 2007-2018., Methods: The three types of cannabinoid exposures reported to the Israel Poison Information Center (IPIC) between 2007 and 2018 were identified. Differences in distribution of the three types of agents with respect to demographic and clinical factors were examined using univariate statistics, and time trends were plotted., Results: Out of the total 615 poison-exposure cases identified, 55% were recreational cannabis cases, 33% were synthetic cannabinoid cases and 12% were medical cannabis cases. Compared to recreational cannabis exposures, synthetic cannabinoid exposures were more likely to be male, to have both gastrointestinal and cardiovascular manifestations and less likely to be called in by the public as opposed to called in by health care professionals and less likely to be treated on-site. Medical cannabis exposures were less likely to be male, more likely to be called in by the public, less likely to present with co-use of other substances and more likely to have gastrointestinal manifestations. Throughout the study period an increase in exposure cases were observed for medical and recreational cannabis cases, whereas synthetic cannabinoid cases showed an increase until 2014 and then a steep decrease., Conclusions: Despite the low toxicity of different types of cannabinoids, training of physicians and other health care professionals related to cannabinoid poisoning is important. This is particularly important in jurisdictions where legal access to cannabis is becoming increasingly available., Competing Interests: Conflict of Interest Statement The authors declare no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The unpredictable physiologic and pharmacologic effects of synthetic cannabinoids (SCs) are continuously changing as the chemical structure of SCs evolve to avoid classification as a Schedule I drug under the Controlled Substances Act in the U.S. This results in unpredictable pharmacologic effects and subsequent sequelae. Little is known about national or regional trends of SC clusters. The objective of this study is to investigate trends in SC exposure using emergency department (ED) syndromic data., Methods: We analyzed ED syndromic data to detect quarterly trends from January 2016 through September 2019 for SC-related exposures within 59 jurisdictions in 47 states by U.S. region. Pearson chi-square tests detected quarter-to-quarter changes and Joinpoint regression assessed trends over time., Results: From January 2016 to September 2019, 21,714 of 303.5 million ED visits involved suspected SC exposures. Nationally, SC-related exposures decreased by 1.9 % (p = .04) on average per quarter, yet exposures increased in the Midwest by 6.3 % (p = .002) and in the Northeast by 3.2 % (p = .03) on average per quarter, and decreased on average per quarter by 7.7% (p ≤ .001) in the Southeast and 11.4 % in the West (p ≤ .001). Known SC exposures that may align with clusters were identified in quarter-to-quarter monitoring., Conclusions: Only a small proportion of ED visits were related to suspected SC exposure. Although we did identify a small decrease in national SC exposures, there was wide variation by region. Additional efforts are needed to understand variation and to develop prevention and response strategies., (Published by Elsevier B.V.)

In Hungary, N-ethyl-hexedrone (NEH) was the most frequently seized stimulant designer drug in 2017, while among synthetic cannabinoids ADB-FUBINACA and AB-FUBINACA were the most popular. Symptoms of intoxication by these substances are well known but less is known about the pathology of overdose-related death. NEH-induced fatal intoxication has not been described in the literature and knowledge surrounding the particular circumstances of death could be useful better public education of risk and more adequate treatment of overdose patients. In this report, we characterize the case of a 23-year-old male regular drug user who died a few hours after NEH and ADB-FUBINACA consumption. His medical history showed arrhythmia in childhood, and some seizures. Autopsy found he had a BMI of 42.9, a hypertrophic and dilated heart, severe atherosclerosis of the valves, coronaries and the arteries, and edema of the internal organs. Histology confirmed those findings. Postmortem blood levels of NEH were 285 ng/ml, along with 0.08 ng/ml ADB-FUBINACA and five ADB-FUBINACA metabolites. Based on the blood concentrations measured in suspected drug users (≤83.9 ng/ml) we hypothesize that NEH intoxication was the cause of death in this case, with heart disease being a co-factor and that the synthetic cannabinoid effect might have been accompaniment. This case also offered the opportunity to identify the metabolites of ADB-FUBINACA in the blood. We identified metabolites in the post-mortem blood by comparing them to human liver microsomal enzyme metabolites in vitro. Three major and two minor metabolites were found in the blood, of which two could only be derived from ADB-FUBINACA, as opposed to other cannabinoids. The case highlights the importance of the complex analysis of drug related deaths by medico-legal autopsy, histopathology and toxicology., (Copyright © 2019. Published by Elsevier Ltd.)

Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or "fake weed" highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management., (© 2019 by The American Society of Hematology.)

Background: Synthetic cannabinoid intoxication has become difficult to diagnose and manage in the United States, in part due to varying clinical effects within this heterogeneous group of compounds., Case Report: A 38-year-old man was admitted with altered mental status and bradycardia. He demonstrated progressive encephalopathy, seizure activity, second-degree atrioventricular block type I, respiratory failure, hypotension, hypothermia, and hypoglycemia. A computed tomography scan of the abdomen and pelvis revealed multiple packages in the patient's stomach and rectum. Multiple attempts at gastrointestinal decontamination were unsuccessful. On hospital day 8 the patient developed hypertensive emergency and was taken to the operating room for exploratory laparotomy. Twenty-two poorly wrapped packages were removed from the bowel. Postoperatively the patient demonstrated both generalized and focal seizure activity. His mental status slowly returned to baseline over the period of about 1 week and he was ultimately discharged without neurological sequelae after 1 month. Analysis of patient serum, urine, and plant matter from the packages identified cannabis and 2.N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-carboxamide (ADB-FUBINACA). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The case presented demonstrates the suspected toxidrome associated with severe ADB-FUBINACA intoxication, including mental status depression, bradycardia, autonomic instability, seizure, hypoglycemia, and hypothermia. Although the patient had simultaneous exposure to cannabis, his constellation of symptoms is not consistent with cannabis intoxication. A previous animal model supports the potential of this specific synthetic cannabinoid to cause the reported toxidrome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Although the past few years have seen a significant increase in the use of synthetic cannabinoids, very few fatalities have been reported whereby synthetic cannabinoids have contributed or were solely responsible for the death of an individual. We report a rapid death of an individual following ingestion of 5 F-PB-22 and 5 F-AKB-48. Case information and autopsy findings are presented. Post-mortem blood samples were obtained and 5 F-PB-22 and 5 F-AKB-48 were detected along with 311 mg/100 ml alcohol. The cause of death was certified as the effects of a combination of alcohol and synthetic cannabinoids (5 F-PB-22 and 5 F-AKB-48)., (Copyright © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background: The emergence of new psychoactive substances (NPS), including synthetic cannabinoid receptor agonists (SCRAs) poses novel challenges for drug regulation and public health. Misconceptions of safety and legality, coupled with the fact that NPS are undetectable on routine drugs screens contributes to their popularity. Concerns over the unpredictable toxicity and abuse potential of NPS has led to a variety of legislative responses worldwide. We wish to describe Australian trends in SCRA use, examining the effects of legislative changes on calls to Australia's largest poisons centre., Methods: A retrospective review of calls to the New South Wales Poisons Information Centre (NSWPIC). Cases occurring between 1 January 2010 and 30 June 2015 with documented use of SCRAs were included., Results: There were 146 exposures to SCRAs recorded in the NSWPIC database. Federal bans of specific SCRA compounds in 2011/2012 had little impact on call volumes. State-based legislation introduced in 2013 banning specific brand names of SCRA products was followed by a dramatic, sustained decrease in exposures. The most common symptoms reported with SCRA use were tachycardia, vomiting, drowsiness, anxiety/panic, decreased level of consciousness, chest pain, agitation, hallucinations, confusion, seizures and hypertension., Conclusion: Banning of specific brand names of SCRA (timed with raids and social media campaigns) appears effective at reducing SCRA exposures. We postulate that this raised awareness within the community of the illegality of these substances while also reducing supply through bricks-and-mortar shops. These results could help inform future legislative responses., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Synthetic cannabinoids, referred to as "Bonzai" in Turkey, are relatively new recreational drugs of abuse. Although the use of synthetic cannabinoids has been dramatically increasing in young populations in many countries, their adverse effects are not well known., Objectives: To report on the clinical features and social history of pediatric patients with a diagnosis of synthetic cannabinoid intoxication and to highlight the dangers of these drugs to public health., Methods: We retrospectively reviewed 16 cases presenting to our Emergency Department (ED) with synthetic cannabinoid intoxication in the last 10 months. Usage characteristics and the psychoactive, physical, and metabolic effects of synthetic cannabinoids were analyzed., Results: The mean age of the 16 patients with a diagnosis of synthetic cannabinoid intoxication was 15.4 ± 1.7 years (15 males, 1 female). The most common physical symptoms were eye redness, nausea/vomiting, sweating, and altered mental status; the main psychoactive findings were agitation, anxiety, hallucinations, and perceptual changes. We observed hypotension and bradycardia in 8 (50%) and 5 (31.3%) of the patients, respectively. Although most patients were discharged from the ED, 25% were transferred to an intensive care unit. They all had reduced school attendance and performance. The rates of cigarette smoking and alcohol drinking were also significantly higher., Conclusion: Synthetic cannabinoids are unsafe and potentially harmful drugs of abuse; they may even cause life-threatening effects. It is important for pediatricians to be familiar with the signs and symptoms of consumption of synthetic cannabinoid products. Education of parents, teachers, and adolescents about the potential health risks of using these products is essential., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Since 2009, synthetic cannabinoid (SC) use has emerged as a growing public health threat in the United States (US). Several outbreaks of unexpected, severe toxicity linked to SC use have been reported since 2012. Reports of varied and significant morbidity after SC use are expected to increase because newer compounds enter the marketplace more frequently as manufacturers attempt to circumvent regulatory efforts., Case Report: We report a cluster of 7 patients who experienced a spectrum of anxiety, delirium, psychosis, and aggressive behaviors after smoking the same SC-containing product at a party. An 8th patient with the same exposure source presented with delayed onset seizures. Biologic samples were analyzed for novel, newly identified SCs belonging to the FUBINACA family of compounds. A previously unknown SC, N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-pentyl-1H-indazole-3-carboxamide (ADB-PINACA) was identified in biologic samples from 7 of the individuals. ADB-PINACA was identified in the SC-containing product ("Crazy Clown") seized by law enforcement and identified as the product smoked by the 8 patients in the reported cluster. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The information compiled using this cluster of cases, and a similar reported outbreak of altered mental status in Colorado, implicating the same SC (ADB-PINACA) and brands of SC-containing products, aided the US Drug Enforcement Administration in its temporary scheduling of ADB-PINACA and three other SCs. In this outbreak, close cooperation between public health and law enforcement allowed for a rapid intervention, which halted the outbreak by interrupting the common source and accelerated regulatory efforts to prevent further morbidity and mortality., (Published by Elsevier Inc.)

We describe a case of accidental cannabis poisoning in a 10-month-old girl, who presented with impaired consciousness, with drowsiness and restlessness, generalized hypotonia, and inadequate smiles. No circulatory or respiratory problems were observed. Initial investigations were not informative (blood biology, CT scan, and cerebrospinal fluid examination), while the main causes of coma (meningoencephalitis, head trauma, metabolic disorders) were excluded. Questioning the parents led to suspecting accidental ingestion of a piece of cannabis, which was confirmed by the detection of high blood and urine levels of cannabinoid derivatives. Management was symptomatic and the clinical course, marked by the occurrence of agitation and irritability episodes lasting up to H18, led to complete regression of symptoms. Because of the high consumption in France, pediatric poisoning by cannabis seems increasingly common. The toxic levels in children are unknown however. Diagnosis is based on questioning and the search for cannabinoid derivatives in urine. In children, clinical symptoms are more expressive compared to adults, with neurological (drowsiness, agitation, abnormal behavior, ataxia, hypotonia, coma, and convulsions) or cardiopulmonary (tachycardia, bradypnea, apnea) or homeostatic presentations (hypothermia). Treatment in children is essentially symptomatic but sometimes requires active resuscitation. Recommendations are based on clinical monitoring the first 24h after intoxication and on medicosocial support., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Three patients involved in illicit drug smuggling via the swallowing of high dose, high purity drugs packed in multiple condoms are reported. Two of these patients experienced drug overdose symptoms due to leakage or rupture of the condoms in the GI tract. They were treated successfully.