This isn’t your parent’s marijuana, thats for sure. As we continue to develop as a species, individuals are continuously attempting to develop newer and greater drug highs. As a result, the toxicologic world is continuously expanding, and in Emergency Medicine it is our job to keep up with trends in toxicology, and familiarize ourselves with emerging drugs of abuse.
- Discuss trends in cannabis and cannabis-derived product use.
- Review the recent Fentanyl epidemic.
- Look at trends in NPS (New Psychoactive Substances), including synthetic cannabinoids, phenethylamines and cathinones.
- Discuss local prevalence and monitoring methods for emerging drugs of abuse.
- Psychoactive compounds mainly consist of THC and CBD; which have opposite effects upon cannabinoid receptors.
- Historically, cannabis contained 2-4% THC and an equivalent proportion of CBD; which contained antipsychotic properties.
- Modern products contain 12-18% THC, and undetectable amounts of CBD; and this seems to be increasing the incidence of psychosis.
- Dabbing: a new practice consisting of inhaling the vapours of cannabis resin, which contains 80% THC.
- The production is highly dangerous, and the use poses risks of airway burns, and unclear long term risks due to potential inhalation of solder and rust.
- Synthetic cannabinoids are a wide family of laboratory made compounds, with significant activity on cannabinoid receptors. Their metabolism often involves a number of active metabolites with unpredictable properties.
- A number of dangerous side effects from their use have been reported, including: psychosis, seizures, rhabdomyolysis, acute kidney injury, cardiovascular instability and sudden death.
- Treatment is mostly supportive, with a potential role for intralipid therapy.
- There has been an significant surge in fentanyl deaths across the country in recent years, some are deliberate users diverting patches, or buying used ones to chew/smoke or boil.
- Many other users are intending to purchase cocaine, heroin, oxycontin, etc, but are sold fentanyl instead by dealers as it is cheaper and easier to obtain.
- Synthetic fentanyl analogs were initially discovered in the US in 2014, and found to be produced in Mexican clandestine labs. Similar products are both being made in local labs and imported in large qualities into Canada at very low cost.
- Overdose occurs very quickly and unexpectedly in users.
- Self-administered Narcan is not available in many places, but would likely improve outcomes.
New Psychoactive Substances (NPS)
- Despite the reputation initially obtained, bath salts were the fastest growing family of NPS worldwide in 2014, and the second most commonly found after cannabinoids.
- In the past year there has been increased use of a particular cathinone called alpha-PVP (“gravel” or “flakka“), a very inexpensive hallucinogen.
- Cathinones are known for causing prominent aggression, agitated delirium as well as hyperthermia and rhabdomyolysis.
- There is also a significant prevalence of mechanical suicide in patients intoxicated with these drugs.
- The cornerstone of treatment is aggressive sedation and cooling.
- NBOMe is a new phenethylamine that is a very potent hallucinogenic and serotonergic agent that is often sold as LSD in the form of blotters, but is also occasionally nasally insufflated.
- Patients tend to present with hallucinations, a sympathomimetic toxidrome and serotonin syndrome.
- Benzodiazapines are the mainstay of treatment, due to the risk of seizures.
- Unlike LSD, this drug leads to death from overdose and potential serotonin syndrome.
- PMMA/PMA have been identified in Canada in “ecstasy” tablets. They are cheap compounds that are easier and cheaper to synthesize than MDMA. Their onset is typically slower than MDMA, leading users to redose – resulting in significant potential toxicity.
- Users typically present with a sympathomimetic toxidrome, serotonin syndrome and multiorgan failure. They are also noted to commonly have hyperkalemia and hypoglycemia.
- Globally, there has been a dramatic increase in NPS, compounds are becoming more varied an increasing number no longer belong to traditional synthetic drug ‘families’.
- The emergence of new substances is being followed by drug forum monitoring, internet searches and surveys.
- The presence of known compounds in some regions is followed by wastewater analysis.
- CCENDU and the Canadian Centre on Substance Abuse provide an excellent source of local information on drug prevalence.
1. Van amsterdam et al Journal of Psychopharmacology 2015, Vol. 29(3) 254 –263
2. Di Forti et al The British Journal of Psychiatry (2009) 195, 488–491
3. Death Following Ingestion of an Edible Marijuana Product — Colorado, March 2014. MMWR2015 July 24;64:771-772.
4. Half-Baked — The Retail Promotion of Marijuana Edibles. MacCoun RF, Mello MM. N Engl J Med2015 Mar 12;372:989-991. MMWR June 12 2015, vol 64 (22)
5. Su MK, Metabolism of Classical Cannabinoids and the Synthetic Cannabinoid JWH-018; Clin pharm & therapeutics 2015 97 (6) 562
6. Trecki, J, Synthetic Cannabinoid–Related Illnesses and Deaths NEJM, 2015, 373 (2) 103 Gunderson EW, A Survey of Synthetic Cannabinoid Consumption by Current Cannabis Users, Subs Abuse, 35: 184–189, 2014) .
7. Bonar EE et al Synthetic cannabinoid use among patients in residential substance use disorder treatment: prevalence, motives, and correlates. Drug Alcohol Depend 2014;143:268-71
8. Kikura-Hanajiri R, Changes in the prevalence of new psychoactive substances before and after the introduction of the generic scheduling of synthetic cannabinoids in Japan; Drug Test. Analysis2014, 6, 832–839
9. Shanks KG Case reports of synthetic cannabinoid XLR-11 associated fatalities Forensic Science International 252 (2015) e6–e9
10. Behonick, G Four Postmortem Case Reports with Quantitative Detection of the Synthetic Cannabinoid,5F-PB-22 Journal of Analytical Toxicology 2014;38:559–562
11. Schwartz, MD A COMMON SOURCE OUTBREAK OF SEVERE DELIRIUM ASSOCIATED WITH EXPOSURE TO THE NOVEL SYNTHETIC CANNABINOID ADB-PINACAThe Journal of Emergency Medicine, Vol. 48, No. 5, pp. 573–580, 2015
12. Askel G. Et al Intravenous Lipid Emulsion Therapy for Acute Synthetic Cannabinoid Intoxication: Clinical Experience in Four Cases, Case Reports in Emergency Medicine Volume 2015, Article ID 180921, 5 pages.
13. MacfarlaneV,Christie G.Synthetic cannabinoid withdrawal: A new demand on detoxiﬁcation services. Drug Alcohol Rev 2015;34:147–53
14. Nacca N,Vatti D,Sullivan R,Sud P,Su M,Marraffa J.The synthetic cannabinoid withdrawal syndrome. J Addict Med 2013;7:296–8
15. Zimmermann US, Winkelmann PR, Pilhatsch M, Nees JA, Spanagel R, Schulz K. Withdrawal phenomena and dependence syndrome after the consumption of ‘ Spice Gold’. Dtsch Arztebl Int 2009;106:464–7
16. M.J. Lozier Acetyl Fentanyl, a Novel Fentanyl Analog, Causes 14 Overdose Deaths in Rhode Island, March–May 2013 J. Med. Toxicol. (2015) 11:208–217
17. Cole, J.B et al. Butyrfentanyl Overdose Resulting in Diffuse Alveolar Hemorrhage, PEDIATRICS Volume 135, number 3, March 2015
18. Stratton, SJ, Factors Associated With Sudden Death of Individuals Requiring Restraint for Excited Delirium Am J Emerg Med 2001;19:187-191
19. Banks, ML, Synthetic Cathinones (“Bath Salts”)The Journal of Emergency Medicine, Vol. 46, No. 5, pp. 632–642, 2014
20. Froberg, BA, Acute Methylenedioxypyrovalerone Toxicity J. Med. Toxicol. (2015) 11:185–194
21. G le Roux et al Drug and Alcohol Dependance 154 (2015) 46-53
22. Zuba, D et al, Forensic Science International 2013, 227, 7
23. Wood D.M., Prevalence of use and acute toxicity associated with the use of NBOMe drugs Clinical Toxicology (2015), 53, 85–92
24. King, L.A., New Phenethylamines in Europe, Drug Test. Analysis 2014,6, 808–818
25. Srisuma, S., et al. NBOMe and 2C substitute phenylethylamine exposures reported to the National Poison Data System, Clinical Toxicology (2015), 53, 624–628
26. Nikolaou, P., 2C-I-NBOMe, an “N-bomb” that kills with “Smiles”. Toxicological and legislative aspects, Drug and Chemical Toxicology, 38:1, 113
27. Laskowski, L. K., Evolution of the NBOMes: 25C- and 25B- Sold as 25I-NBOMe, J. Med. Toxicol. (2015) 11:237–241
28. Suzuki, J., toxicities Associated with NBOMe ingestions – A novel Class of Potent Hallucinogenics: A Review of the Litterature. Psychosomatics 2015:56:129
29. Lawn, W. The NBOMe hallucinogenic drug series: Patterns of use, characteristics of users and self-reported effects in a large international sample Journal of Psychopharmacology 2014, Vol. 28(8) 780–788
30. Johansen, Three Fatal Cases of PMA and PMMA Poisoning in Denmark, Journal of Analytical Toxicology, VoL 27, May/June 2003 , 253
31. Nicol, J.J.E., Deaths from exposure to paramethoxymethamphetamine in Alberta and British Columbia, Canada: a case series, CMAJ Open Jan 2015 3(1)
32. Vevelstad, M et al. The PMMA Epidemic in Norway: Comparison of Fatal and Non-Fatal Intoxications, Forensic Science International 219 (2012)151–157
33. Kamour A., et al Patterns of presentation and clinical features of toxicity after reported use of ([2-aminopropyl]-2,3-dihydrobenzofurans), the ‘ benzofuran ’ compounds. A report from the United Kingdom National Poisons Information Service Clinical Toxicology (2014), 52, 1025
34. Helander A., et al Intoxications by the dissociative new psychoactive substances diphenidine and methoxphenidine Clinical Toxicology (2015), 53, 446–453
35. Burns, L., Monitoring Drug markets in the internet age and the evolution of drug monitoring systems in Australia Drug Test. Analysis 2014, 6, 840–845
36.Gine, C.V., New Psychoactive Substances as adulterants of controlled drugs. A worrying phenomenon? Drug Test. Analysis 2014, 6, 819–82
37. Helander et al. Detection of New Psychoactive Substances among Emergency Room patients: Results from the Swedish STRIDA project. Forensic Science International 243 (2014) 23–2924
38. Reid, M.J, Analysis of new classes of recreational drugs in sewage: Synthetic cannabinoids and amphetamine-like substances Drug Test. Analysis 2014, 6, 72 –79
39. Archer, JRH, Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances Clinical Toxicology (2014), 52, 160–165