II. Pharmacology

  1. Synthetic Cannabinoids
    1. Produced by spraying herbal plant leaves with cannabinoid receptor agonists
    2. Synthetic agonists are THC-like agents based on one of four synthetic parent agents
    3. Synthetic agonists are small, lipid soluble, non-polar molecules (22 to 26 carbons)
  2. Agents act at two cannabinoid receptors
    1. CB1 - CNS receptors (decrease intracellular cAMP and increase MAP kinase)
      1. Elevates mood and increases feelings of well being
      2. Affects pain tolerance, time perception, memory
    2. CB2 - T Cells, B Cells and Macrophages as well as peripheral nerves
  3. Most agents are pure agonists at cannabinoid CB1 cerebral receptor (contrast with THC as a partial agonist)
    1. Synthetics result in more intense, and unpredictable Intoxication than THC
    2. Synthetic THC lacks the cannabidiol (Antipsychotic, anticonvulsant) effects of Cannabis sativa (Marijuana)
      1. Hence the unpredictable psychotic effects and Seizures with synthetic THC
  4. Typically smoked in pipe or Cigarette paper, but has also been inhaled and ingested

III. Preparations

  1. Sold in 1-3 gram foil pouches of dried Herbals
    1. Typically labeled as "not for human consumption"
    2. More than 50 distinct products have been identified in the U.S.
    3. Various Herbals and crushed leaves are added for appearance only (drug is dripped onto the leaves)
  2. Street Names
    1. K2
    2. Kronic
    3. Spice
    4. JWH (John W. Huffman)
    5. Legal Marijuana
    6. Fake Weed
    7. Intensely aromatic incense
    8. Cloud-9 (AB-PINACA)
      1. Liquid form vaporized and resulted in multiple hospitalizations in 2014

IV. Symptoms: Sought effects

  1. Euphoria, elevated mood or intense "high"
  2. Uncontrolled laughter
  3. Disinhibition

V. Signs

  1. Diaphoresis
  2. Hyperreflexia
  3. Nystagmus
  4. Conjunctival injection

VI. Adverse Effects

  1. Neuropsychiatric effects
    1. Confusion
    2. Agitation, irritation or Violent Behavior
    3. Severe anxiety
    4. Memory loss
    5. Loss of consciousness
    6. Generalized Seizures
  2. Acute Psychosis ("Spiceophrenia")
    1. Severe paranoia and Hallucinations (auditory and visual)
    2. May persist for days to months
    3. May occur after a single dose
  3. Gastrointestinal effects
    1. Nausea or Vomiting
    2. Diarrhea
  4. Cardiovascular effects
    1. Palpitations
    2. Heart Rate changes (Tachycardia or Bradycardia)
    3. Blood Pressure changes (Hypertension or Hypotension)
    4. Cardiac ischemia
  5. Endocrine and renal effects
    1. Hypokalemia
    2. Metabolic Acidosis
    3. Hyperglycemia
    4. Acute Kidney Injury
  6. Withdrawal symptoms with regular use
    1. Anxiety, irritability, Insomnia
    2. Chills
    3. Profuse diaphoresis
    4. Tremors
    5. Myalgias
    6. Headaches
    7. Anorexia, Nausea, Vomiting

VII. Labs

VIII. Management

  1. IV crystalloid fluid Resuscitation
    1. Indicated for dehydration
  2. Benzodiazepines
    1. First-line agent
    2. Indicated for agitation
  3. Diphenhydramine
    1. Indicated for Dystonia
  4. Cooling
    1. Indicated for hyperthermia
  5. Antipsychotics (e.g. Zyprexa, Haloperidol)
    1. Indicated for acute Psychosis, esp. refractory to Benzodiazepines
    2. Avoid prophylactically due to theoretical risk of Seizure

IX. Precautions

  1. Agents are unregulated and unpredictable with variable components, potency and toxicity
  2. Acute Psychosis lasting months may occur after only a single dose

XI. References

  1. Tomaszewski (2016) Drugs of Abuse, ACEP PEM Conference, Orlando, attended 3/8/2016
  2. Fattore (2011) Front Behav Neurosci 5: 60
    1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3187647/
  3. Haynes, Meadors and Yuan (2016) Crit Dec Emerg Med 30(2): 3-9
  4. Rosenbaum (2012) J Med Toxicol 8(1): 15–32
    1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550220/
  5. Khullar (2014) J Gen Intern Med 29(8):1200-4 +PMID:24553958 [PubMed]

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