Synthetic Cannabinoid Induced Psychosis in a Previously Nonpsychotic Patient

The American Journal on Addictions, 21: 287–288, 2012 Copyright C American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/j.1521-0391.2012.00222.x Synthetic Cannabinoid Induced Psychosis in a Previously Nonpsychotic Patient Stephanie Peglow, DO,1 Jessica Buchner, BS, MS III,1 Gregory Briscoe, MD2 1Department of Psychiatry and Behavioral Medicine, Eastern Virginia Medical School, Norfolk, Virginia 2Department of Psychiatry, Hampton Veterans Affairs Medical Center, Hampton, Virginia Synthetic cannabinoids are relatively new substances cannabis,6,7 conventional merchant availability, and poten- that have become rapidly popular among young adults. tially negative health impact, synthetic cannabinoids are Despite their legal status in most states, they are virtually anticipated to be an emerging issue in the field of substance unregulated and unstudied. Nevertheless, recent case stud- abuse. ies have brought new attention to their potentially harmful side effects, such as psychosis, agitation, and withdrawal. This case report examines the acute psychosis displayed CASE REPORT by a psychiatric patient after smoking “Spice,” a substance comprised of various synthetic cannabinoids, on three sep- Mr. G is a 59-year-old Latino male with a history of arate occasions. Furthermore, in comparing this patient’s post-traumatic stress disorder (PTSD) and polysubstance lack of psychotic symptoms after tetrahydrocannabinol abuse. Without a prior history of psychosis, he was admit- (THC) use, to the episodes of psychosis experienced af- ted to the same inpatient psychiatric unit three times over a ter “Spice” consumption this case study explores the pos- period of 60 days for the development of psychotic symp- sibility that synthetic cannabinoids are more potent than toms after smoking “Spice.” The patient has a long history their organic counterpart. This is the first case report of of alcohol, heroin, cocaine and THC use that meets the synthetic cannabinoid-induced psychosis in a previously criteria for polysubstance abuse, but he stopped the use of nonpsychotic patient. all of these substances 3 years ago. The patient presented “Spice,” comprised of various synthetic cannabinoids, is to the emergency room before his first admission with de- a growing trend within substance use in young adults. It has tailed flashbacks of trauma related to combat after smok- been tried by up to 6% of 15- to 18-year-olds in Germany.1 ing two joints of “Spice” (1.5 g) daily in addition to using Despite the current lack of data revealing the prevalence of alprazolam 1 mg/day during 3 days per week for the previ- “Spice” use within any age group in the United States, case ous 3 weeks. The patient relapsed on benzodiazepines and reports are documenting a recent increase in emergency “Spice” after discharge and was readmitted 3 weeks later room and forensic presentations related to its use.2,3 with visual hallucinations. He left against medical advice To date, there are no studies of inhaled synthetic 1 day after admission. He was admitted for the third time cannabinoid use in humans. Nevertheless, recent case re- 2 days later after a relapse on “Spice” with visual halluci- ports have shown a correlation between synthetic cannabi- nations and disorganized, bizarre behavior, as reported by noid consumption and acute psychosis2,4 and agitation.3 his family. Benzodiazepines were not used before his third Another study describes acute withdrawal in a patient admission. smoking up to 3 g/day for 8 months.5 During all three admissions the patient rapidly recov- Despite mounting public health concerns and concomi- ered over 24 hours. Labs drawn, including complete blood tant legislative effort to remove it from the public do- count (CBC), basic metabolic panel (BMP), and liver en- main, this compound is still legal in various forms in most zymes, were within normal limits. In addition, his serum states. Given its increased potency compared to harvested alcohol and urine cocaine, opiates, and THC screens were negative. On the third admission, a more extensive serum drug screen was performed and the patient was negative Received April 24, 2011; revised April 27, 2011; accepted for amphetamines, benzodiazepines, barbiturates, cannabi- June 15, 2011. Address correspondence to Dr. Peglow, Eastern Virginia Med- noids, opiates, and phencyclidine (PCP). The patient was ical School, Psychiatry Residency, 825 Fairfax Ave., Norfolk, VA discharged on his outpatient medications, consisting of 23501. E-mail: [email protected]. gabapentin 400 mg QID, hydroxyzine 25 mg TID PRN, 287 apiprazole 10 mg qD, benztropine 1 mg BID, and bupro- synthetic cannabinoids. For example, short-term heavy, pion 150 mg BID. Even though the patient was placed on daily use of synthetic cannabinoids can precipitate simi- alcohol withdrawal precautions and rated by Clinical Insti- lar symptoms to THC withdrawal.5 In addition, JWH-018, tute Withdrawal Assessment for Alcohol (CIWA) scales, he a synthetic cannabinoid often found in “Spice,” is a po- did not require any PRN Ativan and did not score on the tential carcinogen.1 Therefore, synthetic cannabinoids may CIWA scale. On discharge, the patient was referred to an have more extensive side effect profiles than THC, which outpatient substance abuse program as well as Narcotics is concerning, considering their increasing popularity and Anonymous. the alarming presentations of their users. Evidence suggests this patient’s psychotic symptoms This is the first report of suspected psychosis induction were related to his acute synthetic cannabinoid intoxica- by “Spice” in a patient who lacked a previous psychotic dis- tion. For example, his urine drug screens and personal his- order diagnosis despite years of heavy THC use. This case tory reveal that the only common element preceding his suggests that synthetic cannabinoids may be more likely three psychotic episodes was heavy “Spice” consumption. to cause psychosis than THC, their organic counterpart, In addition, his psychotic symptoms rapidly subsided with and, hence, potentially more dangerous. One limitation of discontinued “Spice” use. Furthermore, other case studies this case was the use of urine drug screening as opposed have reported that “Spice” or other synthetic cannabinoid to a more comprehensive battery in assessing this patient consumption causes acute psychosis in selected patients.2,4 during his first two admissions. In these two case reports, however, psychosis was induced in diagnosed schizophrenic patients2 and in a patient who Declaration of Interest had previous THC-induced psychotic episodes.4 This case report marks the first account of psychosis induced by The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this “Spice” in a patient who had never before experienced psy- paper. chotic symptoms. It is important to consider other possible causes of this patient’s psychotic symptoms. For example, his acute REFERENCES presentation with visual hallucinations and disorganized behavior may have been related to benzodiazepine with- 1. European Monitoring Centre for Drugs and Drug Addiction (EM- drawal. This is a less likely explanation, however, because CDDA). Understanding the ‘Spice’ Phenomenon. Lisbon: EMCDDA; the patient had only been using xanax occasionally and in 2009. Available at: http://www.emcdda.Europa.eu/publications/ low doses, did not use benzodiazepines for at least 6 days thematic-papers/spice. Accessed January 10, 2011; Archived at Website before the third admission, did not exhibit any signs of http://www.webcitation.org/5wNZasIsa. benzodiazepine withdrawal, and did not score on CIWA 2. Every-Palmer S. Warning: Legal synthetic cannabinoids-receptor ago- nists such as JWH-018 may precipitate psychosis in vulnerable individ- scale. Substance induced psychosis because of unknown uals. Addiction. 2010;105:1859–1861. drugs, such as PCP lacing of the “Spice,” is also possible, 3. Vearrier D, Osterhoudt KC. A teenager with agitaiton: Higher than but PCP was ruled out in his serum drug screen. Delirium she should have climbed. Pediatr Emerg Care. 2010;26:462–465. is another possible diagnosis because the visual hallucina- 4. Muller¨ H, Sperling W, Kohrmann¨ M, et al. The synthetic cannabi- tions developed over a short period of time (24–48 hours), noid Spice as a trigger for an acute exacerbation of cannabis induced recurrent psychotic episodes. Schizophr Res. 2010;118: but is less likely as the patient did not have a disturbance 309–310. of consciousness, which is a defining factor of delirium. 5. Zimmermann US, Winkelmann PR, Pilhatsch M, Nees JA, et al.With- Another possible cause of this patient’s symptoms is THC drawal phenomena and dependence syndrome after the consumption use. Because of its chemical similarity to synthetic cannabi- of ‘Spice Gold’. Dtsh Artzebl Int. 2009;106:464–467. noids, THC may have precipitated the psychosis, as seen 6. Weissman A, Milne GM, Melvin LS. Cannabimimetic activity from 4 CP-47,497, a derivative of 3-phenylcyclohexanol. J Pharmacol Exp in the study by Muller¨ et al. Evidence reveals that THC Ther. 1982;223:516–523. use is correlated with psychotic episodes in a dose depen- 7. 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