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Expecting the Unexpected: Clinical Effects of Synthetic Cannabinoids

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Expecting the Unexpected: Clinical Effects of Synthetic Cannabinoids Expecting the Unexpected: Clinical Effects of Synthetic Cannabinoids Mark Su, MD, MPH Clinical Associate Professor The Ronald O. Perelman Department of Emergency Medicine New York University School of Medicine Director, New York City Poison Control Center 1 Objective • To describe the clinical toxicity of the synthetic cannabinoid receptor agonists (SCRAs) 2 American Association of Poison Control Centers 3 New York City Poison Control Center 4 Where can we find cannabinoids? 5 Endogenous Cannabinoids 6 Phytocannabinioids - Marijuana (Cannabis Sativa) • First record of use 2727 BC by Chinese Emperor Shen Nung • More than 480 natural components • 66 classified as cannabinoids 7 Medicinal Cannabinoids 8 SCRAs (Synthetic Cannabinoids) 9 Cannabinoids Synthetic Cannabinoids ≠ Marijuana 10 Acute Marijuana Toxicity • Severe toxicity uncommon • Adverse reactions: distrust, dysphoria, fear or panic reactions • Case reports of significant toxicity – Pancreatitis – Ventricular tachycardia – Atrial fibrillation – Myocardial infarction 11 NO CONFIRMATION OF SCRA! EAPCCT 2015 12 ALL CONFIRMED SCRA N Engl J Med 2015; 373:103-7 13 Synthetic Cannabinoid Receptor Agonist Toxicity • Central Nervous • Gastrointestinal System • Pulmonary – Seizures • Miscellaneous – CVA – Metabolic • Psychiatric – Muscular • Cardiovascular – Cutaneous • Renal 14 Neurologic Toxicity - Seizures Reference Synthetic Cannabinoid(s) Notes (biological specimens) Gunderson EW, et. al: JWH-018 3 patients Am J Addict 2012;21:320-6 McQuade D, et al: Eur J Clin AM-2201 Single case Pharmacol 2013;69:373-6 Lapoint J, et al: Clin Toxicol JWH-018 Single case;ETOH; SVT 2011;49:760-4 Hermanns-Clausen M, et al: Drug Test JWH-018, JWH-122, JWH-210 4 patients; coma, apnea Anal 2013;5:790-4 Drenzek C, et al: Morbidity and ADP-PINACA 3/22 patients Mortality Weekly Reports (Nov 22, 2013) Simmons J, et al: Clin Toxicol JWH-018, JWH-073 3 patients 2011;49:431-33 Schneir A, Baumbacher T: J Med JWH-018, JWH-081, JWH-250, AM- Single patient; no biological Toxicol 2012;8:62-64 2201 confirmation 15 Neurologic Toxicity - Seizures Reduced seizure severity and mortality Jones NA, et al. J Pharmacol Exp Ther 2010;332:569-577 16 Neurologic Toxicity - Seizures • Mechanism unknown • Absence of cannabidiol in synthetic cannabinoid products may result in increased risk of seizures Schneir A, Baumbacher T: J Med Toxicol 2012;8:62-64 17 Neurologic Toxicity - CVA XLR-11 Takematsu M, et al: Clin Toxicol 2014;52:973-975 18 Neuropsychiatric Effects 19 Neuropsychiatric Effects • SCRAs associated with: – Confusion – Psychosis – Agitation – Loss of consciousness or memory – Seizures 20 Neuropsychiatric Effects • 22 patients aged 16 – 57 • Toxicologic testing: years ADB-PINACA – Confusion/disorientation (32%) – Somnolence/unresponsiveness (32%) – Aggression (32%) MMWR Morb Mortal Wkly Rep 2013;62:939 21 Cannabis • “Hashish and Mental Illness” (1845) – Cannabis resin could precipitate “acute psychotic reactions, generally lasting but a few hours, but occasionally as long as a week; the reaction seemed dose-related” Jacques-Joseph Moreau (de Tours) 1804 - 1884 22 “Hashish and Mental Illness” (1845) • Main features – Paranoid ideation – Illusions “Delirium” – Hallucinations “Disorientation” – Delusions “Marked clouding of consciousness” – Depersonalization – Confusion – Restlessness – Excitement 23 Cannabis-induced Psychosis Early Developmental Stages of Psychopathology Study Baseline Assessment:1995; Follow-up: 1999 n = 2437 Cecile H, et al: BMJ 2005; 330(7481):11 Epub 2004 Dec 1 24 Cannabis-induced Psychosis Early Developmental Stages of Psychopathology Study Baseline Assessment:1995; Follow-up: 1999 n = 2437 Cecile H, et al: BMJ 2005; 330(7481):11 Epub 2004 Dec 1 25 Cannabis-Induced Pyschosis • Mechanism – Not clearly elucidated – Dopamine hypothesis of schizophrenia: increase in DP into limbic system and neocortex – Stimulation of CB receptors by THC alters release of dopamine – May occur more frequently in patients with previous psychosis Fergusson DM, et al. BMJ 2006;332:172-6 26 Neuropsychiatric Effects from SCRAs • Case series of 8 patients – Anxiety – Delirium – Psychosis – Aggressive behavior • Confirmed ADB- PINACA Schwartz MD, et al. J Emerg Med;2015;48:573-580 27 Neuropsychiatric Effects of SCRAs Paranoia Anxiety Hallucinations Disorientation Altered Mood/ Perception Gunderson ED, et al. Am J Addict 2012;21:320-6 28 Cardiovascular Toxicity Hermanns-Clausen M, et al: Addiction 2013;108:534-44 29 Cardiovascular Toxicity JWH-018, JWH-081, JWH-122, JWH-210, JWH-250, AM-2201 Yeakel JK, Logan BK: J Anal Toxicol 2013;37:547-551 30 Cardiovascular Toxicity • 22 patients aged 16 – • Toxicologic testing of 57 years 5/7 patients tested: • 13 (59%) had • ADB-PINACA tachycardia • 1 had Myocardial infarction MMWR Morb Mortal Wkly Rep 2013;62:939 31 Renal Toxicity AKI in Multiple States 2012 32 Renal Toxicity 33 Renal Toxicity • Renal biopsy – 6 out of 8 patients had acute tubular necrosis (ATN) – 3 out of 8 patients had acute interstitial nephritis • Kidney function – Returned in 3 days in most patients – 5 out of 16 patients required HD • Other causes AKI not found – Infectious, Autoimmune, Pharmacologic 34 Gastrointestinal Effects • Cannabinoid hyperemesis syndrome (CHS) – Recurrent bouts of abdominal pain – Nausea/vomiting – Relieved by frequent hot baths – Resolve when cannabis use is discontinued 35 Gastrointestinal Effects • 30-year-old man previous marijuana user • Frequent visits to ED • Abdominal pain, nausea, vomiting • CT Scan, US, endoscopy, barium swallow… • Urine (LC/MS): JWH-018, JWH-073, AM-2201; negative THC • Symptoms resolved after two weeks Hopkins CY, Gilchrist BL: J Emerg Med 2013;45:544-6 36 Pulmonary Toxicity (Marijuana) MTS = marijuana + tobacco smokers MS = marijuana smokers TS = tobacco smokers NS = non-smokers Tashkin D, et al: Am Rev Respir Dis 1987;135:209-216 37 Pulmonary Toxicity • 21-year-old male involved in MVC • Smoked synthetic cannabinoids for 4 months prior to presentation Alhadi S, et al: J Med Toxicol 2013;9:199-206 38 Pulmonary Toxicity Blood, Saliva, Urine Testing Alhadi S, et al: J Med Toxicol 2013;9:199-206 39 Miscellaneous Toxicity • Metabolic • Cutaneous – Hyperglycemia – Xerostomia – Hypokalemia – Diaphoresis – Hyperthermia – Photosensitivity • Muscular – Myalgias – CK elevation (rhabdo) Müller H, Kornhuber J, Sperling W Brain Res Bull 2015;pii:S0361- 9230(15)30052-6 40 Summary of Clinical Side Effects Müller H, Kornhuber J, Sperling W Brain Res Bull 2015;pii:S0361- 9230(15)30052-6 41 Withdrawal Syndrome • Δ9-THC Syndrome – Anxiety – Myalgias – Chills – Anorexia J Addict Med 2013; 7: 296-298 42 Why are the clinical effects of SCRAs different from cannabis? • Multiple factors – Dosing – Contents variable – Potential contaminants – Metabolic differences – Pharmacology 43 Dosing of Marijuana 44 Dosing of SCRAs (“Spice” or “K2”) 3g 4g 5g 45 Spice/K2 Contents • One gram of spice can contain up to 202 mg of SCRA • High variability in content of individual packets • Potential contaminants – β2 agonists (e.g., clenbuterol) 46 Sample of K2 Packets NYC (July 2015) NYS Wadsworth Laboratory 47 Human Metabolism of Cannabinoids JWH-018 Δ9-THC Su MK, et al: Clin Pharmacol Ther 2015;97:562-4 48 Cytochrome p450 Enzyme System • Enzymes involved in the metabolism of SCRAs have genetic polymorphisms – CYP 3A4 • Involved in metabolism of most drugs – CYP 1A2 • Wide range of expression and activity • Racial differences among gene expression • Affected by cigarette smoking – CYP 2C9 • More than 35 allelic variants 49 Binding Affinities of Synthetic Cannabinoids Forensic Sci Rev 2014;26:53-78 50 QUESTIONS? 51.
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