IN THIS ISSUE……

Heart Attack Tied to

Edible Marijuana is a Warning to Doctors THE OFFICIAL NEWSLETTER OF THE MINNESOTA DRE MARCH 2019 What is Benzedrex, and How is it Abused AND : GETTING HARDER TO ARGUE AGAINST CAUSATION

Medical Application of Case-control study adds to mounting evidence Cannabis in Minnesota – The Basics – People who used cannabis every day were at higher risk of developing a first psychotic episode versus people who never used cannabis, in a case-control study conducted in Use of and Europe and Brazil. Compared with non-users, daily cannabis users had more than a three-fold higher odds Marijuana May for incident psychosis (adjusted odds ratio 3.2, 95% CI 2.2-4.1), reported Marta Di Contribute to Young Forti, PhD, of the Institute of Psychiatry, Psychology, and Neuroscience at King's Adults’ Stroke Risk College London, and colleagues. Daily users in cities with relatively wide- Appellate Court spread availability of high-potency cannabis, Affirms ARIDE defined as a (THC) concentration ≥10%, saw an even higher Officer Being Qualified chance for psychosis versus non-users as an Expert they stated in Lancet Psychiatry. However, one notable study limitation was the lack of E.R. Visits for data on (CBD) concentrations Nonmedical in the cannabis used by these patients. Also, Prescription Use cannabis use in general was self-reported, and not validated by measures like or urine samples. The cutoff between high and low potency (10% THC) was rather conservative, the authors noted. Kratom-Related Calls Despite the researchers "assuming causality" many times throughout their study, "does to Poison Control this mean we can now be sure that (daily and high potency) cannabis use causes Centers on the Rise psychosis? Unfortunately, not all the evidence utilizing different methods is consistent about causality," said Suzanne Gage, PhD, of the University of Liverpool in England, Man Charged With in an accompanying commentary. "Di Forti and colleagues' study asks participants about their cannabis use prior to their Manufacturing first episode psychosis diagnosis, but it is possible that subclinical symptoms might have existed prior to cannabis initiation, meaning that associations in the opposite direction cannot be ruled out," she wrote. It is "perfectly possible" the relationship is Benzodiazepine Misuse bidirectional, Gage added, "as suggested by other work using genetic variables as Among Adults proxies for the exposures of interest in a Mendelian randomization design.

Increasing Continued on Page 3 MARCH 2019 Page 2 ATTACK TIED TO WHAT IS BENZEDREX, AND EDIBLE MARIJUANA IS A HOW IS IT ABUSED?

WARNING TO DOCTORS Benzedrex intranasal are nonprescription . The generic name for the drug is As medical and recreational marijuana becomes legal in . These inhalers are sold over the counter more and more places, experts worry there isn’t enough to alleviate . science on the risks and benefits of the drug, especially Benzedrex intranasal inhalers are meant to temporarily for patients with heart disease. treat nasal congestion that can occur as a result of In a new case report, doctors describe the heart attack of or colds. sulfate was once the active a man who ate a lollipop laced with high levels of THC, ingredient used in Benzedrex inhalers; however, marijuana’s psychoactive ingredient. This patient’s are commonly abused and high doses can story may serve as a warning that cannabis isn’t as be dangerous. In 1949, amphetamine in the inhalers was benign as some would like to think, doctors write in the replaced with propylhexedrine. Canadian Journal of Cardiology. Propylhexedrine is a . The drug causes a release The 70-year-old Canadian man, who had preexisting of , , and from cells. heart disease, suffered a heart attack half an hour after Its stimulant effects are similar to the fight-or-flight consuming most of a lollipop that contained 90 mg of response that occurs in people and animals when they are THC. The man had hoped it would help with arthritis stressed, including (tightening of the pain and sleep. The dose in the lollipop was far greater arterial walls), increased heart rate, increased blood than what people typically inhale with a single marijuana pressure, dilation of the airways, and increased blood (7 mg), the researchers note. sugar levels. The vasoconstriction the drug causes is “With access to marijuana legal now in Canada, it’s responsible for its effectiveness as a nasal . going to be accessible to a larger proportion of the Propylhexedrine is banned in competition by the World population and it’s more likely that some of them will Anti-Doping Agency (WADA). This means that athletes have heart disease,” said study coauthor Dr. Rob are forbidden from using this drug during any Stevenson, a cardiologist at the New Brunswick Heart competitions in organizations that have accepted Center in St. John, New Brunswick. “This could be the WADA’s code. canary in the coal mine.” The man already had been diagnosed with Propylhexedrine Abuse atherosclerosis and had bypass surgery, but he was According to one study, individuals who abuse the drug taking to treat the condition, and his disease generally do not do so by using the nasal properly. was “stable” at the time he consumed the edible Rather, they ingest the orally or inject it into cannabis, said lead study author Dr. Alex Saunders, chief their veins. resident of the internal medicine program at the St. Propylhexedrine abuse has been blamed for several health John’s site for Dalhousie University. “After his bypass problems and even sudden death. So why do people abuse surgery he had no repeats of chest pain other than this it? Some people may be trying to get high legally, and one,” Saunders said. some may be trying to improve their concentration and The man had smoked marijuana in his youth and had productivity. However, propylhexedrine abusers report fond memories of it, Saunders said. But once the effects that it does not actually make them more productive of the high-dose THC in the lollipop started to hit, the man’s and heart rate quickly shot up. “He The Effects of Benzedrex Abuse described fearful hallucinations,” Saunders said “He was When taken as instructed, Benzedrex is generally not a very afraid he was going to die.” dangerous drug. Some individuals may experience side By the time family members got to him, “he was not only effects, such as burning nasal passages, dryness, rebound having hallucinations, but also intense chest pain,” nasal congestion, sweating, tremors, anxiousness, and/or Saunders said, adding that the terror the man restlessness. Widespread effects are more frequent in experienced may have been too much for his heart. individuals who have heart disease and/or who use propylhexedrine excessively. Continued on Page 5 Continued on Page 3 MARCH 2019 Page 3

CANNABIS AND PSYCHOSIS Continued from page 1

The current analysis included data on 901 adults (ages 18 to 64) with first-episode psychosis diagnosed with ICD-10 criteria at a mental health service. These patients came from across 11 different sites in Brazil and Europe, including the Netherlands, the U.K., France, Spain, and Italy. They were compared with over 1,200 psychosis-free controls from the same sites. People with first-episode psychosis tended to be younger, male, an ethnic minority, and less educated than controls. Some 65% of cases reported any lifetime use of cannabis compared with 46% of controls. Via the Cannabis Experience Questionnaire, participants reported six measures of cannabis use, which included lifetime use, current use, age of first use, lifetime frequency, and weekly money spent on cannabis. Those who spent at least €20 per week (around $23) on cannabis also had higher odds of psychosis (aOR 2.5, 95% CI 1.6-3.8, P<0.0001), as well as those who first used cannabis before they were age 16 years (aOR 1.6, 95% CI 1.1-2.1, P=0.01). Di Forti and colleagues wanted to determine whether cannabis potency had any relationship with psychosis risk, but they did not have direct data from the cannabis products that participants reported using. The city of residence was used as a proxy instead, based on published reports about the availability of high-potency cannabis by city. Those reports indicated that THC content varied widely: up to 70% in Amsterdam versus less than 10% in Italy, Spain, and France, where weaker herbal types of marijuana were typical. On the basis of these data, the researchers estimated that if only cannabis with <10% THC was available, about 12% (95% CI 3.0-16.1%) of first-episode psychosis cases from the overall sample could have been prevented. In areas where more potent cannabis is popular, they suggested upwards of 30% (95% CI 15.2-40.0%) of first psychosis cases could have been avoided in London (where the most common product is 14% THC) and over 50% (95% CI 27.4- 66.0%) of cases in Amsterdam could have been prevented if only low potency cannabis was an option.

Source: MedPage Today

WHAT IS BENZEDREX, AND HOW IS IT ABUSED? Continued from Page 2

When people abuse the drug, a number of significant negative effects may occur. According to the Handbook of the Medical Consequences of Alcohol and Drug Abuse, propylhexedrine abuse has been associated with the following: rapid heart rate - blood pressure changes - heart - chest pain - irregular heartbeat - excess fluid surrounding the heart - heart attack - cardiopulmonary arrest - rapid breathing - shortness of breath - respiratory distress - excessive fluid in the lungs – psychosis – fever – chills – shaking – sepsis - death Injecting propylhexedrine is linked with swelling, tissue death, ulcers, cellulitis, changes in sensation, bruising, and abscesses. One study reports that the toxic effects of propylhexedrine are similar to those of amphetamines but can actually produce more severe end-organ problems, especially if it is injected intravenously. This is reportedly because propylhexedrine both constricts blood vessels and raises blood pressure more intensely than amphetamines. In addition to propylhexedrine, Benzedrex inhalers also contain lavender oil and . Although some individuals who misuse the drug seek to extract the propylhexedrine from the mixture, extraction methods may be flawed. Other individuals may consume the cotton rods whole, ingesting all the ingredients of Benzedrex as well as the cotton. Consuming these other components, particularly in large amounts, may be dangerous. Those who abuse the drug may leave broken Benzedrex inhalers, Benzedrex packaging, bits of cotton, etc., in their rooms or in their clothing.

Source: Laguna Treatment Hospital MARCH 2019 Page 4

MEDICAL APPLICATION OF CANNABIS IN MINNESOTA – THE

BASICS

rd In 2014, Minnesota was the 23 state to enter into the arena of medicinal application of cannabis. While cannabis remains an illegal substance under federal laws, states have been permitted to create laws establishing a ‘’ program.

Minnesota’s medical cannabis law is considered the most restrictive of all states because of the limited list of qualifying conditions and the allowed delivery methods. Raw leaf, flowers, and edibles are not allowed under Minnesota law. Legal medical cannabis includes only pills, oil, topical and liquid.

How does someone enroll into the medical cannabis program? There are three basic steps that must be completed in order to purchase Minnesota’s medicinal cannabis.

1) Minnesota currently designates 13 qualifying conditions for entry into the program. The qualifying condition must be certified by a medical professional in order for a person to obtain a permit to purchase

medical cannabis. The qualifying condition must be recertified by a medical professional annually. This is not a prescription, only a verification of their condition.

2) The certification is submitted to the Minnesota Department of Health. Once the certification is verified, the person is allowed purchase their permit. The current cost of the permit is $200.00 (annually).

3) With the permit in hand, the permit holder purchases their product from one of the two manufacturer’s patient centers. All purchase costs are out-of-pocket.

The permit holder’s specific condition will determine what formulation of medicinal cannabis they are allowed to purchase. There are three basic formulations: high THC low CBD, high CBD/low THC, and balanced THC/CBD

(equal amounts).

Medical cannabis produced will be identifiable by the required packaging and labeling. This includes the patient’s registry identification number, name, date of birth, address, name and address of the medical cannabis manufacturer, the chemical composition of medical cannabis (amount of THC and/or CBD), recommended dosage, directions for use, batch number and date of manufacture.

When Minnesota LEOs contact an individual who possesses medical cannabis, it is imperative that the labeling is examined to ensure that the information is accurate. Anyone legally allowed to handle medical cannabis will have their name printed on the label. Unauthorized possession of medical cannabis should be reported to the Department of Health. The Unauthorized Medical Cannabis Possession Report can be found in the Print Materials and Forms link on the Minnesota Department of Health Medical Cannabis webpage.

LEOs should also note the specific formulation of the product. A formulation with a high THC content may be impairing and is not exempted from impaired driving laws. Formulations with high CBD content may still contain some THC. CBD is purportedly non-impairing.

USE OF COCAINE AND MARIJUANA MAY CONTRIBUTE TO

YOUNG ADULTS’ STROKE RISK

Use of cocaine and marijuana may contribute to the risk of stroke in young adults, a new study suggests. Researchers examined 20 years of data from 2,200 adults aged 18 to 54 who had a stroke. Drug use in this group rose from 4.4 percent in 1993-1994 to 30.3 percent in 2015. During the same period, use of alcohol and cigarettes remained stable, HealthDay reports. The findings were presented at the American Stroke Association’s international conference.

“It’s concerning. We need to be doing more to curb this growing problem, and young people especially need to be aware that illicit substances are associated with an increased risk to your health — specifically, the risk of stroke,” said lead author, Dr. Felipe De Los Rios La Rosa.

MARCH 2019 Page 5

APPELLATE COURT AFFIRMS ARIDE OFFICER BEING

QUALIFIED AS AN EXPERT

The Court of Appeals of Iowa issued an opinion in State v Sanchez-Casco on November 21, 2018. Mr. Sanchez-

Casco was charged with third offense driving under the influence. Factually, Mr. Sanchez-Casco was at a convenience store when he began acting in a bizarre and threatening manner. These behaviors included dangerous driving and driving around the parking lot in reverse. The clerk contacted the police. Mr. Sanchez-Casco was located at a second convenience store shortly after the call was received. The first officer on the scene contacted Officer Brewer as she had significant experience with impaired driving cases. At trial, Officer Brewer testified she had investigated at least 500 cases of impaired driving. She was a standardized field sobriety testing instructor and teaches SFSTs to other officers. Also, she has certification in Advanced Roadside Impaired Driving Enforcement or “ARIDE.” The Court of Appeals of Iowa noted, “She is also a certified drug recognition expert, which requires three-and one-half weeks of state-level training to achieve the state certification and an additional week of national-level training to achieve the national certification. As a drug recognition expert, she is trained to recognize intoxication from seven different drug categories.” The trial court qualified Officer Brewer as an expert in the identification of impaired driving based on her qualifications. Mr. Sanchez-Casco objected to her certification as an expert at trial. On appeal he argued that the trial court abused its discretion in allowing Officer Brewer to provide expert testimony on his intoxication. The appeals court held that qualifying Officer Brewer as an expert was not an abuse of discretion and affirmed the conviction. The interesting thing about this case is that although there is a lot of case law nationally affirming qualifying Drug Recognition Experts or “DREs” as expert witnesses, there is not as much case law addressing ARIDE trained officers. Source: National Center of State Courts

HEART ATTACK TIED TO EDIBLE MARIJUANA Continued from Page 3

Once at the hospital, doctors confirmed that he’d had a heart attack. The man survived his heart attack, but tires more quickly than before with exercise. Saunders worries that with marijuana now legal in Canada, increasing numbers of people with heart disease will be using it and some of them will be at risk for heart attacks. “When I was in my rheumatology rotation, over half of my patients were asking if marijuana would help with the aches and pains that don’t get better with traditional medicine,” she said. And while many would have avoided cannabis before, “now that it’s legal they don’t feel as bad,” Saunders said. “One of the most reliable acute effects of the THC in cannabis is that it increases heart rate,” said Ryan Vandrey, who wasn’t involved in the case report. “And it’s dose dependent. Even at modest doses you can get increases in heart rate of 20 to 30 beats per minutes. And it can go higher. If someone with cardiovascular risk factors experiences a short-term bump in heart rate that would be a concern.” Vandrey, a psychiatry researcher at Johns Hopkins Medicine in Baltimore, Maryland, was especially disturbed by the high dose of THC in the lollipop. “Part of my frustration with products like this is that nobody is going to take just a couple of licks and then put it away,” he said. “There should be no circumstance where you get a product and you’re not supposed to consume the whole thing and it’s not clear when you’re supposed to stop.” In an editorial accompanying the case report, Dr. Neal Benowitz of the University of California, San Francisco, outlines the different mechanisms by which THC can affect the heart and cautions doctors to keep these in mind when deciding whether and how to use cannabis to treat patients with heart disease.

SOURCE: Canadian Journal of Cardiology

MARCH 2019 Page 6

E.R. VISITS FOR NONMEDICAL MAN CHARGED WITH

PRESCRIPTION DRUG USE MANUFACTURING

Young adults under age 35 account for half of emergency PSYCHEDELIC DRUG room visits due to nonmedical prescription drug use, A northeast Minnesota man is in custody after according to a new study. authorities conducting a search warrant found a drug

Nonmedical prescription drug use is defined as use that has only been found in the state three times in the without a prescription or use for reasons other than for past decade. The search of a home in Rice Lake, a which the medication is intended. community north of Duluth, was carried out by the St.

In the study, researchers from the Centers for Disease Louis County Sheriff's Office and the Minnesota

Control and Prevention reviewed national data to identify Bureau of Criminal Apprehension. Inside the residence which medications caused the highest numbers of was Dimethyltryptamine, a psychedelic drug similar to emergency room visits following nonmedical use, LSD that is known as "DMT."

Medical Express reports. The man accused to manufacturing the drug, using

They found harm from nonmedical use of medications led Amazonian plants and other products "readily found on to about 360,000 emergency room visits in the United the internet" that can be highly flammable, has been

States in 2016. The most frequent causes of these visits identified as Donald Alan Rankin. were benzodiazepines and opioids, most commonly in The BCA Crime Lab found several mason jars filled combination with other substances such as illicit with brown liquid and a clear top layer, and subsequent and alcohol. Forty percent of patients required testing of the liquid determined that it was in fact DMT. hospitalization, the researchers reported in the American It's only the third known instance of DMT in Minnesota Journal of Preventive Medicine. over the last decade. Because its presence in Minnesota is so unusual, investigators have been working with Los Angeles Police Department, who more commonly deals KRATOM-RELATED CALLS TO with the drug in California. Ranking was formally charged Wednesday morning in POISON CONTROL CENTERS St. Louis County District Court with first-degree ON THE RISE sale/manufacture of a controlled substance. Bail has been set at $75,000. Poison control centers report a growing number of calls Source: BringMeTheNews related to the herbal supplement kratom, according to The Washington Post. There were more than 1,800 calls BENZODIAZEPINE MISUSE related to kratom exposures from January 2011 through AMONG ADULTS INCREASING December 2017, researchers report in the journal Clinical Toxicology. Sixty-five percent of the calls were made in A growing number of U.S. adults are misusing 2016 and 2017. benzodiazepines such as Valium and Xanax, The supplement is not regulated by the Food and Drug researchers at the University of Michigan have found. Administration (FDA) because it is not considered a In a study published in Psychiatric Services, the drug. Kratom is legal in most states. It is taken to relieve researchers report about one in five people who take pain or ease the effects of opioid withdrawal. Some benzodiazepines are misusing them. people take it to boost their mood or help with or Young adults ages 18 to 25 are the most likely to depression. misuse benzodiazepines, the study found. “If you look In September 2018, FDA Commissioner Scott Gottlieb at younger adults, basically misuse was as common as released a statement that said there have been no prescribed use, which obviously is kind of disturbing,” adequate and well-controlled scientific studies involving lead researcher Donovan Maust told HealthDay. the use of kratom as a treatment for opioid use Misuse of the drugs declined with age. Overall use of withdrawal or other diseases in humans. the drugs among adults is more than twice as high as The FDA has said that kratom carries the risk of abuse, previously reported, with almost 13 percent of adults addiction and in some cases, death. using benzodiazepines within the past year.