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 CANNABIS AND PSYCHOSIS: 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 Cocaine 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 tetrahydrocannabinol (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 cannabidiol (CBD) concentrations Nonmedical in the cannabis used by these patients. Also, Prescription Drug Use cannabis use in general was self-reported, and not validated by measures like blood 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 Psychedelic Drug 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 HEART ATTACK TIED TO WHAT IS BENZEDREX, AND EDIBLE MARIJUANA IS A HOW IS IT ABUSED? WARNING TO DOCTORS Benzedrex intranasal inhalers are nonprescription decongestants. The generic name for the drug is As medical and recreational marijuana becomes legal in propylhexedrine. These inhalers are sold over the counter more and more places, experts worry there isn’t enough to alleviate nasal congestion. 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 allergies In a new case report, doctors describe the heart attack of or colds. Amphetamine 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 amphetamines 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 stimulant. The drug causes a release The 70-year-old Canadian man, who had preexisting of dopamine, norepinephrine, and serotonin 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 vasoconstriction (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 joint (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 decongestant. 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 medications to treat the condition, and his disease generally do not do so by using the nasal inhaler properly. was “stable” at the time he consumed the edible Rather, they ingest the medication 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 blood pressure 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 palpitations - 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.