Transcript Synthetic Cannabinoids - Alcohol Medical Scholars Program

SYNTHETIC CANNABINOIDS
Shelley A. Holmer MD
Duke University School of Medicine
©AMSP 2013
© AMSP 2013
1
CASE
• 27 yo woman who presented with
• Trembling
• Confusion
• Voices
• Fears people want to harm her
• No family history of psychosis
• Medical work-up → no major medical dx
• Recent use of the synthetic cannabinoids
© AMSP 2013
2
THIS LECTURE WILL REVIEW
• Background on cannabinoids
• Development of synthetic cannabinoids (SC)
• Risks associated with use
• Synthetic cannabinoids versus marijuana
© AMSP 2013
3
NATURAL CANNABINOIDS = MARIJUANA
• Comes from the plant Cannabis sativa
• Composed of > 500 compounds
• 66 compounds are "cannabinoids”
© AMSP 2013
4
CANNABINOIDS
Psychoactive
• Tetrahydrocannabinols (THC)
• Cannabinol (CBN)
• Cannabinodiol (CBDL)
Non-psychoactive
• Cannabigerols (CBG)
• Cannabichromenes (CBC)
• Cannabidiols (CBD)
© AMSP 2013
5
CANNABINOID RECEPTORS
CB1 receptor
• Psychoactive effects
• In brain and spinal cord (CNS)
• THC = partial agonist (positive effect)
• CBD = antagonist (blocker of CB1)
CB2 receptors
• Immune cells outside CNS
• Immune function and inflammation
© AMSP 2013
6
CANNABINOIDS:
PSYCHOACTIVE EFFECTS
•
•
•
•
•
•
•
Euphoria
Sensation of slowed time
Impaired judgment
Impaired coordination
Social withdrawal
Anxiety
Psychosis
© AMSP 2013
7
PSYCHOSIS
• Hallucinations +/• Delusions
• Without insight
• Alert/oriented
• Potential cannabinoid impact
• THC may ↑ psychosis
• CBD may ↓ psychosis
© AMSP 2013
8
NON-PSYCHOACTIVE EFFECTS
• ↓ Nausea
• ↑ Appetite
• ↓ Pain
© AMSP 2013
9
CHRONIC USE LEADS TO
• Tolerance
• Withdrawal symptoms when stopped
•
•
•
•
•
•
•
Irritability/anger/aggression
Anxiety
Sleep difficulty
↓ Appetite
No legal
Restlessness
Depressed mood
Physical Symptoms
detox
• Peak ~3-4 days, resolves after ~7 days
© AMSP 2013
10
THIS LECTURE WILL REVIEW
• Background on cannabinoids
• Development of synthetic cannabinoids (SC)
• Risks associated with use
• SC versus marijuana
© AMSP 2013
11
SC FOR MEDICAL USE
Dronabinol (Marinol)
Nabilone (Cesamet)
• Nausea/vomiting with cancer chemotherapy
• AIDS associated anorexia and weight loss
© AMSP 2013
12
SC FOR RECREATIONAL USE
• Research compounds
• None approved for humans
• Most >potency than THC
JWH18
• Full agonists at the CB1 receptor
© AMSP 2013
13
SPICE MARKETING
Spice
Red magic
K2
Red dragon
Diesel
Serenity
Sold as herbal incense
Labeled “not for human use”
© AMSP 2013
14
SPICE PRODUCTION
• SC sprayed on substance
• No dose control
• No regulation of ingredients
© AMSP 2013
15
SPICE USE
• First seen in Europe 2004
• First marketed in U.S. 2008
• 2012  used by 11 % of 12th graders
© AMSP 2013
16
SPICE: MEDICAL RECOGNITION
• Calls to US poison control centers
• 2010: 3000
• 2011: 7000
• 2012: 5000
• 11,406 ER visits in 2010
© AMSP 2013
17
LEGAL STATUS OF SPICE
• 2008 Europe banned for health concerns
• 2011 US federal law deemed “no medical use”
• Possession illegal in 41 states
• Remains available
• Head shops
• Convenience stores/gas stations
• Internet
© AMSP 2013
18
WHY IS IT POPULAR?
• New/novel way to get “high”
• False belief SC safe because
• “Herbal”
• Legal
• Might ↓ cannabis withdrawal
• Inexpensive
• Accessible
© AMSP 2013
19
NOT DETECTED ON DRUG SCREENS
• Athletes
• Military personnel
• Students
• People on probation
• Employees with required drug screens
• Patients in drug tx programs
© AMSP 2013
20
THIS LECTURE WILL REVIEW
• Background on cannabinoids
• Development of synthetic cannabinoids (SC)
• Risks associated with use
• SC versus marijuana
© AMSP 2013
21
CASE
Clinical Course
• Pt immobile and incommunicative
• Hospitalized 2 mo with psychosis
• One year later psychosis free
© AMSP 2013
22
CASE REPORTS: ACUTE TOXICITY
PSYCHIATRIC
• Agitation
• Anxiety
• Paranoia
• Delusions
Burroughs
• Hallucinations
© AMSP 2013
23
ACUTE TOXICITY
NEUROLOGIC
• Dilated pupils
• Decreased reflexes
• Jerking movements
• Seizures
© AMSP 2013
24
ACUTE TOXICITY
CARDIOVASCULAR
• ↑ Heart rate
• ↑ Blood pressure
• Chest pain
© AMSP 2013
25
ACUTE TOXICITY
GASTROINTESTINAL
• Nausea
• Vomiting
• Diarrhea
© AMSP 2013
26
TREATMENT OF ACUTE INTOXICATION
PSYCHIATRIC (anxiety/psychosis)
• Verbal reassurance “talk down”
• Medication for agitation (lorazepam)
• Seclusion/restraint only if serious danger
• Evaluate need for ongoing psychiatric care
© AMSP 2013
27
TREATMENT OF ACUTE INTOXICATION
NEUROLOGIC
• Seizure monitoring
• Evaluate muscle injury
• Muscle pain/weakness
• Labs: ↓ kidney function
© AMSP 2013
28
TREATMENT OF ACUTE INTOXICATION
CARDIOVASCULAR
• Monitor
• Blood pressure
• Heart rate
• Check EKG
• Labs: heart damage enzymes
• Troponin > 0.2 ng/ml
• CKMB > 3 ng/ml
© AMSP 2013
29
TREATMENT OF ACUTE INTOXICATION
GASTROINTESTINAL
• Medication for nausea
• IV fluids
• Labs: check for low potassium
© AMSP 2013
30
LASTING CONSEQUENCES
Heart attacks
• 3 healthy adolescents with MI
• No personal or family history
• All smoked the SC “K2”
© AMSP 2013
31
LASTING CONSEQUENCES
May trigger psychosis if prior history
• 15 forensic inpts with psychotic illness
• All actively taking antipsychotics
• 5 with relapse of psychotic symptoms
• 24 hours after smoking JWH-018
© AMSP 2013
32
LASTING CONSEQUENCES
May cause first episode psychosis
• 10 men admitted for psychosis
• 9 had no FH of psychosis
• 7 needed meds
• 3 still psychotic 5 mo later
© AMSP 2013
33
LASTING CONSEQUENCES
Self harm/suicide while intoxicated
• Suicidal thoughts
• Reports of self-injury
© AMSP 2013
34
THIS LECTURE WILL REVIEW
• Background on cannabinoids
• Development of synthetic cannabinoids (SC)
• Risks associated with use
• SC versus marijuana
© AMSP 2013
35
Marijuana vs Synthetic Cannabinoids
•
•
•
•
Nature controls dose
Low-medium potency
Partial CB1 agonist
Contains CBD
•
•
•
•
© AMSP 2013
No dose control
High potency
Full CB1 agonist
No CBD
36
COMPARING SC TO MARIJUANA (MJ)
• MJ contains CBD: potential antipsychotic
• Natural marijuana may ↓ seizures
• No long-term SC studies
© AMSP 2013
37
CONCLUSIONS
• SC are commonly used
• Easy to obtain despite ban
• Not detected on urine tests
• Risks not commonly known
• Ask about use
• Tell patients about risks
© AMSP 2013
38