Background

• Natural Marijuana Contains >60 Cannabinoids
  • Delta 9-Tetrahydrocannabinol (THC)
  • Cannbidiol
  • Cannabinol

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Agents

• Compounds: most of these are far more potent than THC (anywhere from 2-800x more potent than THC)

JWH-015
JWH-018: short half-life, 5x as potent as Delta 9-THC
JWH-073
JWH-200
JWH-081
JWH-122
JWH-210
JWH-250
JWH-398
CP-47,497
(C8)-CP-47,497
HU-210
CP-55,490
AM-2201
WIN-48,098
WIN-54,461
WIN-55,212-2
XLR-11
UR-144

• Street Names

Spice
K2
Happy tiger incense
Spice gold
Spice silver
Spice diamond
Spice Egypt
Spice arctic synergy
SpicyXXX
Smoke
Banana cream nuke
Aroma
Aztec fire
Black mamba
Blueberry posh
Bombay blue Blaze
Bliss
Chill zone cherry
Chaos mint
Clover spring
Fake weed
Genie
Eclipse
Krypton
Moon rocks
Mr Smiley
Sensation vanilla
Yucatan fire
Zohai

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Route of Exposure

• Inhalation

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Pharmacology

Bind to Cannabinoid Receptors

• Varying Effects are Due to Variable Agonism/Antagonism at the Receptors, as Well as Varying Potency of the Compounds
  • CB1 G-protein coupled receptors are abundant in the brain and modulate g-aminobutyric acid and glutamate neurotransmission
  • CB1 receptors exists in the basal ganglia
  • CB2 receptors are typically found in the peripheral tissues (spleen and immune cells) and possibly mediate immunosuppression, but may also be present in the central nervous system (CNS)
  • CBRs are also complexed with other receptors, including opioid and dopamine receptors
  • Cannabinoids themselves can modulate various receptors including acetylcholine, opioid, serotonin, glycine, glutamatergic, and nuclear peroxisome proliferation-activated receptor a receptors

Metabolism

• Hepatic: cytochrome P450 with conjugation with glucuronic acid
  • Renal Excretion of Metabolites

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Diagnosis

Urine Toxicology Screen (see Urine Toxicology Screen, [[Urine Toxicology Screen]])

• Usually Not Detected as These Compounds Do Not Cross-React with YHC

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Synthetic Cannabinoid Intoxication

Clinical Effects/Adverse Effects

General Comments

• Duration: hours-days

Cardiovascular Effects/Adverse Effects

• Acute Myocardial Infarction (MI) (see Coronary Artery Disease, [[Coronary Artery Disease]])
  • Epidemiology: cases have been reported in teenagers with normal coronary arteries
• Arrhythmias
  • Supraventricular Tachycardia (SVT) (see Supraventricular Tachycardia, [[Supraventricular Tachycardia]])
    • Epidemiology: case reports with JWH-018 (Clin Toxicol-Phila, 2011) [MEDLINE]
• Chest Pain (see xxxx, [[xxxx]])
• Hypertension (see xxxx, [[xxxx]])
• Tachycardia (see xxxx, [[xxxx]])

Gastrointestinal Effects/Adverse Effects

• Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

Neurologic Effects/Adverse Effects

• Agitation (see Agitation, [[Agitation]])
• Anxiety (see Anxiety, [[Anxiety]])
• Ataxia (see Ataxia, [[Ataxia]])
• Confusion (see xxxx, [[xxxx]])
• Delirium (see Delirium, [[Delirium]])
• Hallucinations (see Hallucination, [[Hallucination]])
• Irritability
• Ischemic Cerebrovascular Accident (CVA) (see xxxx, [[xxxx]])
  • Epidemiology: has been reported
• Memory Changes
• Paranoia/Psychosis (see xxxx, [[xxxx]])
• Sedation (see xxxx, [[xxxx]])
• Seizures (see Seizures, [[Seizures]])
  • Epidemiology: case reports with JWH-018 (Clin Toxicol-Phila, 2011) [MEDLINE]
• Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]])
  • Epidemiology: has been reported
• Tremor (see Tremor, [[Tremor]])

Ophthalmologic Effects/Adverse Effects

• Conjunctival Injection (see Conjunctival Injection, [[Conjunctival Injection]])
• Mydriasis (see xxxx, [[xxxx]])
• Nystagmus (see Nystagmus, [[Nystagmus]])

Renal Effects/Adverse Effects

• Acute Kidney Injury (AKI) (see xxxx, [[xxxx]])
• Hypokalemia (see xxxx, [[xxxx]])

Other Effects/Adverse Effects

• Hyperthermia/Fever (see Fever, [[Fever]])
• Dependence
• Tolerance
• Rhabdomyolysis (see Rhabdomyolysis, [[Rhabdomyolysis]])

Treatment

• Supportive Care: symptoms usually resolve over 36 hrs
• Intravenous Fluid Resuscitation: as required
• Management of Hyperthermia/Fever (see Fever, [[Fever]])
  • Evaporative Cooling
• Management of Seizures (see Seizures, [[Seizures]])
  • Benzodiazepines (see Benzodiazepines, [[Benzodiazepines]])

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Synthetic Cannabinoid Withdrawal

Clinical

Neurologic Manifestations

• Anxiety (see xxxx, [[xxxx]])
• Drug-Craving: may last 1-2 wks
• Insomnia (see xxxx, [[xxxx]])
• Irritability
• Malaise
• Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

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References

• Severe toxicity following synthetic cannabinoid ingestion. Clin Toxicol (Phila). 2011 Oct;49(8):760-4. doi: 10.3109/15563650.2011.609822 [MEDLINE]
• An outbreak of exposure to a novel synthetic cannabinoid. Engl J Med. 2014 Jan 23;370(4):389-90. doi: 10.1056/NEJMc1313655 [MEDLINE]
• Emerging drugs of abuse. Emerg Med Clin North Am. 2014 Feb;32(1):1-28. doi: 10.1016/j.emc.2013.09.001. Epub 2013 Oct 15 [MEDLINE]