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Cheap and Available: The Growing Threat of Synthetic Cannabinoids

Synthetic Cannabinoids
Synthetic cannabinoids (sometimes referred to as “synthetic marijuana,” “spice,” or “K2”) are a family of man-made, psychoactive chemicals that are sprayed onto plant material, which is often smoked or ingested to achieve a “high.” Use of these products carries the potential for acute adverse health effects.

Historically, synthetic cannabinoid compounds were developed to study cannabinoid receptors, but in recent years these compounds have emerged as drugs of abuse. In 2005, synthetic cannabinoid products emerged in European countries before appearing in the United States in 2009.

Today, synthetic cannabinoid products are distributed worldwide under countless trade names and packaged in colorful wrappers designed to appeal to teens, young adults, and first-time drug users. These products are sold under a variety of names and are sometimes sold in convenience stores and other retail outlets as incense or natural herbal products. The lack of oversight over the manufacture and labeling of synthetic cannabinoid products means that users do not actually know the kind of synthetic cannabinoids in the product and the amount to which they are being exposed.[1]

Although these products are often labeled as “not for human consumption” and marketed as “incense,” health professionals and legal authorities are keenly aware that people use these products for their psychoactive effects. Despite federal and state regulations to prohibit synthetic cannabinoid sale and distribution, reports of harmful effects are increasing. All states now have at least one law on the books, but these laws vary widely. This is not only a problem in the United States but around the world.

Signs and Symptoms of Synthetic Cannabinoid Exposure
In April 2015, the CDC’s Health Studies Branch worked with the Mississippi Department of Health during an outbreak of 724 cases of illness and death associated with synthetic cannabinoid use in the state.[2] We used clinician-suspected or patient-reported synthetic cannabinoid use, plus the presence of symptoms, as our case criteria, so it is possible that 724 cases are an underrepresentation. Synthetic cannabinoids are metabolized quickly, so not detecting them (even if testing is available) does not rule out exposure. Of course, this method may also have included people whom providers suspected of having used synthetic cannabinoids but who did not actually use the drug.

As part of that investigation, CDC analyzed the medical records of 119 patients who presented to the University of Mississippi Medical Center (UMMC) for illness related to synthetic cannabinoid use. Like other instances of synthetic cannabinoid intoxication, these patients had nonspecific symptoms, but the most frequently reported signs and symptoms were:

Hypertension;

Tachycardia;

Aggressive or violent behavior;

Confusion;

Alternating agitation and aggression; and

Depressed mental status (such as somnolence or unresponsiveness).

As seen in previous outbreaks of adverse events linked to synthetic cannabinoid use, most users were young men, with a median age of 29 years. Statewide, from April 2 to May 3, 2015, nine deaths associated with synthetic cannabinoid use were reported to the state’s poison center, although the number of people who died could be higher due to underreporting. At the UMMC, patients who were older and had a history of psychiatric illness or substance abuse were more likely to die or be admitted to the intensive care unit. The median age of those who died was 32 years.

Synthetic cannabinoids are not detected on routine urine or serum drug screens, and most hospital laboratories do not have the capability to test for synthetic cannabinoids. Testing at referral laboratories is available; however, clinicians should be aware that test panels are limited in scope and will not detect all of the synthetic cannabinoids currently being used. In the Mississippi investigation, patient samples were sent to a research laboratory that specializes in detecting novel synthetic cannabinoids. The lab detected MAB-CHMINACA, a chemical compound that had recently entered the market.

An Emerging Public Health Threat
The use of synthetic cannabinoids may indicate an emerging public health threat due to:

Apparent rapid increase in use;

Variable and unpredictable toxicity of new compounds on the market; and

Difficulty in enforcing legal bans due to fast-changing types and mixtures of drug contents.

Here are some key points to keep in mind about synthetic cannabinoid use:

Synthetic cannabinoids are not marijuana and are not safe.

They are dangerous and can cause severe illness and even death.

Easy access and a misperception that these products are legal and relatively safe are contributing to their popularity.

Although the legality of these products may vary by state, many specific synthetic cannabinoids have been banned at the federal level. Consider synthetic cannabinoid use in patients with symptoms of drug intoxication with negative drug screens. Symptoms are generally short-lived, and most patients recover rapidly.

If you suspect that a severely ill patient may have used synthetic cannabinoids, check for rhabdomyolysis and kidney injury, and monitor for seizures and cardiac arrhythmias. Care is symptomatic and supportive. Low-dose benzodiazepines have been used successfully to treat agitation.

And finally, if you see severe illness or clusters of illness following patients’ use of these products, notify your local poison center or health department.

Medical Community Needs Better Understanding of Power of AA

The medical-community-needs-better-understanding-of-power-of-alcoholics-anonymous.Many doctors, even those who specialize in addiction treatment, do not have a good understanding of Alcoholics Anonymous (AA) and its benefits for people struggling to give up drinking, says Marc Galanter, M.D., Founding Director of the Division of Alcoholism and Drug Abuse at NYU Langone Medical Center.

“Doctors don’t necessarily know about the 12 Steps and how going to AA can be useful to patients,” says Dr. Galanter, a former president of the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry. “They need to know how valuable it can be for people to go to meetings and meet people who have achieved abstinence, and learn how the program helped them.”

Of the more than 3,400 addiction treatment programs in the United States, many use the AA model, but half don’t have any relationship with a physician, Dr. Galanter notes. “It’s essential to bridge the gap between the medical and rehab communities,” he says.

Although it began in the 1930s, AA still has an important place in addiction treatment today, in an era when people tend to look to medications as the answer to solving everything, Dr. Galanter says.

“I can tell them as their doctor that they need to stop drinking, but if they go to AA meetings and meet other people with the same problem, it can mean more to them in terms of recovery,” says Dr. Galanter, author of What is Alcoholics Anonymous? A Path from Addiction to Recovery (Oxford).

Last year, Dr. Galanter published a study that looked at the effect of prayer on the brains of 20 long-term AA members, as measured by MRI. The twelfth step in AA involves “spiritual awakening,” an important part of the AA experience that can be interpreted in different ways. For many people spiritual awakening is related to prayer and meditation, which helps them stay sober, Dr. Galanter explains. “We wanted to see if there is a physiologic basis for prayer and meditation having a role in keeping people sober,” he said.

The participants were placed in an MRI scanner and then shown either pictures of alcoholic drinks or people drinking. The pictures were presented twice: first after asking the participant to read neutral material from a newspaper, and again after the participant recited an AA prayer promoting abstinence from alcohol.

Dr. Galanter found members who recited an AA prayer after viewing drinking-related images reported less craving for alcohol after praying than after reading a newspaper. The reduced cravings in people who prayed corresponded to increased activity in brain regions responsible for attention and emotion.

He said the findings suggest that AA has a physiologic effect on the brain, and doesn’t just lead to a general change in attitude about drinking. “A lot of people don’t appreciate that AA isn’t just a sort of club. It actually changes how people think and how their brains work,” Dr. Galanter said.

Alcohol Dependence Linked to Insufficient Enzyme ?

Alcoholism, or alcohol dependence, whichever you prefer, is a condition characterized by a physical and/or mental addiction to alcohol. Persons with this addiction continue to drink frequently, despite the negative effects associated with their behavior, health, and life outcomes.

Expert insight has pointed to impaired function in alcoholics in the the brain’s frontal lobes. This impairment is thought to lead to a decrease in impulse control when it comes to drinking. However, the exact molecular mechanism has remained somewhat of a mystery.

Recently,however, a study reviewed in the Molecular Psychiatry journal revealed that a specific enzyme is lacking in the brain of alcohol-dependent rats. The study was led by professor Markus Heilig of Linkoping University (Sweden). The enzyme in question is PRDM2, a member of the histone/protein methyltransferase family.

Past studies on the enzyme have mostly focused on its relationship to cancer. However, in this study researchers found additional functions in the brain. PRDM2 regulates the expression of genes necessary to transmit data between neurons.

Heilig’s team of researchers took a close look at alcohol-dependent rats and discovered that a history of alcoholism consistently affected the producton of PRDM2. This decrease ultimately disrupts impulse control.

In additional experiments, the researchers intentionally suppressed PRDM2 expression in non-alcohol-dependent rats, and discovered that their impulse control was disrupted as well, thus resulted in a signficant uptick in alcohol consumption.

Heilig:

“PRDM2 controls the expression of several genes that are necessary for effective signalling between nerve cells. When too little enzyme is produced, no effective signals are sent from the cells that are supposed to stop the impulse.”

He continues to add:

“We see how a single molecular manipulation gives rise to important characteristics of an addictive illness. Now that we’re beginning to understand what’s happening, we hope we’ll also be able to intervene. Over the long term, we want to contribute to developing effective medicines, but over the short term the important thing, perhaps, is to do away with the stigma of alcoholism.”

This new finding is exciting in the field of addiction medicine, and reveals a promising new approach to treating alcohol dependence.

Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014

The United States is experiencing an epidemic of drug overdose (poisoning) deaths. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin). CDC analyzed recent multiple cause-of-death mortality data to examine current trends and characteristics of drug overdose deaths, including the types of opioids associated with drug overdose deaths. During 2014, a total of 47,055 drug overdose deaths occurred in the United States, representing a 1-year increase of 6.5%, from 13.8 per 100,000 persons in 2013 to 14.7 per 100,000 persons in 2014. The rate of drug overdose deaths increased significantly for both sexes, persons aged 25–44 years and ≥55 years, non-Hispanic whites and non-Hispanic blacks, and in the Northeastern, Midwestern, and Southern regions of the United States. Rates of opioid overdose deaths also increased significantly, from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014, a 14% increase. Historically, CDC has programmatically characterized all opioid pain reliever deaths (natural and semisynthetic opioids, methadone, and other synthetic opioids) as “prescription” opioid overdoses (1). Between 2013 and 2014, the age-adjusted rate of death involving methadone remained unchanged; however, the age-adjusted rate of death involving natural and semisynthetic opioid pain relievers, heroin, and synthetic opioids, other than methadone (e.g., fentanyl) increased 9%, 26%, and 80%, respectively. The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid; however, illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificate data. These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence, and death, improve treatment capacity for opioid use disorders, and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl.

During 2014, 47,055 drug overdose deaths occurred in the United States. Since 2000, the age-adjusted drug overdose death rate has more than doubled, from 6.2 per 100,000 persons in 2000 to 14.7 per 100,000 in 2014 (Figure 1). The overall number and rate of drug overdose deaths increased significantly from 2013 to 2014, with an additional 3,073 deaths occurring in 2014 (Table), resulting in a 6.5% increase in the age-adjusted rate. From 2013 to 2014, statistically significant increases in drug overdose death rates were seen for both males and females, persons aged 25–34 years, 35–44 years, 55–64 years, and ≥65 years; non-Hispanic whites and non-Hispanic blacks; and residents in the Northeast, Midwest and South Census Regions (Table). In 2014, the five states with the highest rates of drug overdose deaths were West Virginia (35.5 deaths per 100,000), New Mexico (27.3), New Hampshire (26.2), Kentucky (24.7) and Ohio (24.6).† States with statistically significant increases in the rate of drug overdose deaths from 2013 to 2014 included Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia.

In 2014, 61% (28,647, data not shown) of drug overdose deaths involved some type of opioid, including heroin. The age-adjusted rate of drug overdose deaths involving opioids increased significantly from 2000 to 2014, increasing 14% from 2013 (7.9 per 100,000) to 2014 (9.0) (Figure 1). From 2013 to 2014, the largest increase in the rate of drug overdose deaths involved synthetic opioids, other than methadone (e.g., fentanyl and tramadol), which nearly doubled from 1.0 per 100,000 to 1.8 per 100,000 (Figure 2). Heroin overdose death rates increased by 26% from 2013 to 2014 and have more than tripled since 2010, from 1.0 per 100,000 in 2010 to 3.4 per 100,000 in 2014 (Figure 2). In 2014, the rate of drug overdose deaths involving natural and semisynthetic opioids (e.g., morphine, oxycodone, and hydrocodone), 3.8 per 100,000, was the highest among opioid overdose deaths, and increased 9% from 3.5 per 100,000 in 2013. The rate of drug overdose deaths involving methadone, a synthetic opioid classified separately from other synthetic opioids, was similar in 2013 and 2014.

More persons died from drug overdoses in the United States in 2014 than during any previous year on record. From 2000 to 2014 nearly half a million persons in the United States have died from drug overdoses. In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes Opioids, primarily prescription pain relievers and heroin, are the main drugs associated with overdose deaths. In 2014, opioids were involved in 28,647 deaths, or 61% of all drug overdose deaths; the rate of opioid overdoses has tripled since 2000. The 2014 data demonstrate that the United States’ opioid overdose epidemic includes two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.

Drug overdose deaths involving heroin continued to climb sharply, with heroin overdoses more than tripling in 4 years. This increase mirrors large increases in heroin use across the country and has been shown to be closely tied to opioid pain reliever misuse and dependence. Past misuse of prescription opioids is the strongest risk factor for heroin initiation and use, specifically among persons who report past-year dependence or abuse. The increased availability of heroin, combined with its relatively low price (compared with diverted prescription opioids) and high purity appear to be major drivers of the upward trend in heroin use and overdose.

How to treat an Overdose with Naloxone

“Fatal Drug Overdoses Play a Role In Rise of Accidental Deaths”

“Your Kid on Heroin, It Could Happen”

The news is full of headlines on the opioid crisis, and the overdoses suffered by so many families in our country. While there is no single, clear-cut solution to the crisis, one action every family impacted by opioids can take is to get overdose prevention training and have naloxone in the home. Naloxone, also known as Narcan, is a drug that can reverse an overdose, and if used in time, can save your loved one’s life.

Prescription pain medicine What are Opioids?

Opioids are powerful pain relievers. They include prescription medications such as Vicodin, Oxycontin, Percocet, Codeine, Morphine and Buprenorphine, and illegal opioids, like heroin and non-pharmaceutical fentanyl.

What are the Risk Factors of an Overdose?

Anyone using opioids for recreational purposes, to manage withdrawal symptoms or pain management can be at risk for an overdose. Other risk factors include:

Using or taking drugs alone
Mixing opioids with other drugs like alcohol, benzodiazepines (e.g., Xanax and Ativan) and prescription stimulants (e.g., cocaine and Adderall)
Having lower tolerance due to recent detox/drug treatment or incarceration, or having a recent or chronic illness
Not knowing what drugs one is consuming (e.g. using heroin cut with fentanyl)
What are the Signs of an Overdose?

Overdose results when too much of the opioid medication or illegal opioid is taken and body functions shut down. The victim’s breathing is suppressed, which prevents oxygen from getting to body tissues and organs. It is important to note that an overdose can take anywhere from 20 minutes to 2 hours to occur after drug use.

The signs of an overdose are:

Face is clammy to touch and has lost color
Blue lips and fingertips
Non-responsive to his/her name or a sternum rub using knuckles. In deep sleep.
Slow or erratic breathing, or no breathing at all
Deep snoring or a gurgling sound (i.e. death rattle)
Heartbeat is slow or has stopped

What Should You Do if You Suspect an Overdose?

Call 911: If you suspect an overdose and your loved one is non-responsive, call 911. If you must leave the person alone to make the call, put the person in the recovery position, lying on the side with the bottom arm under the head and the top leg crossed over the body. This is to avoid aspiration if he or she vomits. Give the address or location and as much information as you have about the situation (i.e., unconscious, not breathing, drugs used if known, etc.)

Administer Naloxone: If the naloxone is in the form of a nasal sprayer, assemble it if necessary, tilt the head back and spray half of the atomizer/nasal sprayer into each nostril. Provide rescue breathing (one breath every 5 seconds as described below) for 2-4 minutes. If there is no response, give a second dose of naloxone.

How to administer Naloxone

If the naloxone is in the form of an auto-injector, place the black end against the middle of the person’s outer thigh, through clothing (pants, jeans, etc.) if necessary, then press firmly and hold in place for 5 seconds.Naloxone

Provide rescue breathing and if there is no response, an additional injection using another auto-injector may be needed. Give additional injections using a new auto-injector every 2 to 3 minutes, continuing to provide rescue breathing until the person can resume breathing on his or her own.

Conduct Rescue Breathing: If the person has labored breathing or is not breathing at all, it is necessary to conduct rescue breathing. Tilt the head back, pinch the nose closed and give one slow breath every 5 seconds until the person resumes breathing on their own or until the paramedics arrive. Watch to see that their chest rises and falls with each breath.

Comfort and Support: Once the person is breathing on their own, place them in the recovery position until paramedics arrive. Comfort the person as he or she may be confused, upset and dope sick when revived. Do not allow them to use drugs.

Aftermath of an Overdose: Once your loved one has been stabilized, this may be an opportunity to suggest detox and treatment. Call the Partnership’s toll-free helpline at 1-855-DRUGFREE to speak with a trained and caring specialist.