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Syrjanen R, Schumann JL, Lyons T, McKinnon G, Hodgson SE, Abouchedid R, Gerostamoulos D, Koutsogiannis Z, Fitzgerald J, Greene SL. A risk-based approach to community illicit drug toxicosurveillance: operationalisation of the Emerging Drugs Network of Australia - Victoria (EDNAV) project. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104251. [PMID: 37952318 DOI: 10.1016/j.drugpo.2023.104251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The Emerging Drugs Network of Australia - Victoria (EDNAV) project is a newly established toxicosurveillance network that collates clinical and toxicological data from patients presenting to emergency departments with illicit drug related toxicity in a centralised clinical registry. Data are obtained from a network of sixteen public hospital emergency departments across Victoria, Australia (13 metropolitan and three regional). Comprehensive toxicological analysis of a purposive sample of 22 patients is conducted each week, with reporting of results to key alcohol and other drug stakeholders. This paper describes the overarching framework and risk-based approach developed within Victoria to assess drug intelligence from EDNAV toxicosurveillance. METHODS Risk management principles from other spheres of public health surveillance and healthcare clinical governance have been adapted to the EDNAV framework with the aim of facilitating a consistent and evidence-based approach to assessing weekly drug intelligence. The EDNAV Risk Register was reviewed over the first two years of EDNAV project operation (September 2020 - August 2022), with examples of eight risk assessments detailed to demonstrate the process from signal detection to public health intervention. RESULTS A total of 1112 patient presentations were documented in the EDNAV Clinical Registry, with 95 signals of concern entered into the EDNAV Risk Register over the two-year study period. The eight examples examined in further detail included suspected drug adulteration (novel opioid adulterated heroin, para-methoxymethamphetamine adulterated 3,4-methylenedioxymethamphetamine (MDMA)), drug substitution (25B-NBOH sold as lysergic acid diethylamide, five benzodiazepine-type new psychoactive substances in a single tablet, protonitazene sold as ketamine), new drug detection (N,N-dimethylpentylone), contamination (unreported acetylfentanyl) and a fatality subsequent to MDMA use. A total of four public Drug Alerts were issued over this period. CONCLUSIONS Continued toxicosurveillance efforts are paramount to characterising the changing landscape of illicit drug use. This work demonstrates a functional model for risk assessment of illicit drug toxicosurveillance, underpinned by analytical confirmation and evidence-based decision-making.
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Affiliation(s)
- Rebekka Syrjanen
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jennifer L Schumann
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Victorian Institute of Forensic Medicine, Toxicology Department, Southbank, Victoria, Australia; Monash University, Monash Addiction Research Centre, Frankston, Victoria, Australia
| | - Tom Lyons
- The Department of Health, Alcohol and Other Drugs Strategy Team, Victorian State Government, Melbourne, Victoria, Australia
| | - Ginny McKinnon
- The Department of Health, Alcohol and Other Drugs Strategy Team, Victorian State Government, Melbourne, Victoria, Australia
| | - Sarah E Hodgson
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rachelle Abouchedid
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Bendigo Health, Emergency Department, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Dimitri Gerostamoulos
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Victorian Institute of Forensic Medicine, Toxicology Department, Southbank, Victoria, Australia
| | - Zeff Koutsogiannis
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia
| | - John Fitzgerald
- The University of Melbourne, Melbourne School of Population and Global Health, Parkville, Victoria, Australia
| | - Shaun L Greene
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia.
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de Oliveira MC, Vides MC, Lassi DLS, Torales J, Ventriglio A, Bombana HS, Leyton V, Périco CDAM, Negrão AB, Malbergier A, Castaldelli-Maia JM. Toxicity of Synthetic Cannabinoids in K2/Spice: A Systematic Review. Brain Sci 2023; 13:990. [PMID: 37508922 PMCID: PMC10377539 DOI: 10.3390/brainsci13070990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Synthetic cannabinoids (SCs) are emerging drugs of abuse sold as 'K2', 'K9' or 'Spice'. Evidence shows that using SCs products leads to greater health risks than cannabis. They have been associated with greater toxicity and higher addiction potential unrelated to the primary psychoactive component of marijuana, Δ9-tetrahydrocannabinol (Δ9-THC). Moreover, early cases of intoxication and death related to SCs highlight the inherent danger that may accompany the use of these substances. However, there is limited knowledge of the toxicology of Spice ingredients. This systematic review intends to analyze the toxicity of SCs compounds in Spice/K2 drugs. (2) Methods: Studies analyzing synthetic cannabinoid toxicity and dependence were included in the present review. We searched the PubMed database of the US National Library of Medicine, Google Scholar, CompTox Chemicals, and Web of Science up to May 2022. (3) Results: Sixty-four articles reporting the effects of synthetic cannabinoids in humans were included in our review. Ten original papers and fifty-four case studies were also included. Fourteen studies reported death associated with synthetic cannabinoid use, with AB-CHMINACA and MDMB-CHMICA being the main reported SCs. Tachycardia and seizures were the most common toxicity symptoms. The prevalence of neuropsychiatric symptoms was higher in third-generation SCs. (4) Conclusion: SCs may exhibit higher toxicity than THC and longer-lasting effects. Their use may be harmful, especially in people with epilepsy and schizophrenia, because of the increased risk of the precipitation of psychiatric and neurologic disorders. Compared to other drugs, SCs have a higher potential to trigger a convulsive crisis, a decline in consciousness, and hemodynamic changes. Therefore, it is crucial to clarify their potential harms and increase the availability of toxicology data in both clinical and research settings.
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Affiliation(s)
- Mariana Campello de Oliveira
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - Mariana Capelo Vides
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - Dângela Layne Silva Lassi
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - Julio Torales
- Department of Psychological Medicine, School of Medical Sciences, National University of Asuncion, San Lorenzo 111421, Paraguay
| | - Antonio Ventriglio
- Department of Experimental Medicine, Medical School, University of Foggia, 71122 Foggia, Italy
| | - Henrique Silva Bombana
- Department of Legal Medicine, Medical School, São Paulo University, São Paulo 05508-090, SP, Brazil
| | - Vilma Leyton
- Department of Legal Medicine, Medical School, São Paulo University, São Paulo 05508-090, SP, Brazil
| | | | - André Brooking Negrão
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - André Malbergier
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - João Maurício Castaldelli-Maia
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
- Department of Neuroscience, Medical School, FMABC University Center, Santo André 09060-870, SP, Brazil
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
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Bäckberg M, Vikingsson S, Strandberg J, Wall S, Åstrand A, Karlsson H, Persson M, Kronstrand R, Green H. Using in vitro receptor activity studies of synthetic cannabinoids to support the risk assessment of new psychoactive substances - A Swedish strategy to protect public health from harm. Forensic Sci Int 2023; 348:111691. [PMID: 37116244 DOI: 10.1016/j.forsciint.2023.111691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
In the past 15 years, close to 1000 of new psychoactive substances (NPS) have been reported in Europe and globally. At the time of identification, data on safety, toxicity and carcinogenic potential of many NPS are not available or very limited. To work more efficiently, a strategy and collaboration between the Public Health Agency of Sweden (PHAS) and the National Board of Forensic Medicine was established involving in vitro receptor activity assays to demonstrate neurological activity of NPS. This report summarizes the first results on the synthetic cannabinoid receptor agonists (SCRAs), and subsequent actions taken by PHAS. A total of 18 potential SCRAs were selected by PHAS for in vitro pharmacological characterization. 17 compounds could be acquired and investigated for their activity on the human cannabinoid-1 (CB1) receptors expressed together with the AequoScreen system in CHO-K1 cells. Dose-response curves were established using eight different concentrations in triplicates at three occasions with JWH-018 as reference. For the MDMB-4en-PINACA, MMB-022, ACHMINACA, ADB-BUTINACA, 5F-CUMYL-PeGACLONE, 5C-AKB48, NM-2201, 5F-CUMYL-PINACA, JWH-022, 5Cl-AB-PINACA, MPhP-2201, 5F-AKB57 the half maximal effective concentration values ranged from 2.2 nM (5F-CUMYL-PINACA) to 171 nM (MMB-022). EG-018 and 3,5-AB-CHMFUPPYCA were none-active. The results contributed to 14 of these compounds being scheduled as narcotics in Sweden. In conclusion, many of the emerging SCRAs are potent activators of the CB1 receptor in vitro, although some lack activity or are partial agonists. The new strategy proved useful when data on psychoactive effects of the SCRAs under investigation were not available or limited.
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Affiliation(s)
- Matilda Bäckberg
- Department of Chemical and Pharmaceutical Safety, RISE Research Institutes of Sweden, SE-151 36 Södertälje, Sweden.
| | - Svante Vikingsson
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden; Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, SE-587 58 Linköping, Sweden; RTI International, Research Triangle Park, 3040 East Cornwallis Rd., NC 27709, USA
| | - Joakim Strandberg
- Department of Living Conditions and Lifestyles, The Public Health Agency of Sweden, SE-831 40 Östersund, Sweden
| | - Sara Wall
- Department of Living Conditions and Lifestyles, The Public Health Agency of Sweden, SE-831 40 Östersund, Sweden
| | - Anna Åstrand
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
| | - Hanna Karlsson
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
| | - Mattias Persson
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, SE-587 58 Linköping, Sweden
| | - Robert Kronstrand
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden; Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, SE-587 58 Linköping, Sweden
| | - Henrik Green
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden; Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, SE-587 58 Linköping, Sweden
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Sparkes E, Boyd R, Chen S, Markham JW, Luo JL, Foyzun T, Zaman H, Fletcher C, Ellison R, McGregor IS, Santiago MJ, Lai F, Gerona RR, Connor M, Hibbs DE, Cairns EA, Glass M, Ametovski A, Banister SD. Synthesis and pharmacological evaluation of newly detected synthetic cannabinoid receptor agonists AB-4CN-BUTICA, MMB-4CN-BUTINACA, MDMB-4F-BUTICA, MDMB-4F-BUTINACA and their analogs. Front Psychiatry 2022; 13:1010501. [PMID: 36245876 PMCID: PMC9558907 DOI: 10.3389/fpsyt.2022.1010501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Synthetic cannabinoid receptor agonists (SCRAs) continue to make up a significant portion new psychoactive substances (NPS) detected and seized worldwide. Due to their often potent activation of central cannabinoid receptors in vivo, use of SCRAs can result in severe intoxication, in addition to other adverse health effects. Recent detections of AB-4CN-BUTICA, MMB-4CN-BUTINACA, MDMB-4F-BUTICA and MDMB-4F-BUTINACA mark a continuation in the appearance of SCRAs bearing novel tail substituents. The proactive characterization campaign described here has facilitated the detection of several new SCRAs in toxicological case work. Here we detail the synthesis, characterization, and pharmacological evaluation of recently detected SCRAs, as well as a systematic library of 32 compounds bearing head, tail, and core group combinations likely to appear in future. In vitro radioligand binding assays revealed most compounds showed moderate to high affinity at both CB1 (pK i = < 5 to 8.89 ± 0.09 M) and CB2 (pK i = 5.49 ± 0.03 to 9.92 ± 0.09 M) receptors. In vitro functional evaluation using a fluorescence-based membrane potential assay showed that most compounds were sub-micromolar to sub-nanomolar agonists at CB1 (pEC50 = < 5 to 9.48 ± 0.14 M) and CB2 (pEC50 = 5.92 ± 0.16 to 8.64 ± 0.15 M) receptors. An in silico receptor-ligand docking approach was utilized to rationalize binding trends for CB2 with respect to the tail substituent, and indicated that rigidity in this region (i.e., 4-cyanobutyl) was detrimental to affinity.
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Affiliation(s)
- Eric Sparkes
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Chemistry, The University of Sydney, Sydney, NSW, Australia
| | - Rochelle Boyd
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Shuli Chen
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Jack W. Markham
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Chemistry, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Jia Lin Luo
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Tahira Foyzun
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Humayra Zaman
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Charlotte Fletcher
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Ross Ellison
- Clinical Toxicology and Environmental Biomonitoring Laboratory, University of California, San Francisco, San Francisco, CA, United States
| | - Iain S. McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | | | - Felcia Lai
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Roy R. Gerona
- Clinical Toxicology and Environmental Biomonitoring Laboratory, University of California, San Francisco, San Francisco, CA, United States
| | - Mark Connor
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - David E. Hibbs
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Elizabeth A. Cairns
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Michelle Glass
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Adam Ametovski
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Chemistry, The University of Sydney, Sydney, NSW, Australia
| | - Samuel D. Banister
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Chemistry, The University of Sydney, Sydney, NSW, Australia
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Lin CC, Weng TI, Ng CJ, Shih CP, Hsu J, Liao YC, Yang CC, Fang CC. Emergency department visits due to new psychoactive substances and other illicit drugs in Taiwan: preliminary results of the Taiwan Emergency Department Drug Abuse Surveillance (TEDAS) project. Clin Toxicol (Phila) 2022; 60:708-715. [PMID: 35315299 DOI: 10.1080/15563650.2022.2038793] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The use of new psychoactive substances (NPSs) has markedly increased worldwide; thus, it is important to monitor NPS-related effects. The Taiwan Emergency Department Drug Abuse Surveillance (TEDAS) project aims to assess the patterns of recreational drug use in patients presenting to emergency departments (EDs) across the country. Here, we report the preliminary results of this project. METHODS This observational study included the collection and analysis of urine samples and assessment of the clinical presentation of patients from 79 EDs across Taiwan. Clinical features were recorded through a questionnaire filled by attending doctors or nurses who collected urine samples for clinical diagnosis. Urine samples were analyzed for 110 drugs and metabolites using electrospray ionization liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS Between February and November 2019, a total of 2649 patients were enrolled for urine drug analysis. A total of 675 cases older than 12 years (males, n = 480) had NPS or other illicit drugs detected in their urine samples. Overall, 1271 counts of drugs, among which 717 (56.4%) were NPS. At least one NPS was detected in 340 patients (50.4%), and 292 cases were positive for multiple drugs. The most frequently detected drug was methamphetamine/amphetamine, followed by synthetic cathinones, ketamine and its two analogs, and opioids. The most common drug combination was cathinones plus ketamine and/or its analogs (n = 56). Younger patients (OR = 3.3, p≤.0001) and women (OR = 1.5, p = .01) were more likely to have NPS detected in their urine samples. NPS-positive cases frequently experienced chest pain (OR = 2.6, p = .03), tachycardia (OR = 2.6, p = .0002), and suicide attempt/non-suicidal self-harm (OR = 1.8, p = .004), whereas depressed consciousness (OR = 0.5, p = .001) was less frequent among NPS-positive cases than among other illicit drug-positive cases. CONCLUSIONS The TEDAS project provides a nationwide epidemiological profile of recreational drug use in Taiwan. More than half of the recreational drugs were NPSs, which were comprehensively detected using LC-MS/MS.
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Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, ROC
| | - Te-I Weng
- Department of Emergency Medicine, National Taiwan University College of Medicine, and National Taiwan University Hospital, Taipei, ROC.,Forensic and Clinical Toxicology Center, College of Medicine and National Taiwan University Hospital, National Taiwan University, Taipei, ROC.,Department of Forensic Medicine, College of Medicine, National Taiwan University, Taipei, ROC
| | - Chip-Jin Ng
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, ROC
| | - Chia-Pang Shih
- Department of Nursing, Yuanpei University of Medical Technology, Hsin-Chu, ROC
| | - Jui Hsu
- Division of Controlled Drugs, Taiwan Food and Drug Administration, Ministry of Health and Welfare, Taipei, ROC
| | - Yuan-Chun Liao
- Division of Controlled Drugs, Taiwan Food and Drug Administration, Ministry of Health and Welfare, Taipei, ROC
| | - Chen-Chang Yang
- Institute of Environmental & Occupational Health Sciences, School of Medicine, National Yang Ming Chiao Tung University, Taipei, ROC.,Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, ROC
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University College of Medicine, and National Taiwan University Hospital, Taipei, ROC.,Forensic and Clinical Toxicology Center, College of Medicine and National Taiwan University Hospital, National Taiwan University, Taipei, ROC
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Overview of Synthetic Cannabinoids ADB-FUBINACA and AMB-FUBINACA: Clinical, Analytical, and Forensic Implications. Pharmaceuticals (Basel) 2021; 14:ph14030186. [PMID: 33669071 PMCID: PMC7996508 DOI: 10.3390/ph14030186] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/08/2023] Open
Abstract
ADB-FUBINACA and AMB-FUBINACA are two synthetic indazole-derived cannabinoid receptor agonists, up to 140- and 85-fold more potent, respectively, than trans-∆9-tetrahydrocannabinol (∆9-THC), the main psychoactive compound of cannabis. Synthesised in 2009 as a pharmaceutical drug candidate, the recreational use of ADB-FUBINACA was first reported in 2013 in Japan, with fatal cases being described in 2015. ADB-FUBINACA is one of the most apprehended and consumed synthetic cannabinoid (SC), following AMB-FUBINACA, which emerged in 2014 as a drug of abuse and has since been responsible for several intoxication and death outbreaks. Here, we critically review the physicochemical properties, detection methods, prevalence, biological effects, pharmacodynamics and pharmacokinetics of both drugs. When smoked, these SCs produce almost immediate effects (about 10 to 15 s after use) that last up to 60 min. They are rapidly and extensively metabolised, being the O-demethylated metabolite of AMB-FUBINACA, 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamide)-3-methylbutanoic acid, the main excreted in urine, while for ADB-FUBINACA the main biomarkers are the hydroxdimethylpropyl ADB-FUBINACA, hydroxydehydrodimethylpropyl ADB-FUBINACA and hydroxylindazole ADB-FUBINACA. ADB-FUBINACA and AMB-FUBINACA display full agonism of the CB1 receptor, this being responsible for their cardiovascular and neurological effects (e.g., altered perception, agitation, anxiety, paranoia, hallucinations, loss of consciousness and memory, chest pain, hypertension, tachycardia, seizures). This review highlights the urgent requirement for additional studies on the toxicokinetic properties of AMB-FUBINACA and ADB-FUBINACA, as this is imperative to improve the methods for detecting and quantifying these drugs and to determine the best exposure markers in the various biological matrices. Furthermore, it stresses the need for clinicians and pathologists involved in the management of these intoxications to describe their findings in the scientific literature, thus assisting in the risk assessment and treatment of the harmful effects of these drugs in future medical and forensic investigations.
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Ordak M, Zmysłowska A, Bielski M, Rybak D, Tomaszewska M, Wyszomierska K, Kmiec A, Garlicka N, Zalewska M, Zalewski M, Nasierowski T, Muszynska E, Bujalska-Zadrozny M. Pharmacotherapy of Patients Taking New Psychoactive Substances: A Systematic Review and Analysis of Case Reports. Front Psychiatry 2021; 12:669921. [PMID: 33967865 PMCID: PMC8102790 DOI: 10.3389/fpsyt.2021.669921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: In recent years, an increase in the frequency of hospitalizations of patients taking newer and newer psychoactive substances has been observed around the world. Each year, authors publish case reports of patients who consumed previously unknown NPS. Most publications of this type concern the period between 2014 and 2016. However, no publication systematically reviews the pharmacotherapy used in these cases. This study aims to review the case reports of patients taking NPS published between 2010 and 2019, as well as analyzing the pharmacotherapy used. Methods: We searched the Thomson (Web of Knowledge), PubMed/Medline, Science Direct, Scopus and Google Scholar databases. The search was performed using all possible combinations of the term "case report" describing the use of NPS, also referred to as designer medications, internet medications, research chemicals and herbal highs. Results: We analyzed 51 case reports on the intake of various types of NPS. Most of them (p < 0.001) concerned the use of synthetic cannabinoids (41.2%) and cathinones (31.4%). The pharmacotherapy applied primarily (p < 0.001) consisted of administering benzodiazepines to patients (62.7%), most of whom took only this group of medications (25.5%), followed by groups receiving benzodiazepines combined with neuroleptics (15.7%) and muscle relaxants (11.8%). Opioids were administered primarily to patients taking synthetic opioids (p < 0.001). Of the 5 cases of deaths from NPS reported in the literature, three relate specifically to the synthetic opioid MT-45. The later the time period, the more medications patients were administered (p = 0.02). Conclusion: In the pharmacotherapy for NPS poisoning, one should focus primarily on combating psychomotor agitation.
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Affiliation(s)
- Michal Ordak
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Zmysłowska
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Miłosz Bielski
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Daniel Rybak
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Maja Tomaszewska
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Wyszomierska
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Kmiec
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Natalia Garlicka
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Maria Zalewska
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Michal Zalewski
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | | | - Elzbieta Muszynska
- Department of Medical Biology, Medical University of Bialystok, Bialystok, Poland
| | - Magdalena Bujalska-Zadrozny
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
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Carroll FI, Lewin AH, Mascarella SW, Seltzman HH, Reddy PA. Designer drugs: a medicinal chemistry perspective (II). Ann N Y Acad Sci 2020; 1489:48-77. [PMID: 32396701 DOI: 10.1111/nyas.14349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/28/2020] [Accepted: 03/20/2020] [Indexed: 12/18/2022]
Abstract
During 2012-2018, the clandestine manufacture of new psychoactive substances (NPS) designed to circumvent substance control regulations increased exponentially worldwide, with concomitant increase in fatalities. This review focuses on three compound classes identified as synthetic opioids, synthetic amphetamines, and synthetic cannabinoids and highlights the medicinal chemistry precedents utilized by clandestine laboratories to develop new NPS with increased brain penetration, longer duration of action, and greater potency. Chemical approaches to illicit drug abuse treatment options, particularly for opioid use disorder, are also discussed.
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Affiliation(s)
- F Ivy Carroll
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Anita H Lewin
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, North Carolina
| | - S Wayne Mascarella
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Herbert H Seltzman
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, North Carolina
| | - P Anantha Reddy
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, North Carolina
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9
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The other side of the leaf: Seizures associated with synthetic cannabinoid use. Epilepsy Behav 2020; 104:106901. [PMID: 31958643 DOI: 10.1016/j.yebeh.2020.106901] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 01/19/2023]
Abstract
There has recently been a marked rise in the medicinal use of cannabis for epilepsy and multiple other conditions. While seizures have been reported in association with synthetic cannabinoids, the clinical features and prognosis have not been studied. Thirty patients with a history of seizures occurring within 24 h of synthetic cannabinoid use were identified from a first seizure clinic database in Perth, Western Australia between 2011 and 2016. Eight had a prior history of seizures, three related to synthetic cannabinoid use, with an additional three patients having risk factors for seizures. The presenting event was a tonic-clonic seizure in 27 patients (90%). "Kronic" was the synthetic cannabinoid used by 16 patients. Absorption was via smoking in all cases, with seizures occurring within 30 min of inhalation in 14 patients (46%). Electroencephalography (EEG) showed epileptiform abnormalities in 11%, and neuroimaging revealed epileptogenic lesions in 12%. Nine of 24 patients with follow-up had subsequent seizures, occurring in the setting of further synthetic cannabinoid use in two patients. This seizure recurrence rate is similar to seizures provoked by other acute systemic insults. In conclusion, smoking of some synthetic cannabinoids is associated with seizures, and this may relate to an intrinsic proconvulsant effect.
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10
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Monte AA, Hopkinson A, Saben J, Shelton S, Thornton S, Schneir A, Pomerleau A, Hendrickson R, Arens AM, Cole JB, Chenoweth J, Martin S, Adams A, Banister SD, Gerona RR. The Psychoactive Surveillance Consortium and Analysis Network (PSCAN): the first year. Addiction 2020; 115:270-278. [PMID: 31769125 PMCID: PMC6982594 DOI: 10.1111/add.14808] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/21/2019] [Accepted: 08/30/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIMS The Psychoactive Surveillance Consortium and Analysis Network (PSCAN) is a national network of academic emergency departments (ED), analytical toxicologists and pharmacologists that collects clinical data paired with biological samples to identify and improve treatments of medical conditions arising from use of new psychoactive substances (NPS). The aim of this study was to gather clinical data with paired drug identification from NPS users who presented to EDs within PSCAN during its first year (2016-17). DESIGN Observational study involving patient records and biological samples. SETTING Seven academic emergency medical centers across the United States. PARTICIPANTS ED patients (n = 127) > 8 years of age with possible NPS use who were identified and enrolled in PSCAN by clinical providers or research personnel. MEASUREMENTS Clinical signs, symptoms and treatments were abstracted from the patients' health records. Biological samples were collected from leftover urine, serum and whole blood. Biological and drug samples, when available, were tested for drugs and drug metabolites via liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF/MS). FINDINGS Patients in whom synthetic opioids were detected (n = 9) showed higher rates of intubation (four of nine), impaired mental status (four of nine) and respiratory acidosis (five of nine) compared with the rest of the cohort (nine of 118, P-value < 0.05). Patients in whom synthetic cannabinoid (SC) were found (n = 27) had lower median diastolic blood pressures (70.5 versus 77 mmHg, P = 0.046) compared with the rest of the cohort. In 64 cases of single drug ingestion, benzodiazepines were administered in 25 cases and considered effective by the treating physician in 21 (84%) cases. CONCLUSIONS During its first year of operation, the Psychoactive Surveillance Consortium and Analysis Network captured clinical data on new classes of drugs paired with biological samples over a large geographical area in the United States. Synthetic cannabinoids were the most common new psychoactive drug identified. Synthetic opioids were associated with a high rate of intubation and respiratory acidosis.
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Affiliation(s)
- Andrew A. Monte
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO,Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO
| | - Andrew Hopkinson
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO
| | - Jessica Saben
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO
| | - Shelby Shelton
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO
| | - Stephen Thornton
- University of Kansas, Department of Emergency Medicine, Kansas City, KS
| | - Aaron Schneir
- University of California San Diego Health System, Division of Medical Toxicology, Department of Emergency Medicine, San Diego, CA, USA
| | - Adam Pomerleau
- Department of Emergency Medicine, Emory University, Atlanta, GA
| | - Robert Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Ann M. Arens
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Jon B. Cole
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | | | - Spencer Martin
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California San Francisco, San Francisco, CA
| | - Axel Adams
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California San Francisco, San Francisco, CA
| | - Samuel D. Banister
- The School of Chemistry, The University of Sydney, Sydney, NSW, Australia,The Lambert Initiative for Cannabinoid Therapeutics, The Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | - Roy R. Gerona
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California San Francisco, San Francisco, CA
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11
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Van Wijk XMR, Goodnough R, Colby JM. Mass spectrometry in emergency toxicology: Current state and future applications. Crit Rev Clin Lab Sci 2019; 56:225-238. [DOI: 10.1080/10408363.2019.1585415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Xander M. R. Van Wijk
- Department of Pathology, Pritzker School of Medicine, University of Chicago, Chicago, IL, US
| | - Robert Goodnough
- California Poison Control System, San Francisco Division, San Francisco, CA, US
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, US
| | - Jennifer M. Colby
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, US
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12
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Wilson CD, Tai S, Ewing L, Crane J, Lockhart T, Fujiwara R, Radominska-Pandya A, Fantegrossi WE. Convulsant Effects of Abused Synthetic Cannabinoids JWH-018 and 5F-AB-PINACA Are Mediated by Agonist Actions at CB1 Receptors in Mice. J Pharmacol Exp Ther 2019; 368:146-156. [PMID: 30420360 PMCID: PMC6323622 DOI: 10.1124/jpet.118.251157] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/07/2018] [Indexed: 01/29/2023] Open
Abstract
Convulsant effects of abused synthetic cannabinoid (SCB) drugs have been reported in humans and laboratory animals, but the mechanism of these effects is not known. We compared convulsant effects of partial CB1R agonist ∆9-tetrahydrocannabinol (THC), full CB1R agonist SCBs JWH-018 and 5F-AB-PINACA, and classic chemical convulsant pentylenetetrazol (PTZ) using an observational rating scale in mice. THC did not elicit convulsions, but both SCBs did so as effectively as and more potently than PTZ. SCB-elicited convulsions were attenuated by the CB1R antagonist rimonabant or by THC, or by dose regimens of THC and JWH-018, which downregulate and desensitize CB1Rs. None of these treatments altered the convulsant effects of PTZ, although diazepam attenuated PTZ-elicited convulsions without altering SCB-induced convulsant effects. Repeated administration of a subthreshold dose of PTZ kindled convulsant effects, but this was not observed with the SCBs, and no cross-kindling was observed. Repeated administration of the SCBs resulted in tolerance to convulsant effects, but no cross-tolerance to PTZ was observed. Inhibition on Phase I metabolism via nonselective inhibition of CYP450s with 1-aminobenzotriazole potentiated the hypothermic effects of the SCBs and protected against the convulsant effects of JWH-018, but not those of 5F-AB-PINACA or PTZ. Incubation of human liver microsomes with the SCBs showed that JWH-018 is eliminated via oxidation, whereas 5F-AB-PINACA is not. These studies suggest that SCB-elicited convulsions are mediated by high intrinsic efficacy at CB1Rs and that benzodiazepines may not be effective treatments. Finally, drug metabolism may dramatically modulate the convulsant effects of some, but not all, SCBs.
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Affiliation(s)
- Catheryn D Wilson
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sherrica Tai
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Laura Ewing
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jasmine Crane
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Taylor Lockhart
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ryochi Fujiwara
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Anna Radominska-Pandya
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - William E Fantegrossi
- Departments of Pharmacology and Toxicology (C.D.W., S.T., L.E., J.C., T.L., W.E.F.) and Biochemistry and Molecular Biology (R.F., A.R.-P.), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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13
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Cannabinoid-like effects of five novel carboxamide synthetic cannabinoids. Neurotoxicology 2018; 70:72-79. [PMID: 30439379 DOI: 10.1016/j.neuro.2018.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/08/2018] [Accepted: 11/08/2018] [Indexed: 01/04/2023]
Abstract
A new generation of novel cannabinoid compounds have been developed as marijuana substitutes to avoid drug control laws and cannabinoid blood tests. 5F-MDMB-PINACA (also known as 5F-ADB, 5F-ADB-PINACA), MDMB-CHIMICA, MDMB-FUBINACA, ADB-FUBINACA, and AMB-FUBINACA (also known as FUB-AMB, MMB-FUBINACA) were tested for in vivo cannabinoid-like effects to assess their abuse liability. Locomotor activity in mice was tested to screen for locomotor depressant effects and to identify behaviorally-active dose ranges and times of peak effect. Discriminative stimulus effects were tested in rats trained to discriminate Δ9-tetrahydrocannabinol (3 mg/kg, 30-min pretreatment). 5F-MDMB-PINACA (ED50 = 1.1 mg/kg) and MDMB-CHIMICA (ED50 = 0.024 mg/kg) produced short-acting (30 min) depression of locomotor activity. ADB-FUBINACA (ED50 = 0.19 mg/kg), and AMB- FUBINACA (ED50 = 0.19 mg/kg) depressed locomotor activity for 60-90 min; whereas MDMB-FUBINACA (ED50 = 0.04 mg/kg) depressed locomotor activity for 150 min. AMB-FUBINACA produced tremors at the highest dose tested. 5F-MDMB-PINACA (ED50 = 0.07), MDMB-CHIMICA (ED50 = 0.01 mg/kg), MDMB-FUBINACA (ED50 = 0.051 mg/kg), ADB-FUBINACA (ED50 = 0.075 mg/kg) and AMB-FUBINACA (ED50 = 0.029) fully substituted for the discriminative stimulus effects of Δ9-THC following 15-min pretreatment. All 5 compounds decreased locomotor activity and produced discriminative stimulus effects similar to those of Δ9-THC, which suggests they may have abuse liability similar to that of Δ9-THC. AMB-FUBINACA may have an increased risk of toxicities in recreational users.
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14
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McCutcheon D, Raghavan M, Soderstrom J, Oosthuizen F, Douglas B, MacDonald E, Fatovich D. An early warning system for emerging drugs of concern in the emergency department: Protocol for the Western Australian Illicit Substance Evaluation (WISE) study. Emerg Med Australas 2018; 31:411-416. [DOI: 10.1111/1742-6723.13185] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 11/28/2022]
Affiliation(s)
- David McCutcheon
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency MedicineThe University of Western Australia Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
| | - Mohan Raghavan
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
- Clinical ToxicologyRoyal Perth Hospital Perth Western Australia Australia
| | - Jessamine Soderstrom
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
- Clinical ToxicologyRoyal Perth Hospital Perth Western Australia Australia
| | | | | | - Ellen MacDonald
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency MedicineThe University of Western Australia Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency MedicineThe University of Western Australia Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
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