A review of clinical manifestations in adolescent and young adults after use of synthetic cannabinoids

Insights into the metabolism of CH-PIATA-A novel synthetic cannabinoid featuring an acetamide linker

The recent change from the popular carboxamide to an acetamide (ATA) linker scaffold in synthetic cannabinoid receptor agonists (SCRAs) can be interpreted as an attempt to circumvent legal regulations, setting new analytical challenges. Metabolites of N-cyclohexyl-2-(1-pentyl-1 H-indol-3-yl)acetamide: CH-PIATA, the second ATA type SCRA detected in the EU, were investigated in urine and serum samples by LC-HRMS-MS and LC-MS-MS. Two different in vitro models, a pHLM assay and HepG2-cells, as well as an in silico prediction by GLORYx freeware assisted in metabolite formation/identification. CH-PIATA was extensively metabolized, leading to metabolites formed primarily by mono- and dihydroxylation. For urine and serum specimens, monohydroxylation at the indole core or the methylene spacer of the acetamide linker (M1.8), carboxylic acid formation at the N-pentyl side chain (M3.1) and degradation of the latter leading to a tentatively identified N-propionic acid metabolite (M5.1) are suggested as reliable markers for substance intake. The N-propionic acid metabolite could not be confirmed in the in vitro assays as it includes multiple consecutive metabolic reactions. Furthermore, CH-PIATA could be detected as parent substance in blood samples, but not in urine. Both in vitro assays and the in silico tool proved suitable for predicting metabolites of CH-PIATA. Considering effort and costs, pHLM incubations seem to be more effective for metabolite prediction in forensic toxicology than HepG2 cells. The highlighted Phase I metabolites serve as reliable urinary targets for confirming CH-PIATA use. The in silico approach is advantageous when reference material is unavailable.

Sex-specific behavioural, metabolic, and immunohistochemical changes after repeated administration of the synthetic cannabinoid AKB48 in mice

BACKGROUND AND PURPOSE

AKB48 is a synthetic cannabinoid illegally sold for its psychoactive cannabis-like effects that have been associated with acute intoxication and whose effects are poorly known.

EXPERIMENTAL APPROACH

Using a behavioural, neurochemical, and immunohistochemical approach, we investigated the pharmaco-toxicological effects, pharmacokinetics, and neuroplasticity at cannabinoid CB1 receptors in the cerebellum and cortex induced by repeated AKB48 administration in male and female mice.

KEY RESULTS

The effects of AKB48 varied significantly depending on sex and treatment duration. The first injection impaired sensorimotor responses and reduced body temperature, analgesia, and breath rate to a greater extent in females than in males; the second injection induced stronger effects in males while the third injection of AKB48 induced weaker responses in both sexes, suggesting emergence of tolerance. The CB1 receptor antagonist NESS-0327 prevented the effects induced by repeated AKB48, confirming a CB1 receptor-mediated action. Blood AKB48 levels were higher in females than in males and repeated administration caused a progressive rise of AKB48 levels in both sexes, suggesting an inhibitory effect on cytochrome activity. Finally, immunohistochemical analysis revealed higher expression of CB1 receptors in the cerebellum and cortex of females, and a rapid CB1 receptor down-regulation in cerebellar and cortical areas following repeated AKB48 injections, with neuroadaptation occurring generally more rapidly in females than in males.

CONCLUSION AND IMPLICATIONS

We have shown for the first time that AKB48 effects significantly vary with prolonged use and that sex affects the pharmacodynamic/pharmacokinetic responses to repeated administration, suggesting a sex-tailored approach in managing AKB48-induced intoxication.

Association of cannabis, cannabidiol and synthetic cannabinoid use with mental health in UK adolescents

BACKGROUND

Cannabis has been associated with poorer mental health, but little is known of the effect of synthetic cannabinoids or cannabidiol (often referred to as CBD).

AIMS

To investigate associations of cannabis, synthetic cannabinoids and cannabidiol with mental health in adolescence.

METHOD

We conducted a cross-sectional analysis with 13- to 14-year-old adolescents across England and Wales in 2019-2020. Multilevel logistic regression was used to examine the association of lifetime use of cannabis, synthetic cannabinoids and cannabidiol with self-reported symptoms of probable depression, anxiety, conduct disorder and auditory hallucinations.

RESULTS

Of the 6672 adolescents who participated, 5.2% reported using of cannabis, 1.9% reported using cannabidiol and 0.6% reported using synthetic cannabinoids. After correction for multiple testing, adolescents who had used these substances were significantly more likely to report a probable depressive, anxiety or conduct disorder, as well as auditory hallucinations, than those who had not. Adjustment for socioeconomic disadvantage had little effect on associations, but weekly tobacco use resulted in marked attenuation of associations. The association of cannabis use with probable anxiety and depressive disorders was weaker in those who reported using cannabidiol than those who did not. There was little evidence of an interaction between synthetic cannabinoids and cannabidiol.

CONCLUSIONS

To our knowledge, this study provides the first general population evidence that synthetic cannabinoids and cannabidiol are associated with probable mental health disorders in adolescence. These associations require replication, ideally with prospective cohorts and stronger study designs.

Metacognitive Abilities as a Protective Factor for the Occurrence of Psychotic-Like Experiences in a Non-clinical Population

Psychotic-like experiences (PLEs) are a phenomenon that occurs in the general population experiencing delusional thoughts and hallucinations without being in a clinical condition. PLEs involve erroneous attributions of inner cognitive events to the external environment and the presence of intrusive thoughts influenced by dysfunctional beliefs; for these reasons, the role played by metacognition has been largely studied. This study investigates PLEs in a non-clinical population and discriminating factors involved in this kind of experience, among which metacognition, as well as psychopathological features, seems to have a crucial role. The aim of this study was to extend the knowledge about the relationship between metacognition, psychopathology, and PLEs, orienting the focus on metacognitive functioning. The sample consisted of 207 Italian participants (men = 32% and women = 68%) voluntarily recruited online, who gave consent to participate in the study. The average age of the sample was 32.69 years (SD: 9.63; range: 18-71). Subjects affected by psychosis, neurological disease, and drug addiction were excluded from the analyses. The following scales were used to investigate PLEs: Peters et al. Delusions Inventory (PDI), Launay-Slade Hallucinations Scale-Extended Revised (LSHSE), Prodromal Questionnaire-Brief (PQ-B), and Revised Hallucination Scale (RHS). To assess general psychopathological features, the Behavior and Symptom Identification Scale (BASIS-32) was administrated. The Metacognition Self-Assessment Scale (MSAS) was chosen to evaluate metacognitive functioning. From hierarchical regression analyses, it emerged that the presence of anxiety, depression, and impulsive/addictive symptoms constitute a remarkable vulnerability factor for PLEs, in line with previous evidence regarding the relationship between general psychopathology and PLEs. Metacognition negatively predicts PLEs, and its presence does not affect the significance of psychopathological variables, suggesting that metacognitive abilities seem to play a protective role for the occurrence of PLEs among non-clinical individuals, and such ability operates as an independent predictor along with other variables. These results are explained by the role of metacognitive functions, which allow individuals to operate many mental processes such as interpreting sensorial events as real or illusory, understanding behaviors, thoughts, and drives of others, and questioning the subjective interpretation of facts.

Determination of AB-FUBINACA and 5F-NPB-22 in rats exposed to "Bonsai" via inhalation and analysis of seized product

Synthetic cannabinoids (SCs) are the most rapidly growing class of recreational designer drugs. Illicit drug manufacturers began to produce herbal smoking materials under a variety of brands names, e.g. "Spice, K2, Bonsai, Yucatan Fire". They were appeared on the European market in 2008. In this study, types of SCs in the herbal product sold as "Bonsai" in Turkey were determined and the identification of these substances in biological samples collected from rats depending on the inhalation of different amounts of plant material were aimed. To determine the SC species in the content of the plant product, analysis was performed via gas chromatography-mass spectrometry. Liquid-liquid extraction methods were utilized for blood and organ samples, while solid-phase extraction with β-glucuronidase enzyme treatment was applied for urine sample preparation. The relationship between the amount of burned plant and the amount of SCs accumulated in the blood, urine and organ samples of rats exposed to the plant product by inhalation was examined by liquid chromatography-tandem mass spectrometry. AB-FUBINACA and 5F-NPB-22 were detected in the herbal product. A significant correlation was found between the amount of herbal product inhaled and the prevalence of SCs, especially in lung tissues while no SCs were detected in the blood and urine samples of rats. There is currently no study on biological samples of individuals exposed to herbal products containing SCs by inhalation. Regarding the findings obtained in this study, the overall increase in the amounts of herbal product inhaled was demonstrated to pose a potential risk to humans.

In vitro assessment of the cytotoxic, genotoxic and oxidative stress effects of the synthetic cannabinoid JWH-018 in human SH-SY5Y neuronal cells

BACKGROUND

JWH-018 was the first synthetic cannabinoid introduced as a legal high and the first of the new generation of novel psychoactive substances that flooded worldwide drug markets. JWH-018 was marketed as "spice," "herbal incense," or "herbal blend," as a popular and legal (at the time) alternative to cannabis (marijuana). JWH-018 is a potent synthetic cannabinoid with considerable toxicity associated with its use. JWH-018 has qualitatively similar but quantitatively greater pharmacological effects than cannabis, leading to intoxications and even deaths. The mechanisms of action of the drug's toxicity require research, and thus, the aim of the present study was to investigate the toxicological profile of JWH-018 in human SH-SY5Y neuronal cells.

METHODS

SH-SY5Y neuronal cells were exposed to increasing concentrations from 5 to 150 μM JWH-018 over 24 h. Cytotoxicity, DNA damage, the apoptotic/necrotic rate, and oxidative stress were assessed following SH-SY5Y exposure.

RESULTS

JWH-018 did not produce a significant decrease in SH-SY5Y cell viability, did not alter apoptotic/necrotic rate, and did not cause genotoxicity in SH-SY5Y cells with 24-h exposure. Glutathione reductase and catalase activities were significantly reduced; however, there was no significant change in glutathione peroxidase activity. Also, JWH-018 treatment significantly decreased glutathione concentrations, significantly increased protein carbonylation, and significantly increased malondialdehyde (MDA) concentrations. For significance, all P < 0.05.

DISCUSSION/CONCLUSION

JWH-018 produced oxidative stress in SH-SY5Y cells that could be an underlying mechanism of JWH-018 neurotoxicity. Additional in vivo animal and human-based studies are needed to confirm our findings.

Four cases of death involving the novel synthetic cannabinoid 5F-Cumyl-PEGACLONE

Purpose

Cumyl-PEGACLONE was the first synthetic cannabinoid (SC) with a γ-carbolinone core structure detected in forensic casework and, since then, it has dominated the German SC-market. Here the first four cases of death involving its fluorinated analog, 5F-Cumyl-PEGACLONE, a recently emerged γ-carbolinone derived SC, are reported.

Methods

Complete postmortem examinations were performed. Postmortem samples were screened by immunoassay, gas chromatography mass spectrometry (GC–MS) or liquid chromatography tandem mass spectrometry. For quantification of SCs, the standard addition method was employed. Herbal blends were analyzed by GC–MS. In each case of death, the Toxicological Significance Score (TSS) was assigned to the compound.

Results

5F-Cumyl-PEGACLONE was identified at concentrations ranging 0.09–0.45 ng/mL in postmortem femoral blood. In case 1, signs of hypothermia and kidney bleedings were noted. Despite a possible tolerance due to long term SC use, a TSS of 3 was assigned. In case 2, an acute heroin intoxication occurred and a contributory role (TSS = 1) of 5F-Cumyl-PEGACLONE was suggested. In case 3, a prisoner was found dead. GC–MS analysis of herbal blends, retrieved in his cell together with paraphernalia, confirmed the presence of 5F-Cumyl-PEGACLONE and a causative role was deemed probable (TSS = 2). In case 4, the aspiration of gastric content due to a SC-induced coma was observed (TSS = 3).

Conclusions

5F-Cumyl-PEGACLONE is an emerging and extremely potent SC which raises serious public health concerns. A comprehensive analysis of circumstantial, clinical, and postmortem findings, as well as an in-depth toxicological analysis is necessary for a valid interpretation and for the assessment of the toxicological significance.

Perfusion Index Analysis in Patients Presenting to the Emergency Department Due to Synthetic Cannabinoid Use

Background and Objectives: The perfusion index (PI) indicates the ratio of pulsatile blood flow in peripheral tissue to non-pulsatile blood flow. This study was performed to examine the blood perfusion status of tissues and organs of patients using synthetic cannabinoids (SCs). Materials and Methods: The records of patients aged 17 or over presenting to the adult emergency department due to SC use between 1 January 2016 and 31 December 2017 were examined in this single-center, retrospective, cross-sectional study. Examined factors included time from consumption of SC to presentation to the emergency department, as well as simultaneously determined systolic and diastolic blood pressures, heart rate (beats per min), Glasgow Coma Score (GCS), and PI values. Patients were divided into two groups, A and B, depending on the amount of time that had elapsed between SC consumption and presentation to the emergency department, and statistical data were compared. Results: The mean PI value in Group A was lower than that in Group B. Therefore, we concluded that peripheral tissue and organ blood perfusion is lower in the first 2 h following SC consumption than after 2 h. Systolic, diastolic, and mean arterial blood pressure and mean GCS values were also statistically significantly lower in Group A than in Group B. Conclusions: A decreased PI value may be an early sign of reduced-perfusion organ damage. PI is a practical and useful parameter in the early diagnosis of impaired organ perfusion and in monitoring tissue hypoxia leading to organ failure.

The public health evidence-base on novel psychoactive substance use: scoping review with narrative synthesis of selected bodies of evidence

Background

This review aimed to address what was known about the public health burden associated with novel psychoactive substances (NPS) use, and the effectiveness of responses targeting NPS use and/or associated problems.

Methods

Relevant literature was identified through a range of searches covering the period from January 2006 to June 2016. Data synthesis was undertaken in three stages. Firstly we mapped the evidence available in order to characterize the literature according to a set of analytic categories developed a priori. Secondly, we identified evidence gaps from a set of a priori research questions. Finally, we then undertook a narrative synthesis of selected bodies of evidence, interpreting data using a conceptual framework specifically designed for use in this review.

Results

A total of 995 articles were included in the scoping review with the majority being case reports/series on individual level adverse effects due to NPS use. We synthesized UK data from 29 surveys and 7 qualitative studies, and international data in 10 systematic reviews on harms associated with NPS use, and 17 evaluations of policy responses. We found little data on risk factors, harms associated with long-term NPS use, and interventions.

Conclusion

In all cases we found the available evidence to be at an early stage of development.

Pharmacological and Behavioral Effects of the Synthetic Cannabinoid AKB48 in Rats

AKB48 is a designer drug belonging to the indazole synthetic cannabinoids class, illegally sold as herbal blend, incense, or research chemicals for their psychoactive cannabis-like effects. In the present study, we investigated the in vivo pharmacological and behavioral effects of AKB48 in male rats and measured the pharmacodynamic effects of AKB48 and simultaneously determined its plasma pharmacokinetic. AKB48 at low doses preferentially stimulated dopamine release in the nucleus accumbens shell (0.25 mg/kg) and impaired visual sensorimotor responses (0.3 mg/kg) without affecting acoustic and tactile reflexes, which are reduced only to the highest dose tested (3 mg/kg). Increasing doses (0.5 mg/kg) of AKB48 impaired place preference and induced hypolocomotion in rats. At the highest dose (3 mg/kg), AKB48 induced hypothermia, analgesia, and catalepsy; inhibited the startle/pre-pulse inhibition test; and caused cardiorespiratory changes characterized by bradycardia and mild bradipnea and SpO2 reduction. All behavioral and neurochemical effects were fully prevented by the selective CB₁ receptor antagonist/inverse agonist AM251. AKB48 plasma concentrations rose linearly with increasing dose and were correlated with changes in the somatosensory, hypothermic, analgesic, and cataleptic responses in rats. For the first time, this study shows the pharmacological and behavioral effects of AKB48 in rats, correlating them to the plasma levels of the synthetic cannabinoid.

Chemical Compound Studied in This Article: AKB48 (PubChem CID: 57404063); AM251 (PubChem CID: 2125).

End User-Informed Mobile Health Intervention Development for Adolescent Cannabis Use Disorder: Qualitative Study

BACKGROUND

The rates of cannabis use continue to increase among adolescents and the current interventions have modest effects and high rates of relapse following treatment. There is increasing evidence for the efficacy of mobile technology-based interventions for adults with substance use disorders, but there is limited study of this technology in adolescents who use cannabis.

OBJECTIVE

The goal of our study was to elucidate elements of an app-based adjunctive intervention for cannabis cessation that resonate with adolescents who use cannabis.

METHODS

Adolescents, aged between 14 and 17 years, who used cannabis were recruited from San Diego County high schools. Semistructured focus groups (6 total; N=37) were conducted to examine the ways in which participants used smartphones, including the use of any health behavior change apps, as well as to elicit opinions about elements that would promote engagement with an app-based intervention for adolescent cannabis cessation. An iterative coding structure was used with first cycle structural coding, followed by pattern coding.

RESULTS

Themes that emerged from the analysis included (1) youth valued rewards to incentivize the progressive reduction of cannabis use, which included both nontangible rewards that mimic those obtained on social media platforms and prosocial activity-related rewards, (2) having the ability to self-monitor progression, (3) peer social support, (4) privacy and confidentiality discrete logo and name and usernames within the app, and (5) individualizing frequency and content of notifications and reminders.

CONCLUSIONS

Integrating content, language, interfaces, delivery systems, and rewards with which adolescents who use cannabis are familiar, engage with on a day-to-day basis, and identify as relevant, may increase treatment engagement and retention for adolescents in substance use treatment. We may increase treatment effectiveness by adapting and individualizing current evidence-based interventions, so that they target the needs of adolescents and are more easily incorporated into their everyday routines.

The use of new psychoactive substances (NPS) in young people and their role in mental health care: a systematic review

Introduction: Over the past 10 years, a large number of New Psychoactive Substances (NPS) have entered the recreational drug scenario. NPS intake has been associated with health-related risks, and especially so for vulnerable populations such as the youngsters. Currently, most knowledge on the NPS health effects is learnt from both a range of users' reports, made available through the psychonauts' web fora, and from the few published, related toxicity, clinical observations.Areas covered: This paper aims at providing an overview of NPS effects on youngsters' mental health, whilst performing a systematic review of the current related knowledge.Expert opinion: NPS consumption poses serious health risks, due to both a range of unpredictable clinical pharmacological properties and the typical concomitant use of other psychoactive molecules; overall, this can lead to near misses and fatalities. In comparison with adults, the central nervous system of children/adolescents may be more vulnerable to the activity of these molecules, hence raising even further the levels of health-related concerns. More research is needed to provide evidence of both short- and long-term effects of NPS, related health risks, and their addiction potential.

Evidence for public health on novel psychoactive substance use: a mixed-methods study

Background

Novel psychoactive substances (NPSs) contribute to the public health impact of substance misuse. This report provides research evidence addressing 11 research questions related to NPSs, covering types, patterns and settings of use; supply sources; and implications for policy and practice.

Methods

The study used a conceptually linked three-phase mixed-methods design with a shared conceptual framework based on multiple-context risk and protective factors. Phase 1 was a quantitative phase involving secondary data analysis of the longitudinal Belfast Youth Development Study (BYDS), a latent class analysis using the 2039 BYDS participants. Phase 2 was an extensive qualitative analysis via narrative interviews with participants, sampled from BYDS, drug/alcohol services and prisons, to explore NPS use trajectories. Phase 3 was the final quantitative phase; generalisability of the shared risk factor part of the model was tested using the manual three-step approach to examine risk factors associated with latent class membership. The quantitative and qualitative analyses were integrated, thus allowing emerging findings to be further explored.

Results

The data suggest that NPSs have a place within a range of polydrug use trajectories. Models showed no distinctive NPS class, with no clear evidence of differential risks for NPS use compared with the use of other substances. From the qualitative analysis, a taxonomy of groups was derived that explored how and where NPSs featured in a range of trajectories. This taxonomy was used to structure the analysis of factors linked to use within a risk and protective framework. Drivers for use were considered alongside knowledge, perceptions and experience of harms. Suggestions about how interventions could best respond to the various patterns of use – with special consideration of synthetic cannabinoids (SCs), including how they relate to the use of heroin and the potential for NPSs to operate as a ‘snare’ to more problem use – were also presented.

Limitations

The study was conducted during 2016/17; generalisability beyond this sample and time point is limited. The level of missing data for some of the BYDS analysis was a limitation, as was the fact that the BYDS data were collected in 2011, so in a different context from the data collected during the narrative interviews. The Psychoactive Substances Act 2016 (Great Britain. Psychoactive Substances Act 2016. London: The Stationery Office; 2016) came into force during qualitative fieldwork and, although not particularly influential in this study, may be influential in future work. It is acknowledged that many of the data related to SCs and mephedrone. Although drug use was measured by self-report, the strength of rapport within interviews, reflective diaries and methodological acceptability checks helped to mitigate self-report bias.

Conclusions

NPSs continue to present significant challenges for legislation and monitoring, researching and developing interventions. Understanding of usage patterns remains poor, with most information based on populations and settings where problems have already occurred. This research contributes to the evidence base by providing much needed further empirical data on the lived experiences of NPS users across a range of settings. In the light of these data, implications for policy and practice are discussed.

Future work

Future research must generate improved epidemiological data on the extent, patterns and motivations for use longitudinally. The uniqueness of the information concerning SC use points to a specific set of findings not evidenced in other literature (e.g. intensity of SC withdrawal). Future research should focus on the symbiotic link between SC and heroin use.

Funding

The National Institute for Health Research Public Health Research programme.

What are the psychological effects of using synthetic cannabinoids? A systematic review

BACKGROUND

Synthetic cannabinoids are, typically, full agonists at the cannabinoid CB1 receptor, and therefore considerably more potent than natural cannabis and may have correspondingly more serious psychological effects. Despite government sanctions against their production they continue to be available in ever-increasing varieties over the Internet. The psychological consequences of synthetic cannabinoid use are relatively unknown.

AIM

The purpose of this study was to synthesise the available research on the psychological consequences of synthetic cannabinoid use.

METHOD

A literature search of three databases was conducted in February 2018, including the following keywords: Spice, synthetic cannabis, cognition, affect, behaviour, psychosis, depression and anxiety.

RESULTS

Seventeen studies involving a variety of participants were eligible for inclusion: one controlled administration study, seven cross-sectional studies, five Internet surveys and four qualitative studies. The controlled administration study showed that, compared to placebo, synthetic cannabinoids acutely affected some aspects of cognitive functioning and subjective psychological ratings. Non-controlled, cross-sectional studies generally showed that synthetic cannabinoid users had lower performance on cognitive tasks and showed elevated symptomatology (e.g. paranoia) compared to both natural cannabis and non-cannabis users. Methodological limitations were noted across different study designs. There is limited research on how doses, frequency or type of synthetic cannabinoid influence outcomes.

CONCLUSIONS

Acute synthetic cannabinoid use can result in a range of psychological outcomes and, when non-intoxicated, synthetic cannabinoid users appear to differ from natural cannabis and non-users on various affective and cognitive domains. As synthetic cannabinoid use is increasing in at-risk populations there is an urgent need for more and better research to inform users, professionals and policymakers.

Synthetic and Other Drug Use among High School Students: The Role of Perceived Prevalence, Access, and Harms

BACKGROUND

Synthetic and other drugs have become available to teens, yet little is known about risk factors of use.

OBJECTIVE

To examine adolescent use of one class of synthetic drugs and its association with perceptions about its prevalence, access, and risk of substance use.

METHODS

Adolescents from a convenience sample of 104 middle and high schools (N = 59,218) participated in an anonymous survey to assess school climate and substance use in 2013-2014. Multilevel logistic regression examined the association between risk for synthetic and other drug use, perceptions of substance use, and school-level characteristics.

RESULTS

Results indicated that 2,407 (4.3%) students reported synthetic and other drug use in the past 30 days. A large proportion of youth perceived drugs to be problematic at school but underestimated the harms associated with drug use. Participants also perceived tobacco, alcohol, marijuana, and prescription drugs are easy to obtain. Risk factors for synthetic and other drug use included the perception that substance use was a large problem at school, ease of access to drugs, and limited harm associated with drug use. School enrollment and socio-economic status of students reduced odds of drug use. Similar trends were found regarding marijuana use. Conclusion/Importance: Synthetic and other drug use is an emerging public health concern. Many youth identified substances as problematic and easily accessible in their schools but underestimated their potential harms. Health and education professionals need to increase effective education around substance use, including common risk factors for synthetic drug use.

Synthetic and Non-synthetic Cannabinoid Drugs and Their Adverse Effects-A Review From Public Health Prospective

There is a growing use of novel psychoactive substances containing synthetic cannabinoids. Synthetic cannabinoid products have effects similar to those of natural cannabis, yet, these drugs are more potent and dangerous, and have been associated with dangerous adverse effects. Here, we review current literature on the epidemiology, acute, and chronic effects of synthetic and natural cannabinoid-based drugs. Synthetic drugs contain a mixture of psychoactive compounds that mostly bind cannabinoid receptors with high potency. These synthetic drugs replicate the effects of natural cannabis and Δ9-tetrahydrocannabinol but they induce more severe adverse effects including respiratory difficulties, hypertension, tachycardia, chest pain, muscle twitches, acute renal failure, anxiety, agitation, psychosis, suicidal ideation, and cognitive impairment. Chronic use of synthetic cannabinoids has been associated with serious psychiatric and medical conditions and even death. Given the growing popularity in the use of cannabinoid-based drugs and their harmful potential, there is a need for further research in this field.

Bilateral multiple exudative retinal detachments and macular edema in a patient diagnosed with synthetic cannabinoid (Bonzai) intoxication

PURPOSE

To report the first case of a patient with bilateral multiple exudative retinal detachments and macular edema after smoking Bonzai.

METHODS

A 17-year-old girl presented with a complaint of a sudden onset of reduced vision in both eyes. She was admitted to the emergency service 3 days ago with the symptoms of hallucination and convulsion and diagnosed with synthetic cannabinoid intoxication.

RESULTS

After consultation with an internal medicine specialist, intravenous fluid treatment was initiated. Laboratory findings resolved rapidly and recovery of fundus findings was achieved at 6 months of follow-up.

CONCLUSIONS

Synthetic cannabinoid abuse has been increasing in young populations in recent years and has become an important health concern. It is important for health providers to be aware of ocular signs and symptoms of intoxication.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

Longitudinal Predictors of Synthetic Cannabinoid Use in Adolescents

BACKGROUND

Synthetic cannabinoids (SCs) are a large, heterogeneous group of chemicals that are structurally similar to δ-9-tetrahydrocannabinol. Many SCs are high-efficacy full agonists of the CB1 and/or CB2 cannabinoid receptors, resulting in a potent group of chemicals with a variety of negative health effects, including death. SCs are available to adolescents at convenience stores and smoke shops and on the Internet. However, little is known about the risk factors that contribute to eventual use of SCs in adolescents, and no research has examined the psychiatric, personality, and substance-use risk factors that prospectively predict SC use. On the basis of extant cross-sectional research, we hypothesized that anxiety, depression, impulsivity, and marijuana use would prospectively predict eventual SC use.

METHODS

Data were collected across 2 time points 12 months apart on adolescents attending multiple public high schools in southeast Texas (n = 964).

RESULTS

Path analysis indicated that depressive symptoms, marijuana use, alcohol use, and SC use at baseline were predictive of SC use at 1-year follow-up, whereas anxiety symptoms and impulsivity were not. In addition, SC use at baseline was not predictive of marijuana use at the 1-year follow-up. Females and African Americans were less likely to use SCs than males or those of other ethnicities.

CONCLUSIONS

SC-use prevention programming should consider depressive symptoms, marijuana use, and alcohol use as risk factors for SC use. Of particular significance, traditional marijuana use was predictive of subsequent SC use, but SC use was not predictive of later marijuana use.

Health Risk Behaviors With Synthetic Cannabinoids Versus Marijuana

BACKGROUND AND OBJECTIVES

Data are limited on the behavioral risk correlates of synthetic cannabinoid use. The purpose of this study was to compare the behavioral risk correlates of synthetic cannabinoid use with those among marijuana users.

METHODS

Data from the 2015 Youth Risk Behavior Survey, a cross-sectional survey conducted in a nationally representative sample of students in grades 9 through 12 (N = 15 624), were used to examine the association between self-reported type of marijuana use (ie, never use of marijuana and synthetic cannabinoids, ever use of marijuana only, and ever use of synthetic cannabinoids) and self-report of 36 risk behaviors across 4 domains: substance use, injury/violence, mental health, and sexual health. Multivariable models were used to calculate adjusted prevalence ratios.

RESULTS

Students who ever used synthetic cannabinoids had a significantly greater likelihood of engaging in each of the behaviors in the substance use and sexual risk domains compared with students who ever used marijuana only. Students who ever used synthetic cannabinoids were more likely than students who ever used marijuana only to have used marijuana before age 13 years, to have used marijuana ≥1 times during the past 30 days, and to have used marijuana ≥20 times during the past 30 days. Several injury/violence behaviors were more prevalent among students who ever used synthetic cannabinoids compared with students who ever used marijuana only.

CONCLUSIONS

Health professionals and school-based substance use prevention programs should include strategies focused on the prevention of both synthetic cannabinoids and marijuana.

Acute intoxication caused by synthetic cannabinoids 5F-ADB and MMB-2201: A case series

Synthetic cannabinoids are relatively new substances of abuse. Recently, abuse of synthetic cannabinoids has been increasingly reported in the lay press and medical literature. When new compounds are introduced, their use is initially not restricted by prohibition therefore their consumption cannot be verified by standard drug tests. The use of these compounds among adolescents and young adults is constantly growing, making it important for emergency services to be familiar with the signs and symptoms of intoxication present. Overdose and chronic use of these substances can cause adverse effects including altered mental status, tachycardia, and loss of consciousness. Here, we report five cases of acute intoxication by synthetic cannabinoids 5F-ADB and MMB-2201 with analytical confirmation.

Psychostimulant Effect of the Synthetic Cannabinoid JWH-018 and AKB48: Behavioral, Neurochemical, and Dopamine Transporter Scan Imaging Studies in Mice

JWH-018 and AKB48 are two synthetic cannabinoids (SCBs) belonging to different structural classes and illegally marketed as incense, herbal preparations, or chemical supply for theirs psychoactive cannabis-like effects. Clinical reports from emergency room reported psychomotor agitation as one of the most frequent effects in people assuming SCBs. This study aimed to investigate the psychostimulant properties of JWH-018 and AKB48 in male CD-1 mice and to compare their behavioral and biochemical effects with those caused by cocaine and amphetamine. In vivo studies showed that JWH-018 and AKB48, as cocaine and amphetamine, facilitated spontaneous locomotion in mice. These effects were prevented by CB₁ receptor blockade and dopamine (DA) D_1/5 and D_2/3 receptors inhibition. SPECT-CT studies on dopamine transporter (DAT) revealed that, as cocaine and amphetamine, JWH-018 and AKB48 decreased the [¹²³I]-FP-CIT binding in the mouse striatum. Conversely, in vitro competition binding studies revealed that, unlike cocaine and amphetamine, JWH-018 and AKB48 did not bind to mouse or human DAT. Moreover, microdialysis studies showed that the systemic administration of JWH-018, AKB48, cocaine, and amphetamine stimulated DA release in the nucleus accumbens (NAc) shell of freely moving mice. Finally, unlike amphetamine and cocaine, JWH-018 and AKB48 did not induce any changes on spontaneous [³H]-DA efflux from murine striatal synaptosomes. The present results suggest that SCBs facilitate striatal DA release possibly with different mechanisms than cocaine and amphetamine. Furthermore, they demonstrate, for the first time, that JWH-018 and AKB48 induce a psychostimulant effect in mice possibly by increasing NAc DA release. These data, according to clinical reports, outline the potential psychostimulant action of SCBs highlighting their possible danger to human health.

Psychiatric comorbidity associated with synthetic cannabinoid use compared to cannabis

BACKGROUND

Synthetic cannabinoids (SC) use has had a dramatic increase in recent years, but data regarding their adverse effects on mental health is limited. In this study, we compared clinical presentations of SC users with cannabis users in a psychiatric inpatient setting.

METHODS

Digital charts of all patients who were admitted to a dual diagnosis psychiatric unit in one year were reviewed. Patients who had any current substance use disorder were categorized in four groups: (1) SC use and cannabis use (SC+MJ+), (2) SC use without cannabis use (SC+MJ-), (3) cannabis use without SC use (SC-MJ+), and (4) No SC or cannabis use (SC-MJ-).

RESULTS

A total of 594 charts were included. SC+MJ- patients had significantly more psychotic symptoms (OR: 4.44, 95% CI: 1.98-9.94), followed by SC+MJ+ (OR: 3.61, 95% CI: 1.87-6.97) and SC-MJ+ (OR: 1.87, 95%CI: 1.33-2.64) patients. The SC+MJ- group also had more agitation and aggression was most prominent in SC+MJ+ subjects. Multivariate analyses showed that the psychiatric associations of SC and cannabis use remained significant even after controlling for potential confounds such as other substance use.

CONCLUSIONS

The prominent psychiatric features of SC users as compared to cannabis users in an inpatient setting are psychotic presentations and agitation, which have important treatment implications.

Evaluation of first generation synthetic cannabinoids on binding at non-cannabinoid receptors and in a battery of in vivo assays in mice

Anecdotal reports suggest that abused synthetic cannabinoids produce cannabis-like "highs," but some of their effects may also differ from traditional cannabinoids such as Δ(9)-tetrahydrocannabinol (THC). This study examined the binding affinities of first-generation indole-derived synthetic cannabinoids at cannabinoid and noncannabinoid receptors and their effects in a functional observational battery (FOB) and drug discrimination in mice. All seven compounds, except JWH-391, had favorable affinity (≤159 nM) for both cannabinoid receptors. In contrast, binding at noncannabinoid receptors was absent or weak. In the FOB, THC and the six active compounds disrupted behaviors in CNS activation and muscle tone/equilibrium domains. Unlike THC, however, synthetic cannabinoids impaired behavior across a wider dose and domain range, producing autonomic effects and signs of CNS excitability and sensorimotor reactivity. In addition, mice acquired JWH-018 discrimination, and THC and JWH-073 produced full substitution whereas the 5-HT2B antagonist mianserin did not substitute in mice trained to discriminate JWH-018 or THC. Urinary metabolite analysis showed that the compounds were extensively metabolized, with metabolites that could contribute to their in vivo effects. Together, these results show that, while first-generation synthetic cannabinoids shared some effects that were similar to those of THC, they also possessed effects that differed from traditional cannabinoids. The high nanomolar (or absent) affinities of these compounds at receptors for most major neurotransmitters suggests that these divergent effects may be related to the greater potencies and/or efficacies at CB1 receptors; however, action(s) at noncannabinoid receptors yet to be assessed or via different signaling pathways cannot be ruled out.

[New patterns of substance use and abuse among French adolescents, a knowledge synthesis]

AIM

There have been significant changes in adolescent consumption habits over the past fifteen years. New molecules have been synthesized, new devices created and a number of products have increased in popularity; and as a result clinicians sometimes lack information. We chose to focus on this population because of its vulnerability, as adolescents show low sensitivity to long-term outcomes of their actions and may be easily influenced by peers as regards experimentation of new drugs. The most consumed products by adolescents in France are tobacco, alcohol and cannabis with the physiological effects and consumption patterns of these drugs well documented. The purpose of this review is to identify and describe other products that are frequently used by adolescents to get high, to increase performance, for purposes of self-medication or because of peer pressure. We summarized the current scientific evidence regarding drug availability, physical and chemical properties, pharmacodynamics and adverse effects.

METHOD

A literature review was conducted from 2000 to 2015 based on Pudmed, Google Scholar and governmental websites, using the following keyword alone or in combination: "adolescent", "new", "misuse", "abuse", "toxicity", "pharmacology" "cocaine", "MDMA", "inhalant", "poppers", "magic mushroom", "psilocybin", "designer drug", "legal high", "smart drug", "cathinone", "mephedrone", "cannabinoid", "prescription drug", "codeine", "opioid", "methylphenidate", "cough syrup", "purple drank".

RESULTS

New products, including synthetic cannabis, cathinone or purple drank seem to be the most dangerous. They are easily accessible and may lead to short-term severe or lethal complications. Other substances do not pose a major short-term health risk by themselves. However, their consumption may be an indication of other unhealthy risk behaviors, such as prescription drug use, which may be related to psychiatric comorbidity. Unfortunately, we do not have enough data to determine the long-term consequences of the use of these substances. Moreover, these products have a strong addictive potential and may be a risk factor for other addictions. For this reason, increased supervision is justified, both for surveillance and reduction of harm.

CONCLUSION

Taking care of an adolescent with substance abuse can be difficult. Updated information regarding these new substances and the particular danger they pose to adolescent health is needed. Informed clinicians can provide up to date and accurate information to the patient and family, assess potential risk factors and comorbidities, and provide appropriate support. Furthermore, because of the high prevalence of substance abuse in the adolescent population, systematic screening of adolescent consumption habit is useful to avoid or anticipate complications. Often, problematic substance consumption behaviors are signs of more complicated psychological or psychiatric issues. Substance abuse behaviors will often disappear over time but they can also become a major problem as the adolescent moves into adulthood. If problems persist, consultation with an addiction specialist may be warranted.

Designer Drugs and the Impact on the Adolescent User

There are serious concerns regarding adolescent use of designer drugs. Designer drug usage is often undetected and can result in life-threatening physical and psychiatric reactions. This article explores the history of designer drugs, identifies some of the more recent designer drugs available, distinguishes the symptoms of designer drugs usage, and identifies reasons the designer drugs are popular with our young population. Lastly, this paper addresses what nurses can do to facilitate early and proper treatment to reduce serious physiological damage and death that can result from not detecting the use of designer drugs.

Neuropharmacology of New Psychoactive Substances (NPS): Focus on the Rewarding and Reinforcing Properties of Cannabimimetics and Amphetamine-Like Stimulants

New psychoactive substances (NPS) are a heterogeneous and rapidly evolving class of molecules available on the global illicit drug market (e.g smart shops, internet, “dark net”) as a substitute for controlled substances. The use of NPS, mainly consumed along with other drugs of abuse and/or alcohol, has resulted in a significantly growing number of mortality and emergency admissions for overdoses, as reported by several poison centers from all over the world. The fact that the number of NPS have more than doubled over the last 10 years, is a critical challenge to governments, the scientific community, and civil society [EMCDDA (European Drug Report), 2014; UNODC, 2014b; Trends and developments]. The chemical structure (phenethylamines, piperazines, cathinones, tryptamines, synthetic cannabinoids) of NPS and their pharmacological and clinical effects (hallucinogenic, anesthetic, dissociative, depressant) help classify them into different categories. In the recent past, 50% of newly identified NPS have been classified as synthetic cannabinoids followed by new phenethylamines (17%) (UNODC, 2014b). Besides peripheral toxicological effects, many NPS seem to have addictive properties. Behavioral, neurochemical, and electrophysiological evidence can help in detecting them. This manuscript will review existing literature about the addictive and rewarding properties of the most popular NPS classes: cannabimimetics (JWH, HU, CP series) and amphetamine-like stimulants (amphetamine, methamphetamine, methcathinone, and MDMA analogs). Moreover, the review will include recent data from our lab which links JWH-018, a CB1 and CB2 agonist more potent than Δ⁹-THC, to other cannabinoids with known abuse potential, and to other classes of abused drugs that increase dopamine signaling in the Nucleus Accumbens (NAc) shell. Thus the neurochemical mechanisms that produce the rewarding properties of JWH-018, which most likely contributes to the greater incidence of dependence associated with “Spice” use, will be described (De Luca et al., 2015a). Considering the growing evidence of a widespread use of NPS, this review will be useful to understand the new trends in the field of drug reward and drug addiction by revealing the rewarding properties of NPS, and will be helpful to gather reliable data regarding the abuse potential of these compounds.

Are the last grade medical students aware of the danger of synthetic cannabinoids?

Synthetic cannabinoids are drugs which are increasingly used by especially adolescents and young people. In recent years hospital admissions even concluding with deaths have been observed. Therefore, the awareness of medical students, who will be in challenge with this new drug abuse, is an important issue. The aim of this study is to figure out the awareness of the last grade medical students and its correlates. This is a questionnaire based descriptive study with the participation of 148 students at Karadeniz Technical University Medical Faculty, Turkey. An awareness score was produced to measure awareness (cronbach alpha = 0.67). The 17.6% (26/148) of students who reported not knowing what synthetic cannabinoids were and hearing the name for the first time in this study. The 16.4% of students assumed that synthetic cannabinoid use was legal, and 16.2% assumed that synthetic cannabinoids are not drugs. The internet (including social media) (48.6%) and pharmacology lectures (40.5%) were identified as the most stated sources of information. The students who have synthetic cannabinoid user friends and social media account have significantly higher awareness scores (p < 0.05 for both). Last grade medical students have a lack of awareness towards synthetic cannabinoids which is an increasing threat that they have to challenge.

Emerging drugs of abuse: current perspectives on synthetic cannabinoids

New psychoactive drugs that have appeared over the last decade are typically dominated by cathinones and synthetic cannabinoids (SCs). SCs have been emerging as recreational drugs because they mimic the euphoria effect of cannabis while still being legal. Sprayed on natural herb mixtures, SCs have been primarily sold as "herbal smoking blends" or "herbal incense" under brand names like "Spice" or "K2". Currently, SCs pure compounds are available from websites for the combination with herbal materials or for the use in e-cigarettes. For the past 5 years, an ever increasing number of compounds, representative of different chemical classes, have been promoted and now represent a large assortment of new popular drugs of abuse, which are difficult to properly identify. Their legal status varies by country with many government institutions currently pushing for their control. The in vitro binding to CB1/CB2 receptors is usually well-known and considerable differences have been found in the CB1 versus CB2 selectivity and potency within the different SCs, with several structure-activity relations being evident. Desired effects by CB1 agonist users are relaxation/recreative, however, cardiovascular, gastrointestinal, or psychiatric/neurological side effects are commonly reported. At present there is no specific antidote existing if an overdose of designer drugs was to occur, and no curative treatment has been approved by health authorities. Management of acute toxic effects is mainly symptomatic and extrapolated from experience with cannabis.

Rapid analysis of synthetic cannabinoids using a miniature mass spectrometer with ambient ionization capability

Synthetic cannabinoids are an emerging class of drugs of abuse and are of a great concern for transport control and usage regulation. In this study, we have developed rapid analytical methods using a miniature mass spectrometer for the identification of synthetic cannabinoids, as the traces of bulk powders on surfaces or substances in blood and urine. Significantly simplified work flows were developed by employing two ambient ionization methods, the paper spray and extraction spray ionization. Using five synthetic cannabinoids as examples, a limit of detection of 2 ng was estimated for the detection of trace powders on a bench surface and limits of quantitation as good as 10 ng/mL were obtained for the analysis of blood and urine samples.

New synthetic drugs in addictovigilance

New substances, also known as "designer drugs" or "legal highs" are increasingly available to drug users. Two hundred and fifteen hitherto unlisted substances have been notified by European Union member states since 2005. These synthetic drugs, which have been developed to side-step the legislation on drugs, are analogues or derivatives of existing drugs and medications. The availability of these "legal highs", sold on Internet under various denominations such as bath salt, plant fertilizer, chemical not intended for human use, or spice, is unlimited. The effects felt by users vary, and the substances may be stimulant, entactogenic, hallucinogenic, psychedelic or dissociative. The pharmacological targets also vary, and may be either the increase of extracellular levels of neurotransmitters via different mechanisms (reuptake inhibition, stimulation of intracellular release) or else fixation on specific receptors. Several chemical classes, themselves divided into sub-classes, are involved: phenethylamines, tryptamines, piperazines, cathinones, cannabinoids etc. The toxicity of the main members of these categories is increasingly well known, the most deleterious being behavioural effects, physical manifestations, and cardiovascular consequences. However, small variations in their chemical structure can generate effects that are quantitatively different, thus enhancing their toxicity or addictive potential, and much remains to be achieved in terms of knowledge about these new drugs. These substances are indeed present on the French territory, as shown by data provided by the Observatoire Français des Drogues et Toxicomanies, and notifications by the French Addictovigilance network. Screening in clinical toxicology laboratories is not widespread, since these molecules are not detected by the standard screening tests, so that there is probably an under-estimation of the use of these new drugs. The legislation on these substances changes regularly, with more and more countries classifying them as "narcotics" or illegal psychotropic drugs so as to restrict their use, applying a generic classification when possible.

Legal highs: staying on top of the flood of novel psychoactive substances

There has been growing clinical, public, and media awareness and concern about the availability and potential harmfulness of so-called 'legal highs', which are more appropriately called new or novel psychoactive substances (NPS). A cat-and-mouse process has emerged wherein unknown chemists and laboratories are producing new, and as yet nonproscribed, compounds for human consumption; and as soon as they are banned, which they inevitably are, slightly modified analogues are produced to circumvent new laws. This rapidly changing environment, 81 new substances were identified in 2013 alone, has led to confusion for clinicians, psychopharmacologists, and the public at large. Our difficulties in keeping up with the process has had a two-fold negative effect: the danger of ignoring what is confusing; and the problem that some of the newer synthesized compounds appear ever more potent. This review aims to circumscribe a quick moving and growing field, and to categorize NPS into five major groups based upon their 'parent' compounds: stimulants similar to cocaine, amphetamines and ecstasy; cannabinoids; benzodiazepine based drugs; dissociatives similar to ketamine and phencyclidine (PCP); and those modelled after classic hallucinogens such as LSD and psilocybin. Pharmacodynamic actions, subjective and physical effects, harmfulness, risk of dependency and, where appropriate, putative clinical potentials are described for each class. Clinicians might encounter NPS in various ways: anecdotal reportage; acute intoxication; as part of a substance misuse profile; and as a precipitant or perpetuating factor for longer-term physical and psychological ill health. Current data are overall limited, and much of our knowledge and treatment strategies are based upon those of the 'parent' compound. There is a critical need for more research in this field, and for professionals to make themselves more aware of this growing issue and how it might affect those we see clinically and try to help: a brave new world of so-called 'psychonauts' consuming NPS will also need informed 'psychotherapeutonauts'. The paper should serve as a primer for clinicians and interested readers, as well as provide a framework into which to place the new substances that will inevitably be synthesized in the future.

Designer drugs 2015: assessment and management

Recent designer drugs, also known as “legal highs,” include substituted cathinones (e.g., mephedrone, methylone, and methylenedioxypyrovalerone, often referred to as “bath salts”); synthetic cannabinoids (SCs; e.g., Spice); and synthetic hallucinogens (25I-NBOMe, or N-bomb). Compound availability has evolved rapidly to evade legal regulation and detection by routine drug testing. Young adults are the primary users, but trends are changing rapidly; use has become popular among members of the military. Acute toxicity is common and often manifests with a constellation of psychiatric and medical effects, which may be severe (e.g., anxiety, agitation, psychosis, and tachycardia), and multiple deaths have been reported with each of these types of designer drugs. Clinicians should keep designer drugs in mind when evaluating substance use in young adults or in anyone presenting with acute neuropsychiatric complaints. Treatment of acute intoxication involves supportive care targeting manifesting signs and symptoms. Long-term treatment of designer drug use disorder can be challenging and is complicated by a lack of evidence to guide treatment.

The adverse health effects of synthetic cannabinoids with emphasis on psychosis-like effects

Cannabis use is associated with an increased risk of psychosis in vulnerable individuals. Cannabis containing high levels of the partial cannabinoid receptor subtype 1 (CB1) agonist tetrahydrocannabinol (THC) is associated with the induction of psychosis in susceptible subjects and with the development of schizophrenia, whereas the use of cannabis variants with relatively high levels of cannabidiol (CBD) is associated with fewer psychotic experiences. Synthetic cannabinoid receptor agonists (SCRAs) are full agonists and often more potent than THC. Moreover, in contrast to natural cannabis, SCRAs preparations contain no CBD so that these drugs may have a higher psychosis-inducing potential than cannabis. This paper reviews the general toxicity profile and the adverse effects of SCRAs with special emphasis on their psychosis-inducing risk. The review shows that, compared with the use of natural cannabis, the use of SCRAs may cause more frequent and more severe unwanted negative effects, especially in younger, inexperienced users. Psychosis and psychosis-like conditions seem to occur relatively often following the use of SCRAs, presumably due to their high potency and the absence of CBD in the preparations. Studies on the relative risk of SCRAs compared with natural cannabis to induce or evoke psychosis are urgently needed.

Pulmonary effects of synthetic marijuana: chest radiography and CT findings

OBJECTIVE

The purpose of this article is to present the first chest radiographic and CT descriptions of organizing pneumonia in response to smoking synthetic marijuana.

CONCLUSION

Chest radiographs showed a diffuse miliary-micronodular pattern. Chest CT images showed diffuse centrilobular nodules and tree-in-bud pattern and a histopathologic pattern of organizing pneumonia with or without patchy acute alveolar damage. This distinct imaging pattern should alert radiologists to include synthetic marijuana abuse in the differential diagnosis.

Impact of Cannabis Use on the Development of Psychotic Disorders

The link between cannabis use and psychosis comprises three distinct relationships: acute psychosis associated with cannabis intoxication, acute psychosis that lasts beyond the period of acute intoxication, and persistent psychosis not time-locked to exposure. Experimental studies reveal that cannabis, tetrahydrocannabinol (THC) and synthetic cannabinoids reliably produce transient positive, negative, and cognitive symptoms in healthy volunteers. Case-studies indicate that cannabinoids can induce acute psychosis which lasts beyond the period of acute intoxication but resolves within a month. Exposure to cannabis in adolescence is associated with a risk for later psychotic disorder in adulthood; this association is consistent, temporally related, shows a dose-response, and is biologically plausible. However, cannabis is neither necessary nor sufficient to cause a persistent psychotic disorder. More likely it is a component cause that interacts with other factors to result in psychosis. The link between cannabis and psychosis is moderated by age at onset of cannabis use, childhood abuse and genetic vulnerability. While more research is needed to better characterize the relationship between cannabinoid use and the onset and persistence of psychosis, clinicians should be mindful of the potential risk of psychosis especially in vulnerable populations, including adolescents and those with a psychosis diathesis.