JWH-122 Levonantradol (Nantrodolum). AM-694. HU-211. HU-345SR144528 JWH-133 Oleamide. Cannabicyclohexanol HU-239. JWH-007. JWH-200 RCS-4.
Synthetic Marijuana: A Clinician’s Conundrum Nitin Chopra MD, Cletus Carvalho MD Department of Psychiatry, University of Kentucky, Lexington, KY HISTORY OF PRESENT ILLNESS
LEARNING OBJECTIVES • Present a clinical case of a patient intoxicated on synthetic marijuana in the emergency room • Identify chemical components of synthetic marijuana • Describe treatment recommendations
BACKGROUND • Synthetic marijuana is the second most used illicit substance after cannabis • Synthetic marijuana is a $ 5 Billion per year industry Synthetic Marijuana Exposure Cases 700
600
Number of Cases Per Month
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Figure 1. Human exposures to synthetic marijuana (THC homologs) reported to poison centers. Data from American Association of Poison Control Centers.
• 26 year old African American female with two similar presentations to the emergency room in a one month span. • She reports almost daily use of “Serenity,” which she identified as synthetic marijuana. • She presented as confused, agitated, paranoid, and disorganized in her thoughts • She also reported vague sexually based delusions. • She had a self-reported history of Bipolar Disorder and Schizophrenia, neither of which could be verified through previous records or based on retrospective collateral history.
WHAT IS SYNTHETIC MARIJUANA ? • Over 100 identified street and commercial names for synthetic marijuana products AM-1220 AM-1221 AM-2201 AM-694 Cannabicyclohexanol CP-47,497 CP-55,940
Delta-9-THC Dimethylheptylpyran (DMHP) HU-210 HU-211 HU-239 HU-243 HU-308
HU-320 HU-331 HU-336 HU-345SR144528 JWH-007 JWH-018 JWH-019
JWH-073 JWH-081 JWH-122 JWH-133 JWH-200 JWH-203 JWH-210
JWH-250 JWH-398 Levonantradol (Nantrodolum) Oleamide RCS-4 RCS-8 WIN 55,212-2 WIN-48,098
Table 1: Some of the chemical components of synthetic cannabinoids identified and present in commercially available products.
CHEMICALS IDENTIFIED AS SCHEDULE I DIAGNOSTIC WORK-UP • • • •
CBC, CMP, and TSH were within normal limits Urine Drug Screen was positive for cannabinoids CT Brain with contrast was normal a quantitative synthetic cannabinoids analysis for metabolites of JWH-018, JWH-073, JWH-122, JWH-250, and RCS-4 was sent out and found to be negative.
CLINICAL COURSE • She was admitted to the inpatient psychiatric unit, requiring seclusion, and was initially started on risperidone 0.5 mg orally twice daily, which was titrated up to 1 mg orally twice daily on her first admission. • Her acute psychosis resolved within less than 72 hours on both admissions. SYNTHETIC MARIJUANA LAB TESTING • Urine sample collected and analyzed via liquid chromatography/tandem mass spectrometry • Turnaround time ranges from 4 to 15 days • Variation among panels for components analyzed • Most include at least JWH-018, JWH-250, CP 47, 497, HU-210, and Delta-9-THC CURRENT TREATMENT RECOMMENDATIONS • Symptom-based • No current literature comparing efficacy of anti-psychotics for managing psychosis secondary to “synthetic marijuana”
CLINICAL IMPLICATIONS • Challenge to distinguish synthetic marijuana from other designer drugs • Paucity of clinically relevant testing • Concern for recent surge in the context of legalization of marijuana • Consideration of effectiveness of high-potency anti-psychotic (eg. Risperidone) in the management of acute psychosis secondary to synthetic marijuana
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