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Acute toxicity due to the confirmed consumption of synthetic cannabinoids: clinical and laboratory findings.

AIMS Recently, several synthetic cannabinoids were identified in herbal mixtures consumed as recreational drugs alternative to cannabis products. The aim was to characterize the acute toxicity of synthetic cannabinoids as experienced by emergency patients. DESIGN This was a retrospective study targeting patients seeking emergency treatment after recreational use of synthetic cannabinoids. SETTING AND PARTICIPANTS Patients were selected from the database of the Poisons Information Center Freiburg between September 2008 and February 2011. The inclusion criteria were: hospitalization, available clinical reports and analytical verification of synthetic cannabinoid uptake. In total, 29 patients were included (age 14-30 years, median 19; 25 males, four females). MEASUREMENTS Clinical reports were evaluated and synthetic cannabinoids and other drugs were determined analytically. FINDINGS CP-47,497-C8 (one), JWH-015 (one), JWH-018 (eight), JWH-073 (one), JWH-081 (seven), JWH-122 (11), JWH-210 (11), JWH-250 (four) and AM 694 (one) were quantified in blood samples. JWH-018 was most common in 2008-9, JWH-122 in 2010, and JWH-210 in 2011. Tachycardia, agitation, hallucination, hypertension, minor elevation of blood glucose, hypokalaemia and vomiting were reported most frequently. Chest pain, seizures, myoclonia and acute psychosis were also noted. CONCLUSIONS There appears to have been an increase in use of the extremely potent synthetic cannabinoids JWH-122 and JWH-210. Acute toxic symptoms associated with their use are also reported after intake of high doses of cannabis, but agitation, seizures, hypertension, emesis and hypokalaemia seem to be characteristic to the synthetic cannabinoids, which are high-affinity and high-efficacy agonists of the CB(1) receptor. Thus, these effects are due probably to a strong CB(1) receptor stimulation.

Driving under the influence of synthetic cannabinoids (“Spice”): a case series

Recreational use of synthetic cannabinoid receptor agonists—so-called “Spice” products—became very popular during the last few years. Several reports on clinical symptoms and poisonings were published. Unfortunately, most of these reports do not contain any analytical data on synthetic cannabinoids in body fluids, and no or only a limited number of cases were reported concerning driving under the influence (DUI) of this kind of drugs. In this article, several cases of DUI of synthetic cannabinoids (AM-2201, JWH-018, JWH-019, JWH-122, JWH-210, JWH-307, MAM-2201 (JWH-122 5-fluoropentyl derivative), and UR-144) are presented, focusing on analytical results and signs of impairment documented by the police or the physicians who had taken the blood sample from the suspects. Consumption of synthetic cannabinoids can lead to impairment similar to typical performance deficits caused by cannabis use which are not compatible with safe driving. These deficits include centrally sedating effects and impairment of fine motor skills necessary for keeping the vehicle on track. Police as well as forensic toxicologists and other groups should become familiar with the effects of synthetic cannabinoid use, and be aware of the fact that drug users may shift to these “legal” alternatives due to their nondetectability by commonly used drug screening tests based on antibodies. Sophisticated screening procedures covering the complete range of available compounds or their metabolites have to be developed for both blood/serum and urine testing.

Characteristics of the designer drug and synthetic cannabinoid receptor agonist AM-2201 regarding its chemistry and metabolism.

Aminoalkylindoles, a subclass of synthetic cannabinoid receptor agonists, show an extensive and complex metabolism in vivo, and due to their structural similarity, they can be challenging in terms of unambiguous assignment of metabolic patterns in urine samples to consumed substances. The situation may even be more complicated as these drugs are usually smoked, and the high temperature exposure may lead to formation of artifacts. Typical metabolites of JWH-018 (Naphthalen-1-yl(1-pentyl-1H-indol-3-yl)methanone) were reportedly detected not only in urine samples collected after consumption of JWH-018 but also after AM-2201 (1-(5-fluoropentyl-1H-indol-3-yl)-(naphthalene-1-yl)methanone) use. The aim of the presented study was to evaluate if typical JWH-018 metabolites can be formed metabolically in humans and if JWH-018 may be formed artifactually during smoking of AM-2201. Therefore, one of the authors ingested 5 mg of pure AM-2201, and serum as well as urine samples were analyzed subsequently. Additionally, the smoke condensate from a cigarette laced with pure AM-2201 was investigated. In addition, urine samples of patients after known consumption of AM-2201 or JWH-018 were evaluated. The results of the study prove that typical metabolites of JWH-018 and JWH-073 are built in humans after ingestion of AM-2201. However, the N-(4-hydroxypentyl) metabolite of JWH-018, which is the major metabolite after JWH-018 use, was not detected after the self-experiment. In the smoke condensate, small amounts of JWH-018 and JWH-022 (Naphthalen-1-yl[1-(pent-4-en-1-yl)-1H-indol-3-yl]methanone) were detected. Nevertheless, the results of our study suggest that the amounts absorbed by smoking do not significantly influence the metabolic pattern in urine samples. Therefore, the N-(4-hydroxypentyl) metabolite of JWH-018 can serve as a valuable marker to distinguish consume of products containing AM-2201 from JWH-018 use.

Intrahepatic Cholestasis Following Abuse of Powdered Kratom (Mitragyna speciosa)

IntroductionKratom (Mitragyna speciosa) is a common medical plant in Thailand and is known to contain mitragynine as the main alkaloid. According to an increase in published reports and calls at German poison control centers, it has been used more frequently as a drug of abuse in the western hemisphere during the last couple of years. Despite this increase, reports of severe toxicity are rare within the literature.Case reportWe describe a case of a young man who presented with jaundice and pruritus after intake of kratom for 2 weeks in the absence of any other causative agent. Alkaloids of M. speciosa were detected in the urine.ConclusionWhile M. speciosa is gaining in popularity among illicit drug users, its adverse effects remain poorly understood. This is the first published case of intrahepatic cholestasis after kratom abuse.

Acute intoxication by synthetic cannabinoids – Four case reports

receptor-mediated effectsare changes in mood, pain perception, state of arousal, bodytemperature, cardiovascular regulation, and food intake.Recently, synthetic cannabinoids appeared on the drugmarket, mostly as undeclared additives in ‘herbal mixtures’ namedfor example ‘Spice’, ‘Lava Red’ or ‘Jamaican Gold’. The use ofsynthetic cannabinoids is driven by several factors. After the intro-duction of new compounds, their use is initially not restricted byprohibition. Moreover, their consumption cannot be verified bystandard drug tests, which is particularly interesting for peoplefacing regular drugtesting.Easy accessvia the Internetand afford-ability also contribute to the popularity of these drugs.Since their first detection in herbal mixtures,

Identification of the cannabimimetic AM-1220 and its azepane isomer (N-methylazepan-3-yl)-3-(1-naphthoyl)indole in a research chemical and several herbal mixtures

Recently, a large number of synthetic cannabinoids have been identified in herbal mixtures. Moreover, an even higher number of cannabimimetic compounds are currently distributed as research chemicals on a gram to kilogram scale via several online trading platforms. As this situation leads to a large number of new cannabimimetics and the occurrence of isobaric substances, the analysis of such compounds using mass spectroscopy (MS) involves the risk of incorrect assignments of mass spectra. In certain cases, this leads to considerable analytical challenges. In the majority of cases, these challenges can only be mastered by combining multiple analytical techniques. We purchased a so-called research chemical advertised as the cannabimimetic compound [(N-methylpiperidin-2-yl)methyl]-3-(1-naphthoyl)indole (AM-1220) via an Internet platform. Analysis of the microcrystalline substance using gas chromatography (GC)–MS indicated the presence of pure AM-1220. However, after further purity testing utilizing thin-layer chromatography we were surprised to see an additional spot indicating a mixture of two substances with highly similar physicochemical properties. After isolation, high-resolution mass spectroscopy (HR-MS) revealed an elemental composition of C26H26N2O for both substances, proving the presence of two isobaric substances. Moreover, GC–MS and LC-HR-MS/MS experiments indicated two naphthoylindoles featuring different heterocyclic substituents at the indole nitrogen. Nuclear magnetic resonance spectroscopy verified the presence of the highly potent cannabimimetic AM-1220 and its azepane isomer. Interestingly, only a few weeks after purchasing the powder we also detected both substances in a similar proportion in several herbal mixtures for the first time.

Hair analysis for THCA-A, THC and CBN after passive in vivo exposure to marijuana smoke

Condensation of marijuana smoke on the hair surface can be a source of an external contamination in hair analysis and may have serious consequences for the person under investigation. Δ9-tetrahydrocannabinolic acid A (THCA-A) is found in marijuana smoke and in hair analysis, but is not incorporated into the hair through the bloodstream. Therefore it might be a promising marker for external contamination of hair and could facilitate a more accurate interpretation of analytical results. In this study, three participants were exposed to the smoke of one joint every weekday over three weeks. Inhalation was excluded by an alternative breathing source. Hair samples were obtained up to seven weeks after the last exposure and analyzed for THCA-A, Δ9-tetrahydrocannabinol (THC) and cannabinol (CBN) by liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Additionally 30 hair samples from various regions of the head were obtained seven weeks after the exposure from one participant. The obtained results show that the degree of contamination depends on the hair length, with longer hair resulting in higher THC and CBN concentrations (1300 pg/mg and 530 pg/mg at the end of the exposure period) similar to the ones typically found after daily cannabis consumption. THCA-A could be detected in relatively low concentrations. Analysis of the distribution of the contamination showed that the posterior vertex region was affected most. The relatively low THCA-A concentrations in the samples suggest that most of the THCA-A found in forensic hair samples is not caused by sidestream marijuana smoke, but by other sources.

Designer benzodiazepines: A new challenge

In the February 2015 issue of World Psychiatry, Schifano et al (1) gave an overview of novel psychoactive substances and their potentially harmful effects. They highlighted that in the last couple of years the number of drugs offered via Internet shops has increased dramatically and that benzodiazepines are often used to treat intoxications with these drugs in the clinical setting. We would like to point out that designer benzodiazepines have become a rapidly growing class of drugs of abuse in their own right in the last two years. We believe that mental health professionals should be aware of this new development. The first designer benzodiazepines available online were diclazepam, flubromazepam and pyrazolam (2–4). Recently, five others became readily available (i.e., clonazolam, deschloroetizolam, flubromazolam, nifoxipam and meclonazepam), none of which has been approved for medicinal use in any country. Nearly all of these compounds have been synthesized as drug candidates by pharmaceutical companies and their syntheses, as well as basic animal testing data, are described in the literature along with many more potential successors (5). Typical formulations are tablets, capsules or blotters in various doses. Furthermore, the drugs are also offered as pure powders with prices as low as 5-10 US cents per dose. Immunochemical tests applied in clinical settings and drug rehabilitation detect most of the designer benzodiazepines with sufficient sensitivity. However, the mass spectrometric methods needed for confirmation do not regularly cover the latest designer benzodiazepines, due to lack of reference materials. Practitioners should be aware of this limitation and carefully assess seemingly “false-positive” results. Due to their high potency, compounds like clonazolam or flubromazolam can cause strong sedation and amnesia at oral doses as low as 0.5 mg. Such low doses are extremely difficult to measure for users handling bulk materials, and tablets often vary greatly in the content of the active ingredient. This can lead to unintended overdosing, and could also be of concern in drug facilitated crimes (6). Designer benzodiazepines are often taken as “self-medication” by users of stimulant and hallucinogenic drugs, leading to “upper downer cycles” (7) and risk of severe addiction in people frequenting the party scene. Persons with anxiety disorders also tend to self-medicate on these drugs if a medical prescription cannot be obtained (8). The high availability of these drugs via online vendors and the low price may facilitate development of addiction in this population. Many “classical” benzodiazepines are listed in Schedule 4 of the 1971 United Nations Convention. They are also in Schedule IV of the U.S. Controlled Substances Act, but it is unclear if designer benzodiazepines are covered by the Controlled Substances Analogue Enforcement Act, 1986. Similar legal problems exist in most other countries in the world, making it difficult to reduce availability of these dangerous new drugs.

Characterization of the four designer benzodiazepines clonazolam, deschloroetizolam, flubromazolam, and meclonazepam, and identification of their in vitro metabolites

In 2012, the first designer benzodiazepines were offered in Internet shops as an alternative to prescription-only benzodiazepines. Soon after these compounds were scheduled in different countries, new substances such as clonazolam, deschloroetizolam, flubromazolam, and meclonazepam started to emerge. This article presents the characterization of these four designer benzodiazepines using nuclear magnetic resonance spectroscopy, gas chromatography–electron ionization-mass spectrometry, liquid chromatography–tandem mass spectrometry, liquid chromatography–quadrupole time-of-flight-mass spectrometry, and infrared spectroscopy. The major in vitro phase I metabolites of the substances were investigated using human liver microsomes. At least one monohydroxylated metabolite was identified for each compound. Dihydroxylated metabolites were found for deschloroetizolam and flubromazolam. For clonazolam and meclonazepam, signals at mass-to-charge ratios corresponding to the reduction of the nitro group to an amine were observed. Desalkylations, dehalogenations, or carboxylations were not observed for any of the compounds investigated. Furthermore, for clonazolam and meclonazepam, no metabolites formed by a combination of reduction and mono-/dihydroxylation were detected. This knowledge will help to analyze these drugs in biological samples.

Urine tested positive for ethyl glucuronide and ethyl sulfate after the consumption of yeast and sugar

BACKGROUND To an increasing degree, EtG and EtS are routinely used for the proof of abstinence for purposes of traffic, occupational, addiction and social medicine. This routine use demands further investigations on the sensitivity and specificity of these analytes and the examination of possible genesis of positive EtG and EtS concentrations even without the consumption of ethanol. In vivo fermentation with consecutive formation of EtG and EtS was addressed by experiments with yeast products. METHODS Two experiments with bakers yeast and brewers yeast tablets were performed. The ethanol concentrations in urine of the 2 and 4 volunteers, respectively, were detected by HS-GC-FID, EtG and EtS analysis was performed by LC-ESI-MS/MS, and the creatinine concentration was determined using a method based on the Jaffé reaction. RESULTS AND CONCLUSIONS After the consumption of bakers yeast the maximum concentrations of EtG and EtS normalised to creatinine were found to be 0.67 and 1.41mg/L, respectively, and therefore clearly above the commonly applied cut-off value for the proof of abstinence of 0.1mg/L. In contrast, in this study the, uptake of yeast tablets did not result in a detection of EtG and EtS in urine.