Synthetic Cannabinoids and Their Implications on EMS

Your ambulance has been dispatched for a report of three male teenagers vomiting and acting disoriented at a park in your community. As your unit approaches the scene, you observe one teenage male apparently unconscious on the ground, a second on all fours vomiting and a third talking with a law enforcement officer. You consider the potential for a HAZMAT incident, but you can’t detect any indication of such other than the two individuals experiencing medical emergencies at the same location. You decide to call for a second ambulance to respond and approach the incident scene.

The officer greets you and informs you and your partner the three have been smoking “Spice.” As you partner begins a primary survey on the unconscious patient, the individual who was talking with the officer informs you he is having chest pain. Your partner reports the unconscious individual is only minimally responsive to verbal stimulus and has no apparent airway, breathing or circulatory compromise. The third patient continues to crawl around on the ground and dry heave. You decide to call for a third ambulance.

Background

Synthetic cannabinoids, also known as synthetic marijuana, are an emerging threat to the health and safety of the public. EMS practitioners nationwide are increasingly more likely to encounter a patient under the influence of these substances. 

Synthetic cannabinoids, whose popular brand names include “K2” and “Spice,” are designed to produce effects similar to marijuana. These substances are either smoked or ingested to achieve an intoxicating effect. The main psychoactive ingredient in marijuana is delta-9-tetrahydrocannabinol (∆⁹-THC). ∆⁹-THC “exhibits partial agonistic activity at CB1 cannabinoid receptors, found primarily in the central nervous system, and receptors in the periphery” (Seely, Lapoint, Moran, & Fattore, 2012). Synthetic cannabinoids (classic cannabinoids, cyclohexylphenols and aminoalkylindoles) are designed to produce effects similar to ∆⁹-THC and have been synthesized for recreational purposes for over a decade. The commercial products are a mixture of plant materials laced with these synthetic chemicals.

Synthetic cannabinoids were initially sold legally in convenience stores and head shops as products such as herbs or incense and labeled with a warning “not for human consumption” in order to avoid legal scrutiny. Realizing the threat these substances posed, many states passed laws to make them illegal. They were made federally illegal following the passage of the Synthetic Drug Abuse Prevention Act of 2012, which made synthetic cannabinoids a Schedule I Controlled Substance. Despite these substances being illegal they are still available via the Internet and from illegal distribution networks.

Epidemiology

The magnitude of the problem posed by synthetic cannabinoids continues to increase. A recent study found calls to poison control centers for adverse health effects from synthetic cannabinoids was 229% higher January-May in 2015 than during the same months in 2014 (Law, Schier, Martin, & Wolkin, 2015). The same study found 80% of the patients experiencing adverse health effects from synthetic cannabinoids were male, and the median age of the patients was 26 years. According to the American Association of Poison Control Centers, there were 7,779 exposures to synthetic cannabinoids reported to poison control centers nationwide in 2015.

Signs and symptoms

Clinical signs and symptoms of an adverse reaction to synthetic cannabinoids may include vomiting, tachycardia, hypertension, chest pain, agitation, drowsiness, lethargy, confusion, hallucinations, agitation, delirium, psychosis and seizures. Renal failure and acute kidney injury has been rarely reported as a result of synthetic cannabinoid use (Gudsoorkar & Perez, 2015). There have also been case reports of acute myocardial infarction in healthy teenagers following the use of synthetic cannabinoids (Seely, Lapoint, Moran, & Fattore, 2012). Emergency department laboratory testing commonly finds hypokalemia. There is currently no universally accepted laboratory test for determining the presence of synthetic cannabinoids, since the chemical compounds in these drugs change frequently.

Clinical assessment and treatment

It is invaluable for the EMS services practitioner to obtain a thorough history of the present illness and to alert the emergency department staff of the potential substance ingestion. If a pertinent history cannot be obtained directly from the patient, the practitioner may consider questioning other individuals present on the incident scene about any potential substance ingestion. Questioning should include whether the patient has ingested other drugs in addition to the synthetic cannabinoids. Carefully observe the incident site for important clues, including the presence of drug paraphernalia and the presence of synthetic cannabinoid product packaging. These findings will increase the suspicion of drug ingestion.

Pre-hospital treatment should focus on managing the airway, ensuring adequate ventilation and oxygenation and maintaining circulatory function. Treatment of these patients is largely symptomatic. ALS practitioners should consider antiemetic medications in the presence of vomiting in order to maintain patency of the airway. They should also consider administering benzodiazepines in the presence of seizures or agitated delirium.  

Safety and operational considerations

Safety of the EMS practitioner, the patient and bystanders is of paramount importance. This may require physical or chemical restraint of confused or combative patients. If restraints are utilized, do not place the patient in a prone position, since this has been linked with positional asphyxia. Law enforcement assistance should be considered, particularly if the patient requires physical restraint for the administration of sedative medications.

In some situations, such as the case presented above, there may be multiple patients to manage at these incidents. Requesting additional resources ensures each patient is appropriately cared for. The ICS is an effective tool for managing multiple patient incidents and the initial arriving practitioner should consider establishing command. 

Another available resource is the Poison Help line, maintained by the American Association of Poison Control Centers, which can be reached 24 hours a day at 1-800-222-1222.

Synthetic cannabinoids, and other designer drugs, will continue to present new challenges to EMS practitioners. Use of these substances continues to increase nationwide compared to previous years. Maintaining an awareness of the epidemiology and etiology of synthetic cannabinoids will enable the EMS practitioner to provide high-quality care to this group of patients.

Case conclusion

You established command and directed the second arriving ambulance to care for the patient with decreased level of consciousness first. You directed the third arriving ambulance to care for the patient crawling around and vomiting. Once care of the two patients has been initiated by the other crews, you terminate command. You and your partner then load the remaining patient into your ambulance. Your unit provides an ALS work-up and transportation to a local hospital.

References

American Association of Poison Control Centers. Synthetic marijuana, https://www.aapcc.org/alerts/synthetic-marijuana/.

Gudsoorkar, V. S., & Perez, J. A. A New Differential Diagnosis: Synthetic Cannabinoids-Associated Acute Renal Failure. Methodist DeBakey Cardiovascular Journal, 2015; 11(3): 189–191.

Hermanns-Clausen, M., Kneisel, S., Szabo, B., & Auwärter, V. Acute toxicity due to the confirmed consumption of synthetic cannabinoids: Clinical and laboratory findings. Addiction, 108(3): 534-544.

Law, R., Schier, J., Martin, C., Chang, A., & Wolkin, A. Notes from the field: Increase in reported adverse health effects related to synthetic cannabinoid use – United States, January – May 2015. Morbidity and Mortality Weekly Report (MMWR), 2015 June, 64(22): 618-619.

Rosenbaum, C. D., Carreiro, S. P., & Babu, K. M. Here Today, Gone Tomorrow…and Back Again? A Review of Herbal Marijuana Alternatives (K2, Spice), Synthetic Cathinones (Bath Salts), Kratom, Salvia divinorum, Methoxetamine, and Piperazines. Journal of Medical Toxicology, 2012, 8(1): 15–32.

Seely, K. A., Lapoint, J., Moran, J. H., & Fattore, L. Spice drugs are more than harmless herbal blends: a review of the pharmacology and toxicology of synthetic cannabinoids. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2012, 39(2): 234–243. 

Sean J. Britton, NRP, CPH, is the director of public health and a deputy EMS coordinator for Broome County, NY. He serves as the leader of the Broome County Health Department, which serves a population of 200,000 citizens with a staff of 100 and a $19 million annual budget. The department provides community health assessment, chronic disease prevention, injury prevention, family health services, communicable disease control, environmental health and emergency management. The department houses a licensed diagnostic and treatment center, a licensed home care services agency, and a registered limited service laboratory. As a deputy EMS coordinator, Sean assists to coordinate mutual aid among 11 ambulance agencies and 25 non-transporting agencies responding to 25,000 requests for service annually within Broome County. Sean is a paramedic at Superior Ambulance Service, a 13,000 runs-per-year ambulance service providing 911-system response and inter-facility transfers within Broome County. Sean is an adjunct instructor of Criminal Justice & Emergency Services at SUNY Broome Community College. Sean is an active member of the National Association of Emergency Medical Technicians (NAEMT), where he currently serves as a board member.