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Prete MM, Feitosa GTB, Ribeiro MAT, Fidalgo TM, Sanchez ZM. Adverse clinical effects associated with the use of synthetic cannabinoids: A systematic review. Drug Alcohol Depend 2025; 272:112698. [PMID: 40334326 DOI: 10.1016/j.drugalcdep.2025.112698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Revised: 04/18/2025] [Accepted: 04/21/2025] [Indexed: 05/09/2025]
Abstract
Synthetic cannabinoids (SCs) are potent agonists of CB1 and CB2 receptors, with affinities approximately 100 times greater than that of natural cannabis. This increased potency is associated with severe clinical outcomes, including psychosis, dependence, and various autonomic disturbances, such as seizures and rhabdomyolysis. The objective of this study was to synthesize the existing literature on the clinical effects of SCs, emphasizing health risks and identifying knowledge gaps. Following PRISMA guidelines, a comprehensive search was conducted across three databases-PubMed, Embase, and Lilacs-resulting in 944 studies. Eligible articles focused on clinical effects associated to SC use, while exclusion criteria encompassed studies unrelated to clinical outcomes, other reviews, animal studies, and those concentrating solely on psychiatric symptoms or therapeutic uses of SCs. In total, 49 studies published between 2010 and 2022 were included, representing diverse populations and study designs. Participants were predominantly young adult males, although ages ranged from 12 to 72 years. SCs' clinical effects predominantly affected the neurological and cardiovascular systems, with common symptoms including seizures, altered consciousness, tachycardia, and hypertension. Hospital and ICU admissions varied, reflecting the complex nature of SC toxicity. Compared to cannabis, SC use was linked to more severe cardiovascular and neurological complications. Additional rare complications included thromboembolic events, immune thrombocytopenic purpura, and psychiatric disturbances. This review highlights the urgent need for targeted public health policies to mitigate the risks associated with SC use and improve medical management. It also stresses the importance of further controlled studies to elucidate the underlying mechanisms of these clinical effects and their pharmacological basis.
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Affiliation(s)
- Mariana M Prete
- Departamento de Medicina Preventiva, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Gabriel T B Feitosa
- Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Maria A T Ribeiro
- Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - T M Fidalgo
- Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Zila M Sanchez
- Departamento de Medicina Preventiva, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.
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Kader A, Hermanns-Clausen M, van Riel A, Faber K, Hondebrink L. Advancing toxicovigilance of recreational drugs, including new psychoactive substances, by using data from four European poison centres. Clin Toxicol (Phila) 2025; 63:23-31. [PMID: 39635984 DOI: 10.1080/15563650.2024.2430311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 11/08/2024] [Accepted: 11/11/2024] [Indexed: 12/07/2024]
Abstract
INTRODUCTION Common recreational drugs and new psychoactive substances pose challenges to public health. This study investigated the feasibility of merging cases of recreational drug poisoning reported to European poison centres. METHODS Four European poison centres (Freiburg, Germany; the Netherlands; Sweden and Switzerland) collaborated in a retrospective, observational study. We collected aggregated data on poisonings with 11 common recreational drugs and case-by-case data on poisonings with new psychoactive substances in 2021 by using anonymized data from electronic case reports. RESULTS In 2021, 2.0% of the poison centre calls involved poisonings with recreational drugs. The poison centres were contacted about 3,705 patients, involving 4,380 drug exposures, of which 3,708 were common recreational drugs, and 672 were new psychoactive substances. Per million inhabitants, the poisoning rate with common recreational drugs varied between 48 (Freiburg) and 145 (Sweden). Poisonings with amfetamine (22%), cocaine (20%), all delta-9-tetra-hydrocannabinol-containing preparations (20%), and 3,4-methylenedioxymetamfetamine (13%) exposures were most frequent. The poisoning rate per million inhabitants with new psychoactive substances varied between two (Switzerland) and 29 (Netherlands). Cathinones (43%), designer benzodiazepines (28%), and phenethylamines (13%) were the most commonly involved new psychoactive substance classes. Symptoms following cathinone poisoning were tachycardia (35%) and hypertension (13%), while following designer benzodiazepines, somnolence was most prominent (38%). The majority of users of new psychoactive substances were male (67%), 55% were between 18 and 30 years, and 8% involved minors (<18 years). DISCUSSION This study showed the feasibility of merging data on recreational drug poisoning collected by poison centres in four countries. Despite underestimating the overall incidence of drug-related health incidents, poison centre data offers national coverage, unlike other data sources, such as drug-related emergency department visits. CONCLUSION This multi-centre, multi-national study reported a substantial annual number of recreational drug poisonings, with a variable proportion of new psychoactive substances. It shows that poison centre data offers detailed insights into exposures to common recreational drugs and new psychoactive substances, user characteristics, and symptoms. It can be used for comprehensive monitoring of drug-related health incidents on a multi-national level.
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Affiliation(s)
- Aza Kader
- Swedish Poisons Information Centre, Stockholm, Sweden
| | - Maren Hermanns-Clausen
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Poisons Information Center, Center for Pediatrics, University of Freiburg, Freiburg, Germany
| | - Antoinette van Riel
- Dutch Poisons Information Centre, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Katrin Faber
- Tox Info Suisse, National Poisons Information Centre, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Laura Hondebrink
- Dutch Poisons Information Centre, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Vallersnes OM, Dines AM, Wood DM, Heyerdahl F, Hovda KE, Yates C, Giraudon I, Caganova B, Ceschi A, Galicia M, Liakoni E, Liechti ME, Miró Ò, Noseda R, Persett PS, Põld K, Schmid Y, Scholz I, Vigorita F, Dargan PI. Self-discharge during treatment for acute recreational drug toxicity: an observational study from emergency departments in seven European countries. Int J Emerg Med 2023; 16:86. [PMID: 38030969 PMCID: PMC10685690 DOI: 10.1186/s12245-023-00566-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge. METHODS From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one's own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge. RESULTS Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10-1.89), as were heroin, 1.44 (1.26-1.64), agitation, 1.27 (1.10-1.46), and naloxone treatment, 1.27 (1.07-1.51), while sedation protected from self-discharge, 0.38 (0.30-0.48). CONCLUSION One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge.
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Affiliation(s)
- Odd Martin Vallersnes
- Department of General Practice, University of Oslo, PB 1130, Blindern, Oslo, 0318, Norway.
- Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway.
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Erik Hovda
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma, Spain
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Blazena Caganova
- National Toxicological Information Centre, University Hospital, Bratislava, Slovakia
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Miguel Galicia
- Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias E Liechti
- Clinical Pharmacology and Toxicology, University Hospital and University of Basel, Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Kristiina Põld
- Emergeny Medicine Department, North-Estonia Medical Centre, Tallinn, Estonia
| | - Yasmin Schmid
- Clinical Pharmacology and Toxicology, University Hospital and University of Basel, Basel, Switzerland
| | - Irene Scholz
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Bonner E, Chang Y, Christie E, Colvin V, Cunningham B, Elson D, Ghetu C, Huizenga J, Hutton SJ, Kolluri SK, Maggio S, Moran I, Parker B, Rericha Y, Rivera BN, Samon S, Schwichtenberg T, Shankar P, Simonich MT, Wilson LB, Tanguay RL. The chemistry and toxicology of vaping. Pharmacol Ther 2021; 225:107837. [PMID: 33753133 PMCID: PMC8263470 DOI: 10.1016/j.pharmthera.2021.107837] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 12/20/2022]
Abstract
Vaping is the process of inhaling and exhaling an aerosol produced by an e-cigarette, vape pen, or personal aerosolizer. When the device contains nicotine, the Food and Drug Administration (FDA) lists the product as an electronic nicotine delivery system or ENDS device. Similar electronic devices can be used to vape cannabis extracts. Over the past decade, the vaping market has increased exponentially, raising health concerns over the number of people exposed and a nationwide outbreak of cases of severe, sometimes fatal, lung dysfunction that arose suddenly in otherwise healthy individuals. In this review, we discuss the various vaping technologies, which are remarkably diverse, and summarize the use prevalence in the U.S. over time by youths and adults. We examine the complex chemistry of vape carrier solvents, flavoring chemicals, and transformation products. We review the health effects from epidemiological and laboratory studies and, finally, discuss the proposed mechanisms underlying some of these health effects. We conclude that since much of the research in this area is recent and vaping technologies are dynamic, our understanding of the health effects is insufficient. With the rapid growth of ENDS use, consumers and regulatory bodies need a better understanding of constituent-dependent toxicity to guide product use and regulatory decisions.
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Affiliation(s)
- Emily Bonner
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Yvonne Chang
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Emerson Christie
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Victoria Colvin
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Brittany Cunningham
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Daniel Elson
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Christine Ghetu
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Juliana Huizenga
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Sara J Hutton
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Siva K Kolluri
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Stephanie Maggio
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Ian Moran
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Bethany Parker
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Yvonne Rericha
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Brianna N Rivera
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Samantha Samon
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Trever Schwichtenberg
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Prarthana Shankar
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Michael T Simonich
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Lindsay B Wilson
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA
| | - Robyn L Tanguay
- Department of Environmental and Molecular Toxicology, Sinnhuber Aquatic Research Laboratory, Environmental Health Sciences Center, Oregon State University, Corvallis, OR, USA.
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5
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Zawatsky CN, Abdalla J, Cinar R. Synthetic cannabinoids induce acute lung inflammation via cannabinoid receptor 1 activation. ERJ Open Res 2020; 6:00121-2020. [PMID: 32832534 PMCID: PMC7430153 DOI: 10.1183/23120541.00121-2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/18/2020] [Indexed: 01/08/2023] Open
Abstract
Synthetic cannabinoid (SC) use has persisted in the United States despite schedule-1 placement under the Synthetic Drug Abuse Prevention Act of 2012 [1]. Analysis of the National Poison Data System indicates that hospitalisations caused by SC use increased significantly between 2010 and 2015 [2]. Moreover, there is a trend of the increasing use of such compounds among adolescents [3]. SCs are often 30–100-fold more potent than Δ9-tetrahydrocannabinol (THC), the major psychoactive ingredient of cannabis, in activating Cannabinoid receptor 1 (CB1R). Users are attracted to SCs because of the cheaper, novel and stronger highs such substances offer compared to cannabis, and because the compounds are not screened for in typical drug tests [1, 2]. Among those hospitalised for SC use, some patients exhibited respiratory failure [4–7], pulmonary infiltrates [5, 7], alveolar damage or haemorrhage [5–7] and histopathologic features similar to organising pneumonia [4–6]. The mechanism by which SCs damage pulmonary tissue has yet to be elucidated – whether by SC binding at CB1R, CB2R or another receptor, and what downstream effects such binding elicits. Solving this conundrum is the first step in optimising treatment for patients presenting with SC-related respiratory distress. Synthetic cannabinoids (SCs) induce a pro-inflammatory condition by activating cannabinoid receptor 1 (CB1R) in the lungs of mice, which raises a potential therapeutic use of CB1R antagonists in SC-induced lung disease resulting in hospitalisationhttps://bit.ly/31bWw4Q
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Affiliation(s)
- Charles N Zawatsky
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, MD, USA.,These authors contributed equally
| | - Jasmina Abdalla
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, MD, USA.,These authors contributed equally
| | - Resat Cinar
- Laboratory of Physiologic Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, MD, USA
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Evidence of enzyme-mediated transesterification of synthetic cannabinoids with ethanol: potential toxicological impact. Forensic Toxicol 2019. [DOI: 10.1007/s11419-019-00491-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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7
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Palamar JJ, Le A. Use of new and uncommon synthetic psychoactive drugs among a nationally representative sample in the United States, 2005-2017. Hum Psychopharmacol 2019; 34:e2690. [PMID: 30843283 PMCID: PMC6534815 DOI: 10.1002/hup.2690] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES This study aims to examine patterns and first mentions of reported use of new or uncommon drugs across 13 years, among nationally representative samples in the United States. METHODS Participants (ages ≥12) in the National Surveys on Drug Use and Health (2005-2017, N = 730,418) were provided opportunities to type in names of new or uncommon drugs they had ever used that were not specifically queried. We examined self-reported use across survey years and determined years of first mentions. RESULTS From 2005 to 2017, there were 2,343 type-in responses for use of 79 new or uncommon synthetic drugs, and 54 were first-ever mentions of these drugs. The majority (65.8%) of mentions were phenethylamines (e.g., 2C-x, NBOMe), which were also the plurality of new drug mentions (n = 22; 40.7%). Mentions of 2C-x drugs in particular increased from 30 mentions in 2005 to 147 mentions in 2013. We estimate an upward trend in use of new or uncommon drugs between 2005 and 2017 (p < 0.001). CONCLUSION Although type-in responses on surveys are limited and underestimate prevalence of use, such responses can help inform researchers when new compounds are used. Continued surveillance of use of new and uncommon drugs is needed to inform adequate public health response.
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Affiliation(s)
- Joseph J. Palamar
- Department of Population Health, New York University Langone Medical Center, New York, New York, USA
| | - Austin Le
- Department of Population Health, New York University Langone Medical Center, New York, New York, USA
- New York University College of Dentistry, New York, New York, USA
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