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In their pure form, synthetic cannabinoids are either solids or oils. They are then added to dried herbs, vegetable matter or plant cuttings to make a smoking mixture so that it looks more like real herbal cannabis. The smoking mixtures are packaged in small, often colourful sachets with labels describing the contents as incense or herbal smoking mixture, and usually stating 'not for human consumption'. There are many different names given to herbal smoking mixtures, some of the most common are listed in the 'Also called' section at the top of the. There are many different brand names for smoking mixtures, but it is not uncommon for different brands to contain the same synthetic cannabinoids. Synthetic cannabinoids are normally used in a similar way to cannabis :.
Try out PMC Labs and tell us what you think. Learn More. Use of new psychoactive substances NPS has increased over the last decade.
During this period, variability of both clinical presentations and chemical compositions of these compounds has increased. Synthetic cannabinoids SCs are the most commonly used NPS and there are more than documented unique molecules in this class.
It has been linked to kidney injury, myocardial toxicity, seizures, and death. P SCAN is a geographically representative group of academic hospitals that capture clinical presentation, outcome, and biologic samples from patients that present for emergency stabilization following NPS use. Serum and urine samples were analyzed and quantified by liquid chromatography-quadrupole time-of-flight mass spectrometry after a qualitative screen for over unique NPS compounds.
In the reported eight cases, the median age was 28 years old. There were four male and four females. Normal saline, benzodiazepines and ondansetron Black mamba synthetic the common treatment provided in the emergency department ED.
Two patients were discharged from the ED and six patients being admitted for emergency observation with a median length of stay LOS of six hours. No deaths were reported. Confirmatory testing revealed that only five patients New psychoactive substances NPS are the fastest growing class of illicit drugs in the United States [ 1 ]. Their potency and molecular variability have contributed to numerous outbreaks of severe clinical illness [ 12 ].
Synthetic cannabinoid SC use, a subclass of NPS, has increased dramatically over the last decade [ 13 — 5 ].
Buyers quickly found an intoxicating substance they could purchase legally. Illness associated with SCs ranges from mild nausea [ 6 ], kidney failure [ 7 ], cerebrovascular accidents, seizures [ 8 ], myocardial toxicity [ 9 ] and death [ 7 ]. There is a lack of quality control in the manufacturing of these products and subsequently, buyers may not receive the drug they intended to buy. Patients continue to present for emergency stabilization following reported use of Black Mamba though clinical presentations and response to treatment vary widely.
There are multiple possible explanations for this wide range of clinical illness. Variability in dose, adulteration with other illicit drugs, or substitution with other more dangerous drugs all may contribute.
These cases were collected between August and November, Briefly, this consortium prospectively collects de-identified clinical data and biologic samples from patients that present for emergency stabilization after NPS use. P SCAN is a geographically representative group of academic emergency departments with medical toxicology co-investigators. Patients are eligible for the study if they endorse NPS use, or if the ED provider determines NPS use is the most likely etiology of the patients symptoms.
A medical toxicologist records the clinical data obtained during the index visit and de-identified biologic samples are collected for analysis. Patients verbally consent for the study. This study was approved by the local institutional review board and the P SCAN protocol is approved at each individual consortium site. Blood was obtained Black mamba synthetic arrival when an intravenous catheter was placed. Urine was obtained at the time patient went to use the restroom or a Foley catheter was placed. Any drug or paraphilia found with the patient was confiscated and tested if possible.
Samples were stored on ice for less than 12 hours.
Samples were then shipped on dry ice to the reference laboratory at the University of California-San Francisco for drug identification. For qualitative screening, non-targeted data acquisition was performed during the sample run followed by targeted data analysis using a reference database of compounds with known retention times. Suspect screening of parent drug or metabolites including novel SCsstimulants cathinones and phenethylamineshallucinogens arycyclohexylamines and tryptamines and depressants opioid analogs, barbiturates and benzodiazepines was also performed see online appendix A for the full list of drugs and metabolites detected by this assay.
Quantification of each confirmed drug was done using point calibration curve by isotope dilution using deuterated internal standards. We utilized descriptive statistics to describe demographic data, clinical presentation variables, treatments, and drug identification.
Between August 1 and November 30,eight patients presented to our emergency department with reported smoking of Black Mamba and all presented with acute intoxication; there were four males and four females with a median age of 28 range: 16—43 Table 1.
Chest pain was present in four presentations and one had T-wave inversions on electrocardiogram. One patient, with a seizure history, had a generalized tonic—clonic seizure.
All but one case had elevated blood pressures with a median blood pressure of mmHg systolic and 87 mmHg diastolic. Only two cases presented with a heart rate greater than beats per minute bpm. Two patients were hypokalemic 2. The remainder of the laboratory testing was within normal limits. The urine immunoassay screen for Case 5 was negative and three cases did not have the urine screen performed. Four patients received either diazepam or lorazepam for agitation.
One of these patients also received haloperidol and diphenhydramine in addition to the lorazepam for agitation.
What is synthetic cannabis and why is it called the zombie drug?
Three patients had full resolution of agitation and one patient had partial resolution of symptoms after receiving sedatives. Four patients received ondansetron for nausea. Three patients received at least 1 l of normal saline. Other treatments received were directed towards the clinical presentations of seizure and chest pain Table 1. Six patients were admitted to an emergency observation unit until their symptoms resolved. Two were discharged directly from the ED after resolution of symptoms. The median length of stay LOS for seven patients was six hours range: 2—10 hours.
One patient had a LOS of 26 hours due to social complications around housing with resolution of symptoms within the first few hours. All patients had normal vitals at discharge. A wide variety of xenobiotics Black mamba synthetic confirmed in blood and urine samples Table 2. Only Of the confirmed cases, a variety of SCs were detected.
There was no correlation between confirmed drug and clinical symptoms i.
The concentration ranges observed for the metabolites are All three have high affinities for the CB1 receptor, which causes their clinical effects. All of the NPS and most of the psychoactive xenobiotics identified are known to cause agitation, delirium, tachycardia, hypertension, hyperthermia, seizures, multi-system organ failure and potentially death.
However, the pathophysiology of the elicited clinical effects varies considerably between the agents. Most users likely prefer a known drug in a known dose for predictable clinical effects and ease of titration. Variability in drug and dose complicates the ideal emergency treatment strategy given that anti-dopamine, serotonin antagonists, or GABA antagonism may be preferred, depending upon the agent ingested.
It is impossible for clinicians and public health officials to have a uniform approach that keeps SC users safe. Increasing chemical variability, rising potency, clandestine methods of production and sale le to reactive rather than proactive identification of potentially harmful NPS drugs. The Analog Act of aimed to schedule synthetic Black mamba synthetic of drugs such as methamfetamine and meperidine as Schedule I illicit substances.
We further demonstrate that NPS can contain a variety of xenobiotics, many with new variations of chemical structures. This highlights the need for a more proactive surveillance and drug enforcement strategy. Despite the efforts of congress and medical researchers, the continuing rapid evolution of NPS continues to have serious implications for both healthcare providers and law enforcement.
Users are prone to severe clinical illness due to variability in the products they consume. Our data demonstrate a wide range of drugs sold under the Black Mamba product name Table 2. While some argue that patients are disingenuous about their drug ingestion history in the ED, this cohort is unique in that all patients freely admitted to use illegal substances. However, the drug they ingested was not what they believed they ingested The variability in half-lives of different SCs can further complicate laboratory confirmation. SCs that are quickly metabolized may not be detected without proper testing methods.
We believe clinical history and confirmatory drug testing discordance is more likely due to product variability than misleading patient histories given their admission of use and confirmation with an extremely sensitive testing methodology. These findings present a plausible explanation for the variability of clinical symptoms of Black Mamba in Colorado and this problem is likely pervasive with other NPS drugs sold with brand Black mamba synthetic recognition.
This molecular infidelity should be used in public health messaging to educate prospective users about the inherent risks of product discordance. This consortium provides the framework for rapid molecular identification, which may limit progression of future outbreaks due to emerging NPS-induced clinical illness. Black Mamba is one of many SCs sold using brand name recognition. Consumers believe they are receiving a specific product with anticipated effects though they actually receive a wide range of illicit drugs.
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These findings should prompt public health substance abuse education targeted at prospective SC users. Monte has a patent pending for a synthetic cannabinoid clinical assay.
The contents of this work are the sole responsibility of the authors and do not necessarily represent the views of the National Institutes of Health NIH. Supplemental data for this article can be accessed here. National Center for Biotechnology InformationU.