Saturday, April 7, 2018

CDC Warning - Vitamin K Dependent Antagonist Coagulopathy Associated With Synthetic Cannabinoid Use

Looks like the issue has spread - which isn't all that surprising. But is frightening.

The Center for Disease Control (CDC) issued a warning regarding the surge in severe bleeding cases associated with synthetic cannabinoid use from Illinois. From March 10 to April 5, 2018, ninety-four (94) people have presented to the hospital with severe bleeding symptoms after exposure to herbal incense/potpourri synthetic cannabinoid products. Eighty nine (89) of the cases are in Illinois, with the remaining five (5) originating in Indiana, Maryland, Missouri, and Wisconsin. There has been positive analytical confirmation of Brodifacoum in at least eighteen (18) individuals, with two (2) fatalities. Brodifacoum has been identified as a constituent in three (3) synthetic cannabinoid products.

Read here and here for previous my updates on this issue as well as a quick explainer as to what Brodifacoum actually is.



If you are on Twitter, check out Dr. Steve Aks (@ERtox) and Cook County Medical Examiner's Office (@CookCountyME) for updates.

Be safe.


References

Outbreak Alert: Potential Life-Threatening Vitamin K Dependent Antagonist Coagulopathy Associated With Synthetic Cannabinoid Use
https://content.govdelivery.com/accounts/USCDC/bulletins/1e6dac3
Accessed: April 7, 2018

Tainted Synthetic Pot Eyed As Cause Of Another Illinois Death As Store Owner Accused Of Selling Substance Held Without Bail
http://www.chicagotribune.com/news/local/breaking/ct-met-fake-pot-poison-cook-county-20180406-story.html
Accessed: April 7, 2018

Bleeding and Coagulopathy Associated with Synthetic Cannabinoid Products
https://dosemakespoison.blogspot.com/2018/03/bleeding-and-coagulopathy-associated.html

Update of an Outbreak of Severe Bleeding Cases / Synthetic Cannabinoid Use
http://dosemakespoison.blogspot.com/2018/04/update-of-outbreak-of-severe-bleeding.html

Tuesday, April 3, 2018

Update of an Outbreak of Severe Bleeding Cases / Synthetic Cannabinoid Use

As I wrote about the other day, there was a mass outbreak of severe bleeding cases associated with synthetic cannabinoid use in Illinois during March. As of March 29, there were 22 reports of vitamin K dependent severe coagulopathy.

Five days later and there have been 56 affected individuals. Symptoms include coughing up blood, blood in the urine, severe bloody nose, and/or bleeding gums. Nine people have tested positive for the vitamin K antagonist Brodifacoum (see my last post for explanation of its effects). Two people have died.

Three people have been arrested in Chicago in connection to selling some herbal incense/potpourri products that (according to police) have detectable amounts of Brodifacoum.

Dump your product if you have any.

Stay safe out there.



References

Bleeding and Coagulopathy Associated with Synthetic Cannabinoid Products
https://dosemakespoison.blogspot.com/2018/03/bleeding-and-coagulopathy-associated.html

Second Death of An Individual Who Used Synthetic Cannabinoids
http://www.dph.illinois.gov/news/second-death-individual-who-used-synthetic-cannabinoids
Accessed April 3, 2018.

3 Chicago Store Clerks Charged With Selling Synthetic Pot Laced With Rat Poison
http://abcnews.go.com/US/chicago-store-clerks-charged-selling-synthetic-pot-laced/story?id=54197525
Accessed April 3, 2018.

Thursday, March 29, 2018

Bleeding and Coagulopathy Associated With Synthetic Cannabinoid Products

There have been warnings out of Chicago over the last couple days regarding users of synthetic cannabinoid products experiencing abnormal bleeding issues especially from the eyes and ears. As of today (Thursday, March 29), there have been 22 reports in the Chicago area since March 7. Vitamin K dependent severe coagulopathy has been observed in several cases which is consistent with exposure to a 4-hydroxycoumarin rodenticide (superwarfarin) such as brodifacoum.

 
Chemical Structure of Brodifacoum
Drawn by Kevin G. Shanks (2018)

A substance such as Brodifacoum inhibits the action of the vitamin K epoxide reductase enzyme. This enzyme inhibition interferes with the recycling of vitamin K epoxide to vitamin K and ultimately results in a steady decrease in blood vitamin K, which is a problem, because vitamin K is a vital part of the synthesis of prothrombin (coagulation factor II). Prothrombin is involved in the blood coagulation cascade, also known as blood clotting.

Low vitamin K means severely impacted blood clotting which can result in profuse bleeding.

Another effect of Brodifacoum is the increase in permeability of blood capillaries, leading to internal hemorrhaging, or when blood leaks from vessels. An individual can bleed internally progressively with time.

Brodifacoum is a highly lipophilic substance and has an extremely slow elimination pathway from the body. Biological half-life of the substance is 20-130 days. LD50 values for mammals are substantially less than 1.0 mg/kg. It is a potent substance with a long duration of action that can result in devastating effects in humans (and animals) - afterall, it's primary (only) use is to kill warfarin-resistant rodents (hence the class name superwarfarins).

Other superwarfarins include Bromadiolone, Coumatetralyl, Difenacoum, Flocoumafen, and Tioclomarol.

This is not the typical media hysteria/hyperbole that we all have grown accustomed to over the years with reporting on drugs. While no specific products have yet been implicated, my advice is that if you are a synthetic cannabinoid user (or know a user) in the Illinois area (including bordering states), discard your supply. Immediately.

Be safe.



References

Outbreak: severe coagulopathy associated with synthetic cannabinoids (K2/Spice)
http://myemail.constantcontact.com/Outbreak--Severe-coagulopathy-associated-with-Synthetic-Cannabinoids---K2-Spice--.html?soid=1100929526407&aid=_6hDV-Frs5Q; Accessed March 29, 2018.

Synthetic pot warning issued after 22 people in Illinois report bleeding from eyes, ears
http://www.chicagotribune.com/news/local/breaking/ct-met-fake-weed-synthetic-cannabis-warning-20180329-story.html; Accessed March 29, 2018.

Illinois health officials warn of synthetic pot after 17 people report of severe bleeding.
http://wgntv.com/2018/03/29/illinois-heath-officials-warn-of-synthetic-pot-after-17-people-report-severe-bleeding/; Accessed March 29, 2018.

IDPH issues warning about synthetic cannabinoids.
http://dph.illinois.gov/news/idph-issues-warning-about-synthetic-cannabinoids; Accessed March 28, 2018.

Friday, March 9, 2018

High Impact Research from JAT

One of my papers from 2014 is listed among the "highly cited articles" in the Journal of Analytical Toxicology. It involves the analytical detection of the synthetic cannabinoid 5F-PB-22 in postmortem toxicology and presentation of four deaths that were associated with its use. You can read it, along with other papers, for free at the link below. Have fun reading!

High-Impact Research from JAT

Wednesday, February 14, 2018

Forensic Toxicology Valentines

Happy Valentine's Day!

Here are a few Valentine's wishes.

Roses are CO red.
Violets are cyanotic blue.
Let's hope you're neither already dead,
Nor hypoxic too.

Postmortem blood is red.
And sometimes blue,
And oftentimes green.
And maybe black too.

Decomposed liver is brown.
Decomposed liver is too.
Decomposed kidney is also brown.
Why is everything brown?

Postmortem blood is red.
It may also be blue,
Though it can be black.
It smells horrible, too.

MDMA and cannabis are Schedule I.
LSD is too.
Do they belong?
Let me ask you.

Sunday, February 11, 2018

NERD and Rihanna - Lemon

NERD and Rihanna’s song Lemon came across my Spotify list last night. The song came out a few months ago but this was my first time ever hearing it.

"Bath salt...bitin’ speakers in the face..."

Yes, the infamous 2012 Causeway Cannibal bath salts attack is referenced here - the attack that was not ever shown to be “bath salt” related, not to mention even drug related at all.

Here’s a link to the song. It's got a nice beat. Enjoy!


Friday, February 9, 2018

Kratom Redux

Kratom is back in the news. 

Long story short...

During the summer of 2016, the DEA moved to place kratom (mitragynine/7-hydroxymitragynine) into Schedule I of the Controlled Substances Act. Almost immediately there was a massive outcry from advocates of the plant, as well as members of Congress, toxicologists, and physicians. I initially wrote about this here. In an unprecedented move, the DEA rescinded their Notice of Intent in Fall 2016. In the Withdrawal, the DEA stated that they would accept public comment on the scheduling of these substances until December 1, 2016 as well as request a scientific/medical evaluation of the substances from the Food and Drug Administration (FDA). During the approximate 2 month comment period, the DEA received around 20,000+ comments, with near 100% having positive comments on the plant.

The FDA has now released their report on Kratom. If you want to read the 164 page document, you can find it here.

I'm not going to go into much here, because other folks have covered it comprehensively.

Nick Wing, a senior reporter with the Huffington Post, covered the FDA report and methodically looked at the case reports where Kratom was associated with cause of death that were covered in the FDA report. You can find his article here.

Dr. David Kroll at Forbes covered it as well and his excellent work can be found here.

Kratom researchers in academia from across the USA and Canada also penned a letter to the DEA and the White House's newly established Opioid Commission. The letter can be found here.

I highly recommend reading the links as they are all spot on.

When the DEA initially moved to schedule Kratom in summer 2016, I said the move was misguided. And farcical. And that the DEA hadn't thought it completely through. 

And after reading the FDA's report, I still believe that.