Joseph A Tyndall1, Roy Gerona2, Giuliano De Portu1, Jordan Trecki3, Marie-Carmelle Elie1, Judith Lucas1, John Slish1, Kenneth Rand4, Lindsay Bazydlo1,5, Martina Holder6, Matthew F Ryan1, Paul Myers7, Nicole Iovine8, Michelle Plourde6, Emily Weeks1, James R Hanley9, Greg Endres10, Danielle St Germaine10, Paul J Dobrowolski10, Michael Schwartz11. 1. a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA . 2. b Department of Laboratory Medicine , University of California San Francisco , San Francisco , CA , USA . 3. c Office of Diversion Control/Drug and Chemical Evaluation Section, Drug Enforcement Administration , Springfield , VA , USA . 4. d Division of Infections Disease, Department of Pathology , Immunology and Laboratory Medicine, The University of Florida College of Medicine , Gainesville , FL , USA . 5. e Division of Laboratory Medicine, Department of Pathology , The University of Virginia , Charlottesville , VA , USA . 6. f UF Health Shands , Gainesville , FL , USA . 7. g Florida Department of Health, Alachua County , Gainesville , FL , USA . 8. h Department of Medicine , The University of Florida College of Medicine , Gainesville , FL , USA . 9. i Ochsner Clinic Foundation Hospital , New Orleans , LA , USA . 10. j Cayman Chemical , Ann Arbor , MI , USA , and. 11. k National Center for Environmental Health, Centers for Disease Control and Prevention , Atlanta , GA , USA.
Abstract
BACKGROUND: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. RESULTS: Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. DISCUSSION: The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. CONCLUSION: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.
BACKGROUND: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. RESULTS: Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. DISCUSSION: The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. CONCLUSION: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.
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