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Sonya Chistov

July 21, 2016

Major metropolitan city emergency departments (ED) are constantly inundated with drug and alcohol intoxications. These days, health care providers are noticing a new surge in consumption of “designer drugs”. As a professional working for some time in a Washington D.C. ED, I have personally seen the dramatic increase in synthetic cannabinoids abuse.

What Are Synthetic Cannabinoids?

Synthetic cannabinoids are a new class of synthetic molecules developed to mimic the naturally occurring, psychoactive component of marijuana: tetrahydrocannabinol (THC). THC naturally binds to endogenous cannabinoid receptors, CB1 and CB2, as partial agonists. The resulting interaction between THC and the CB1 receptor causes changes in perception, relaxation, body temperature, and hunger. In addition, THC has been implicated in providing relief to patients with chronic health issues such as wasting disease and chemotherapy-related emesis and nausea. Since the 1960s, cannabinoid research has focused on creating synthetic analogs of THC, with similar analgesic and anti-inflammatory properties, but without the psychoactive effects. However, some of the chemical structures synthesized act as full-agonists at the same CB1 receptor—increasing the inhibition of GABA neurotransmission and therefore, the severity of the psychoactive and physiological symptoms.

“Spice”, “K2” and “Smoke” are common names for products marketed as “incense”. They contain a mixture of natural herbal ingredients that are sprayed with these chemical analogs. The resulting product is marked as “not for human consumption”, which makes it difficult for regulators to control. In 2011, the Federal Drug Administration marked common synthetic cannabinoids (JWH-018, JWH-073, JWH-200, CP 47-497, and CP-47-497C8) as schedule I substances.  However, new synthetic derivatives and homologs with very similar effects are constantly being created, rebranded, and redistributed across the United States. These products are inexpensive and found in local gas stations, bodegas, and on the Internet, which makes them an easy drug to get and use.

What Does A “K2” Patient Look Like In The ED?

ED patients with acute synthetic cannabinoid intoxication may present with a variety of symptoms based on the type, dose and route of consumption. The most notable clinical presentations are either: A) sluggish and drowsy or B) severely agitated and aggressive. Drowsy patients can often present with bradycardia, hypotension, emesis, confusion, and frank unresponsiveness to verbal and physical stimuli. In cases of severe agitation and aggressiveness, patients may present with tachycardia, hypertension, hallucinations, or paranoid behavior, which can be disruptive to a busy ED. These patients sometimes require physical restraints, or chemical restraint, in the form of sedatives. For many patients that I’ve seen, consumption of synthetic cannabinoids is not always an isolated ingestions, but often times combined with alcohol or street drugs.

What are Synthetic Cannabinoids Doing to The Public’s Health and What Can Be Done?

The long-term consequences of prolonged synthetic cannabinoid use remains unclear. Though most of the medical interventions to treat synthetic cannabinoid intoxication is supportive, increased use and abuse of these products is already burdening EDs not inly in major cities, like DC, but around the country. in emergency medicine. Legislation combating the sale of products containing certain ingredients has already been put in place, manufactures simply create new products and distribute them as usual.

However, local communities are doing their part to warn citizens about the harmful effects of the drug. For example, in regions of Washington D.C., educational campaigns have placed advertisements of buses to warn the public of about the dangers of K2 and Spice. Unfortunately, until a broader solution is identified and implemented, healthcare providers in ED across the country will continue to see more and more visits in relation to this dangerous drug.


Sonya Chistov is an ED Technican at The George Washington University.

Evan Kuhl, MD

July 8, 2016

Elderly patients have the highest rate of ED usage amongst all adult populations as well as the highest return rate.  Despite this increased burden on the healthcare system, it is difficult to predict poor outcomes after discharge. We all want to treat each patient “as if they were my grandfather/grandmother” yet we still cannot prevent many catastrophic outcomes. Of course we know that many chronic diseases increase the risk of readmission, and the 1-year mortality of many injuries are very well studied—but translating these risks into improvement of patient care is difficult, and many patients don’t fall so neatly into these boxes. There is still a need to identify risk factors to help providers identify patients at high risk of poor or catastrophic outcomes.

A new article by Dr. Gelareh Gabayan et. Al takes a new perspective on this problem. Instead of identifying historical information, type of injury, or other clinical data that is classically used to highlight at-risk patients, the team instead looked at process-of-care factors which occurred during the ER visit. What are we doing during a visit that can raise a red flag? Their study generated 300 case-control visit pairs of patients >65 years old who were treated in their ED system, and either died or was admitted to the ICU within 7 days of discharge. The chart review matched 300 patients who experienced such an outcome with 300 case control patients who did not, then compared the charts to identify predictors for ICU admission and/or death. Read more about their methods of exclusion, randomization, and measurement in their article, here. The article identifies many characteristics as having an increased adjusted odds ratio for death or ICU admission, including Asian/Pacific islander, Hispanic, or black ethnicity, hypotension, tachycardia, and mental status changes.

Most interesting, however is that changing the disposition of a patient (or noting the consideration of admission) was found to be associated with a greater likelihood of death or an ICU admission. Change in disposition was the only association that was not a hard number. In fact, it’s the only association that we actively play a role in as physicians. Interestingly, Dr. Gabayan’s paper finds that when a change in disposition was related to specialty consultation, there was no longer an increase in risk. It appears these consults were able to provide services or follow-up care outside of an emergency physician’s scope of practice. Per the article; “Our findings, coupled with that of other studies, suggest that regardless of the initiating event causing the change in disposition status, the emergency providers’ clinical judgment about the disposition (admit versus discharge) of the patient should be given special attention by both the care team and the patient.”  Next time you consider your disposition of an elderly patient, take a moment and consider their next 7 days.

Interested in more? This month’s Annals of Emergency Medicine included several articles regarding the care of our elderly patients, including two other very interesting articles: Dr. Fassier’s article explores the attitudes of EM physicians regarding critically ill elderly patients, while Drs. LeFebvre and Platts-Mills provide an editorial to the article, including discussing the frustrations many EM physicians have when it comes to both the patient and family.


Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital