Synthetic cannabinoid drug use as a cause or contributory cause of death
Introduction
Synthetic cannabinoid CB1 and CB2 receptor agonists were developed in an attempt to provide the therapeutic benefits claimed for botanical cannabis, such as appetite stimulation, anti-nausea properties, and pain relief, while limiting the psychoactive effects [1]. The number of synthetic cannabinoids and their potencies has dramatically increased within the last decade. As such, toxicology laboratories have made concerted efforts to keep pace with the rate that at which these drugs are being designed and introduced into the user markets [2]. Only limited data from controlled studies exist however, to evaluate pharmacokinetic parameters [3]. The correlation between concentration and effect therefore is not clearly defined, and the interpretation of postmortem findings is further complicated by the lack of data examining influences from postmortem redistribution. In lieu of this information, pathologists, clinicians and toxicologists have relied upon case studies involving self-reported use where toxicology testing may not have been performed. In one study that surveyed 518 patients from 60 emergency facilities in Japan, 86% claimed to have inhaled synthetic chemicals contained in herbal products. Other than neuropsychiatric behaviors, 10% of patients had physical complications such as rhabdomyolysis [4]. The signs and symptoms that have been associated with synthetic cannabinoid use do include central nervous system effects (e.g., agitation, confusion, sedation and psychosis), cardiovascular effects (e.g., arrhythmia, bradycardia and tachycardia) and gastrointestinal effects (nausea and vomiting) [5], [6], [7]. For some cases, cause of death has been directly attributed to synthetic cannabinoid use [8], [9], [10], [11]. In one case, the 59-year-old male decedent was found with three herbal blend sachets at his residence. MAM-2201 was analytically determined to be present in several of his biological specimens and as no evidence of endogenous disease or external injuries were noted, his death was attributed to the use of this drug. Another case describes a 36-year old man who collapsed at home and experienced seizures after smoking an herbal blend called “Mary Joy Annihilation”. Toxicology testing showed the presence of five different synthetic cannabinoids in peripheral blood in addition to 250 ng/mL amphetamine. The synthetic cannabinoids were included as a contributory factor in his death due to drug intoxication. This study aims to evaluate how this toxicological information is used in cause and manner of death determinations in cases where the presence of at least one synthetic cannabinoid was analytically confirmed.
Section snippets
Case identification and inclusion criteria
The primary inclusion criterion was that the presence of one or more synthetic cannabinoids had to be proven in a postmortem case through toxicology testing. The deaths occurred between November 2010 and May 2014. It should be noted that due to the rapid turnover in the specific synthetic cannabinoids in circulation at any given time, the scope of testing changed over the period during which these cases were analyzed. Therefore, while each case had confirmed toxicology findings, not every case
Initial determination of role of synthetic cannabinoid in cause and manner of death
In total 25 cases met the criteria for inclusion. The cases with the brief history provided, determinative pathology findings, toxicology and initial cause and manner of death information are summarized in Table 3. The subjects (6 female and 19 male) had an age range of 15–61 years for the females and 15–58 years for the males with one male age unspecified. In total, eight different synthetic cannabinoids were identified across all cases, with 16 cases being positive for only one. AM-2201 was
Discussion
The cases detailed in this study further demonstrate that synthetic cannabinoid use has been associated with lethal outcomes. Their role, however, in regard to cause and manner of death has not been clearly defined. In part, this is due to the lack of controlled studies and the inability to correlate the concentration of a synthetic cannabinoid to effect especially perhaps, in the presence of other drugs. Evaluation of these cases reveals risk factors that may place an individual at a greater
Conclusions
Synthetic cannabinoid use is increasingly being tested for in postmortem cases when indicated by investigation and case history. Analytically determined blood concentrations vary widely and some laboratories may be limited to reporting qualitative results due to lack of availability of labeled internal standards. This limits the ability to universally evaluate the relationship between blood concentrations and life-threatening (toxic) and/or lethal case outcomes. The cases presented here in
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2021, International Journal of Drug PolicyCitation Excerpt :The use of the term carries an implicit implication that the same may be true of SCRAs. In sharp contrast, deaths directly attributable to SCRA toxicity do occur, most likely due to acute cardiovascular events (Darke et al., 2020; Gerostamoulos et al., 2015; Labay et al., 2016). Indeed, toxicity is the most frequently reported cause of SCRA-related death.