9/23/2015. Reports of Adverse Health Effects Related to Synthetic Cannabinoid Use New York, April 1 July 31, Synthetic Cannabinoids

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1 9/23/215 September 23, Synthetic Cannabinoids Reports of Adverse Health Effects Related to Synthetic Cannabinoid Use New York, April 1 July 31, 215 Eleni Papadopoulos September 23, 215 Encompass a wide variety of chemicals that are synthesized and marketed to mimic the action of THC (tetrahydrocannibol), the primary psychoactive ingredient in marijuana Challenges in detection Easily changed to create new structures Individual tests must be created for each compound Requires provider s clinical diagnosis September 23, THC: The Synthetic Cannabinoid Model September 23, Synthetic Cannabinoids Sold in bodegas and on the internet as potpourri or incense THC (tetrahydrocannibol) HU 2 (Hebrew University) JWH 18 (John W Huffman) Marked Not for Human Consumption Samples of synthetic cannabinoids 1

2 9/23/215 September 23, September 23, April 16, 215: November 211: in April 16, 215: September 23, September 23, Objectives November 211: in March 28, 212: NYSDOH releases April 16, 215: Assess if 215 outbreak is a current public health threat Compare and 215 outbreaks to evaluate most effective response

3 9/23/215 September 23, September 23, 215 Methods Data was collected from National Poison Data System (NPDS) Case definition- a person with reported exposure to synthetic cannabinoids in New York State (NYS) during: Outbreak: November 7, 211-May 6, Outbreak: April 1-July 31, 215 Study Area All counties except those in NYC, and Westchester, Nassau, and Suffolk counties Upstate PCC Counties NYC PCC Counties County Map of New York State September 23, Methods Data Analysis: Frequencies were calculated for age and sex Chi square analyses determined differences in symptoms and other factors between outbreaks Laboratory Analysis Samples from 215 analyzed using high resolution mass spectrometry September 23, Cannabinoid Use New York, April 1 July 31, 215 (N=4)

4 9/23/215 September 23, Cannabinoid Use New York, April 1 July 31, 215 (N=4) April 17, 215: NYSDOH Advisory September 23, Cannabinoid Use New York, April 1 July 31, 215 (N=4) April 17, 215: NYSDOH Advisory April 22, 215: Office of Alcoholism and Substance Abuse Services (OASAS) Advisory September 23, Cannabinoid Use New York, April 1 July 31, 215 (N=4) April 17, 215: NYSDOH Advisory April 22, 215: Office of Alcoholism and Substance Abuse Services (OASAS) Advisory July 17, 215: and September 23, Cannabinoid Use New York November 7, 211-May 6, April 1, 215-July 31, 215 (N=4) 4

5 9/23/215 September 23, Cannabinoid Use New York November 7, 211-May 6, April 1, 215-July 31, 215 (N=4) July 17, 215: updated emergency regulations September 23, Cannabinoid Use New York November 7, 211-May 6, 212 March 22, 212: PCC issues April 1, 215-July 31, 215 (N=4) July 17, 215: updated emergency regulations September 23, Cannabinoid Use New York November 7, 211-May 6, 212 March 28, 212: emergency regulations March 22, 212: PCC issues April 1, 215-July 31, 215 (N=4) July 17, 215: updated emergency regulations September 23, Outbreak Demographics Outbreak 215 Outbreak (N=4) Sex n (%) Male 161 (75.9) 321 (8.3) Female 5 (23.6) 79 (19.8) Age* Median (range) 2 (1-68) 28 (8 months-65) *Age: (N=2), 215 (N=365) 5

6 9/23/215 September 23, Symptoms Related to Synthetic Cannabinoid Use, and 215 (N=4) a Outbreak 215 Outbreak p value* (N=4) n % n % Agitation/Irritation <.1 Lethargy <.1 Tachycardia Confusion Bradycardia <.1 Vomiting/Nausea Mydriasis (Pupil Dilation) Hypotension Hypertension Seizure Coma Other <.1 b a symptoms are not mutually exclusive b symptoms that resulted in <5% of cases in 215 were added to the Other category *statistical significance (p<.5) September 23, Symptoms Related to Synthetic Cannabinoid Use, and 215 (N=4) a Outbreak 215 Outbreak p value* (N=4) n % n % Agitation/Irritation <.1 Lethargy <.1 Tachycardia Confusion Bradycardia <.1 Vomiting/Nausea Mydriasis (Pupil Dilation) Hypotension Hypertension Seizure Coma Other <.1 b a symptoms are not mutually exclusive b symptoms that resulted in <5% of cases in 215 were added to the Other category *statistical significance (p<.5) September 23, Level of Care Related to Synthetic Cannabinoid Use, and 215 (N=4) September 23, Level of Care Related to Synthetic Cannabinoid Use, and 215 (N=4) Outbreak 215 Outbreak (N=4) p value* Outbreak 215 Outbreak (N=4) p value* n % n % Admissions Hospital Admissions (Critical and Non-Critical Units) Critical Care Unit (CCU) Non Critical Care Unit Psychiatric Facility <.1 Treated/evaluated and Released Patient Refused Referral Patient Lost to Follow up Unknown n % n % Admissions Hospital Admissions (Critical and Non-Critical Units) Critical Care Unit (CCU) Non Critical Care Unit Psychiatric Facility <.1 Treated/evaluated and Released Patient Refused Referral Patient Lost to Follow up Unknown *statistical significance (p<.5) *statistical significance (p<.5) 6

7 9/23/215 September 23, Lab Analysis September 23, Identified different classes of synthetic cannabinoids with much higher potency for the cannabinoid receptor November 211: in March 28, 212: NYSDOH releases April 17, 215: NYSDOH Health Advisory April 16, 215: MAB-CHMINACA (indazole) XLR-11 (indole) September 23, November 211: in March 28, 212: NYSDOH releases July 17, 215: Two new classes of synthetic cannabinoids added to and from NYSDOH April 17, 215: NYSDOH Health Advisory April 16, 215: September 23, November 211: in March 28, 212: NYSDOH releases July 17, 215: Two new classes of synthetic cannabinoids added to and from NYSDOH April 17, 215: NYSDOH Health Advisory April 16, 215: August 6, 215:

8 9/23/215 September 23, Limitations September 23, 215 Conclusions Reporting bias NPDS may not capture all cases Measurement bias Physicians may have limited experience with patients affected by synthetic cannabinoids Lack of laboratory test limits diagnosis Synthetic Cannabinoids pose a public health threat in NYS Different symptoms and newer compounds Percentage of Critical Care Unit admissions doubled from to 215 NYSDOH continues to monitor the outbreak July 17, 215: Two new classes of synthetic cannabinoids added to and from NYSDOH August 6, 215: September 23, Recommendations September 23, Acknowledgements Utilize and compare other data sources Outreach education to healthcare professionals and targeted populations Work with law enforcement organizations Nina Ahmad, MD Samantha Akingbola Kenneth Aldous, PhD Laura Brady, BSN Karen Cummings, MPH Karen Davda Mary Figgatt, MPH Nathan Graber, MD Adam Helman Lingyun Li, PhD Jeanna Marraffa, PharmD, DABAT 8