Effect of Synthetic Cannabinoids in Older Adults

To the Editor: Use of recreational drugs, including synthetic cannabinoids receptor agonists (SCRAs), is increasing.1, 2 Synthetic cannabinoids, known as “k2” or “spice,” contain different chemical substances combined with herbal mixtures to produce cannabinoid-like effects.3 Emergency department (ED) visits have significantly increased as a result of SCRA abuse.2, 3 Abuse among older adults has not been reported. Four cases of older persons presenting for SCRA intoxication are described. A 67-year-old African-American man presented after an episode of syncope witnessed after he used SCRAs. Initial electrocardiogram (ECG) was remarkable for severe sinus bradycardia (37 beats per minute) (Figure 1). He was admitted to the coronary care unit (CCU), paced transcutaneously, and monitored. Urine toxicology was negative, and no other cause for bradycardia was identified in ancillary examination except for the use of SCRAs. He was discharged after a few days without any adverse events. His medical history was positive for hypertension, and all previous ECGs reviewed were normal. A 66-year-old African-American man presented with signs of intoxication, confusion, and vomiting after using SCRAs. His vital signs were normal. He received intravenous (IV) fluids and was discharged after his symptoms resolved. Urine toxicology was negative. A 71-year-old African-American woman presented with elbow pain after a fall. She reported smoking SCRAs, feeling dizzy, falling, and injuring both elbows. Vital signs were normal. IV fluids and pain medication were given, after which she was discharged from the ED. Urine toxicology was negative. A 66-year-old Hispanic male was brought to the ED after being found wandering and dizzy in the street. He reported having used SCRAs minutes before his symptoms started. Urine toxicology was negative. He stayed in ED under observation, received IV fluids, and was discharged with resolution of symptoms. SCRA abuse has increased and raised concern worldwide in the last few years.1, 2 People intoxicated with SCRAs have mainly neurological symptoms: altered mental status, agitation, hallucinations, seizures, and central nervous system (CNS) depression.3 Other side effects such as arrhythmia, hyperthermia, and cardiotoxicity have also been reported.2, 3 SCRAs have become popular because of their easy accessibility, low price, marijuana-like effects, and negative screening results using routine urine toxicological methods. There are several SCRAs, including JWH-018, JWH-073, and HU-210 that were developed for scientific purposes, but illicit laboratories and criminal organizations started to mix or spray them onto herbs for distribution.1-4 Older adults have been exposed to this drug. Of the four people described above, the most-affected required CCU admission for severe bradycardia requiring cardiac monitoring and transcutaneous pacing. No possible cause of bradycardia was identified, including electrolyte abnormalities; hypothyroidism; and use of beta-blockers, calcium channel blockers, and psychotropic medications that can potentially cause QT prolongation. There is lack of evidence concerning the use of cannabinoids specifically in older adults and limited evidence as to whether they can trigger cardiovascular events.5, 6 Endocannabinoids affect contractility and Ca+2 signaling through their affinity for the cannabinoid (CB) 1 and CB2 receptors. Information on the effects of SCRAs on the cardiovascular system is also limited, but they include hypotension, hypertension, tachycardia, bradycardia, chest pain, QT prolongation, myocardial infarction, and cardiac arrest.7-9 Thus, the effect of SCRAs ranges from conduction abnormalities through CB receptors to myocardial depression. Their effects also involve blockage of Na+ channels and inhibition of Na+/Ca+2 exchangers.8, 9 Since the rise of SCRAs, there have been cases of younger individuals with life-threating conditions; a strong CNS depression described as “zombielike” behavior was recently reported in a group of intoxicated individuals in Brooklyn, New York.10 Important aspects of the older population are the presence of comorbid conditions, the number of medication combinations, and the normal age-related physiological changes that make some vulnerable to adverse effects to SCRAs, as well as any medication or toxin. Data regarding older adults intoxicated with SCRAs are limited, which is why this report is important. In addition to considering common causes of intoxication, clinicians need to be aware of this new designer drug and consider that an intoxicated older adult with a negative routine urinary toxicology screen may have used a SCRA, especially if SCRAs can easily be found in the community near the hospital. Because there are no routine tests for SCRAs, information that the individual; witnesses, including emergency medical services; and family members provide must be relied on. Conflict of Interest: The authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: HR, EC, MR, CD: review of cases. HR: writing manuscript. GP, SC, GWH: editing manuscript. Sponsor's Role: None.

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