Suspected synthetic cannabinoid receptor agonist intoxication: Does analysis of samples reflect the presence of suspected agents?

There has been a surge in synthetic cannabinoid receptor agonist (SCRA) exposures reported in recent years. The constituents of SCRA preparations are constantly evolving and rarely confirmed. We sought to characterize the constituents of reported SCRA exposures presenting to the emergency department (ED).

Patients who presented to two academic EDs in Washington, DC with reported or suspected SCRA exposure from July 2015-July 2016 were enrolled at the discretion of the treating provider. Blood and/or urine samples were obtained as part of routine clinical care and sent to the DC medical examiner's office for identification of known SCRAs with liquid chromatography-mass spectrometry-mass spectrometry. Standard toxicology screens were additionally performed to determine the presence of other drugs of abuse.

128 samples were analyzed. Seventy-one (55.5%) were positive for an SCRA. The most common SCRAs detected were AB-fubinaca (28, 39.4%), ADB-fubinaca (15, 21.1%), AB-chminaca 3-methyl-butanoic acid (15, 21.1%), ADB-chminaca (14, 19.7%), and 5-flouro-PB-22 (8, 11.3%). Fifty-seven (44.5%) samples were negative for an SCRA, of which 28 (21.9%) were positive for another substance, most commonly delta-9-tetrahydrocannabinol and phencyclidine. An additional 29 (22.7%) patients had both negative SCRA and toxicology screens.

Of patients presenting with reported SCRA intoxication, 55.5% had detectable SCRAs on analytical testing. These results suggest that in a considerable proportion of cases, clinicians are mis-attributing the effects of other drugs or medical conditions to SCRA use. The individual SCRAs detected in our study differed from compounds detected in earlier studies, suggesting there has been a change in constituents.