Tuesday, April 7, 2015

Case Report - Synthetic Cannabinoid-Induced Mania / And Other Thoughts

Synthetic cannabis-induced mania
Mehmet Fatih Ustundag, Esra Ozhan Ibis, Atakan Yucel, and Halil Ozcan
Case Rep Psychiatry (2015) doi: 10.1155/2015/210930

This case was reported out of the Department of Psychiatry and the Department of Child and Adolescent Psychiatry, Ataturk University in Erzurum, Turkey.

The authors present a case of an 18 year old male who was admitted to an outpatient psychiatric clinic by family.

The brother of the patient noticed drastic change in behavior over the last few months including:

§  Increase self-talking

§  Increase in self-laughing

§  Increase in spending money

§  Increase in interest in religion

§  Lack of need for sleep.

§  Belief that he was an angel, a demon, and a prophet

After admittance to the clinic, the patient’s mood was irritable and euphoric. No hallucinations were observed, but “mystical and grandiose delusions” were observed. I’m guessing that is the angel, demon, and prophet part.

No history of psychiatric or mental conditions was noted by his family. He did have a more recent drug use issue, including volatile substances, cannabis powder, and “synthetic cannabis”, starting about 4 years prior to this admittance. The “synthetic cannabis” use started approximately 6 months prior to this episode. There were no remarkable findings during physical and neurological examinations. A urine drug screen for cocaine, cannabis, opioids, amphetamines, and benzodiazepines was negative. He was diagnosed with substance-induced bipolar disorder and was treated with olanzapine, valproic acid, quetiapine, and lorazepam.

The “mystical and grandiose delusions” were still observed on day 15 of the admittance. By the 30th day, these delusions had significantly decreased and he was discharged. According to the authors, his psychiatric condition “was stable in the first month of follow up with current treatment”.

On followup, the patient stated he had been using synthetic cannabinoid products “in the previous 6 months, several times per week” and consumed the substances via the smoking route of administration.

The authors conclude that this is the first case of manic episode with psychotic symptoms induced by synthetic cannabinoids published in literature.

Overall, a decent case report, but lacking one thing.

Analytical confirmation of substance.

In fact, the only mention of toxicology is a urine drug screen for cocaine, cannabis, opioids, amphetamines, and benzodiazepines. No blood analysis was attempted. No analysis for synthetic cannabinoids was attempted. We’ve known for years now that a standard urine drug screen will not detect synthetic cannabinoids and the authors even mention this in the paper.

This is my main issue with case reports such as these. I completely understand that not all laboratories (especially hospitals) are set up to do confirmation of new psychoactive substances such as synthetic cannabinoids or substituted cathinones or NBOMe hallucinogens via mass spectrometry. But, to not even attempt this analytical confirmation AND then take the time and effort to publish this case as mania induced by a very specific cause - “synthetic cannabinoids” - is negligent at worst and sloppy at best.  If you are going to publish the paper as a case report (whether it’s a death caused by x substance or symptoms caused by y substance), then attempt confirmation of drug in urine, or more preferably blood (that's an argument for another time). To not do so is shoddy science. In a similar vein - we would not publish a case report as death associated with x substance without at least detecting the substance in some sort of biological specimen such as blood, liver, brain, kidney, urine, vitreous humor, etc.

For this described case, how do we know that the patient was using or had been using a synthetic cannabinoid product? Other than anecdotal reports from family during his admission to the clinic and from the patient after the fact, we do not know. That is hardly evidence that should make a case report. We have no true empirical evidence. As a forensic toxicologist, I’d love to find out what specific substance or combination of substances led to this induced mania/bipolar disorder in an ordinarily “normal” individual. “Synthetic cannabinoids” are a vast array of substances with diverse chemical structures and quite possibly diverse pharmacological and toxicological effects. As I like to say, they are a chemical grab bag o’ fun.

That leads to my final question: how and why do these reports keep getting published? Why are the manuscript reviewers and journal editors not questioning the lack of analytical confirmation? Why are we as toxicologists and chemists and generally as scientists not questioning this type of work?

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