Spice poisoning

Spice is a smoking mixture of plant components soaked in synthetic additives with narcotic-psychotropic effects. The use of such mixtures has a detrimental effect on all organs and systems: blood pressure increases, memory, concentration and intelligence suffer, and the respiratory and cardiovascular systems are disrupted. Spice poisoning can be compared to the effect of heavy drugs. In addition to intoxication, withdrawal symptoms are observed, literally destroying the body. [ 1 ]

Information about the variable composition of spice, determination of the mechanisms of its action, signs of differentiation from other narcotics, current methods of first aid in case of poisoning - all this is a pressing issue for emergency physicians and emergency departments, as well as for neurologists and neuropathologists.

Epidemiology

Smoking mixtures called spice (in the United States they are called K-2) have become famous since 2006, when they began to be actively distributed via the Internet. Such mixtures contain a number of substances, agonists of CB1-CB2 cannabinoid receptors. The composition of the raw materials is constantly changing and is almost never the same, which significantly complicates both the diagnosis and treatment of intoxication.

Today, the frequency of poisoning with spice and the development of severe consequences exceeds all other narcotic drugs. The first spice contained marijuana, but the new generation mixtures often contain psychotropics, amphetamines, and antidepressants. Such drugs do not have a constant composition, so they are called "designer". Common components are synthetic analogues of δ 9-tetrahydrocannabinol, the basic active substance of cannabis. Synthetic cannabinoids are much more active than marijuana (more than 4 times), since they significantly increase the response of cannabinoid receptors.

According to the intensity and duration of action, spice is divided into three categories:

• silver – lasts up to 2 hours;
• gold – lasts 2-4 hours;
• diamond – lasts more than 4 hours.

It is currently recognized that absolutely all spice can cause poisoning, that they have a narcotic effect on the body, therefore they are classified as narcotic drugs. Most often, intoxication is found in adolescents and young people aged 15-18, mainly in young men.

Causes spice poisoning

Spice can include a variety of components, including less dangerous ones. However, as a rule, there are many more dangerous narcotic components in mixtures. For example, plant materials are often treated with cannabinoids, and the direct components of the total mass are initially poisonous plants - such as elephant drake (Argyreia sinewy), blue water lily (lotus), narcotic sage (Salvia divinorum), which have psychotropic and narcotic effects. Regular use of spice destroys a person mentally and physically. In addition, the production of such mixtures occurs without observing any sanitary standards, so the composition may contain almost any impurities that can lead to poisoning and the development of adverse effects.

Spice can have a very intense effect on the human body. Even a single use (smoking) can trigger the development of acute toxic psychosis with severe and prolonged neurological complications, with subsequent irreversible mental dysfunction. [ 2 ]

Risk factors

The mechanisms of spice addiction are quite complex and have not been fully studied. However, experts say that there are genetic, medical, psychological and social risk factors that directly influence the formation of dependent need.

The urge to use spice is not directly inherited. But the predisposition may make itself known, as it is a consequence of biochemical brain disorders. Scientists have already identified seven genes responsible for the development of addictive behavior. If a child has such a genetic predisposition, then it is recommended to use a special approach with special upbringing and education that reduces adverse risks.

The woman's lifestyle during pregnancy adds to the danger. Bad habits, stress, and medical regulation of labor with the use of psychoactive drugs, in particular tranquilizers, play a role.

Among the psychological risk factors are family nuances: participation in the child’s life, degree of attention, definition of the boundaries of what is permissible, lack of guardianship or overprotection, etc.

Social disadvantages include free access to spice, the practice of using drugs among close friends, etc.

Pathogenesis

Anyone who uses such a mixture can get poisoned by spice, even if it is the first time. This is due to the following factors:

• the components that make up spice are commonly treated with toxic substances - many of them have a very strong effect, causing poisoning and even death;
• Smoking spice is often combined with the use of other drugs or alcoholic beverages;
• Smoking mixtures contain a variety of herbal and narcotic combinations that are not always compatible with each other.

In addition, it is almost impossible to know the exact composition of the mixture and select a less dangerous dosage. The components are literally prepared "by eye", and there can be no talk of any safety. Most often, spice is made in unfavorable sanitary conditions, which only aggravates its toxic effect.

How do spices work? Under the influence of cannabinoid receptors, the release of inhibitory and excitatory mediators is enhanced. Other mediator mechanisms are modeled. The combination of cannabinoids with psychostimulants leads to an imbalance in favor of excitatory mediator mechanisms (adrenergic, glutamatergic, etc.). Intoxication develops with the subsequent emergence of life-threatening complications. The type of toxic process and its pathogenetic features depend on the composition of the drug. [ 3 ]

Smoking cannabinoids causes the release of approximately half of the active component entering the blood. The maximum amount in the blood plasma is detected within an hour. Deposits occur in adipose tissue, where the substances are detected for another 14-21 days. Metabolism occurs in the liver, excretion - through the hepatobiliary system and to a much lesser extent through the kidneys. The half-life is about 48 hours. In the brain, cannabinoids bind to G-protein-containing neuronal receptors and inhibit adenylate cyclase/cAFM secondary information system. This property becomes the biochemical basis for the drug's effect on the central nervous system.

In designer spice, the pathogenetic mechanism depends on what psychoactive substances are present in them. In essence, the mixtures are crushed plant materials processed with a synthetic narcotic.

In particular:

• The sage component contains salvinorins A and B, which are dissociative hallucinogens.
• Hawaiian rose seeds contain lysergic acid amides, as well as a large number of psychotropic components.

Spice may include the following substances:

• phenylethylamines (analogues of amphetamines MDMA, mescaline);
• tryptamines (psilocin analogues);
• piperazines (have a psychostimulating effect similar to amphetamines);
• opiates (trimethyl fentanyl);
• cannabinoids (in particular, the synthetic JWH-018, which is five times more potent than marijuana in its effects on the brain).

Symptoms spice poisoning

Mild spice poisoning is manifested by tachycardia, anxiety, dizziness, pareidolic illusions, and the onset of toxic psychosis. Neurological signs include:

• tremor of hands, eyes (nystagmus);
• excessive reflexivity (especially knee-jerk reactions);
• decreased Achilles reactions;
• dynamic and static-colocomotor ataxia.
• Sometimes the voice timbre changes and speech slows down.

With moderate spice poisoning, confusion of thoughts, tremors, and increased sweating are observed. Common vegetative symptoms include difficulty breathing, involuntary motor activity reminiscent of "dopamine stereotypes." Muscle tone is observed, from decerebrate rigidity to spasticity, counter-continence, etc. Convulsive and hyperkinetic syndrome, stereotypical chewing, grinding of teeth, screaming (so-called automatisms) are possible. Hallucinations occur, accompanied by panic attacks and phobias.

Severe spice poisoning is characterized by impaired consciousness up to the development of a comatose state, changes in blood pressure, increased heart rate, and episodic respiratory arrest. Tachycardia may be replaced by a threatening slowdown in cardiac activity. The gaze is not fixed, the eyeballs "float". Hyporeflexia, decreased muscle tone (including facial muscles), and bilateral ptosis are possible. Of the inconstant symptoms: pyramidal pathological signs, grasping reactions, oral automatism.

During the somatogenic phase of spice poisoning, emotional diversity and incontinence, hypertension against the background of tachycardia (up to threatening levels), and terrifying hallucinosis are observed. Such a phase can last up to several weeks. Hemorrhagic cerebral infarctions often develop, intracranial pressure increases, resulting in dislocation syndrome.

First signs

The effect of spice on the body is not fully disclosed, since the composition of the product is always different. The clinical picture of poisoning is determined by the ingredients, their quantitative ratio, the presence of random components, and the general condition of the body.

As a rule, signs of intoxication appear suddenly: a person may lose consciousness (fall into a comatose state), his blood pressure suddenly drops to the point of collapse.

Some components lead to the development of toxic myocardial dystrophy, acute renal failure, hepatitis. Often the patient dies before the arrival of the ambulance doctors.

With the development of the somatogenic phase, the appearance of pneumomediastinum and a sharp decrease in body temperature, a failure in blood clotting (coagulopathy), toxic encephalopathy and myocardial dystrophy, intoxication psychosis with phobic hallucinations, and purulent-septic complications is possible.

The onset of acute spice poisoning often resembles a state of alcohol intoxication. The patient experiences a certain motor and speech agitation, vivid hallucinations may occur, and a feeling of carelessness and relaxation appears. The pulse rate increases, as does the systolic blood pressure. Sometimes signs of a panic attack or acute psychotic state occur. Toxic psychosis is characterized by a state of agitation, clouding of consciousness, loss of orientation, delirium, and visual hallucinations. The disorder may be accompanied by abdominal pain, headache, a feeling of fear and anxiety, depression, and uncontrolled aggression. The state of organic psychosis can last from 24 hours or more.

Complications and consequences

Currently, the harm from spice has been proven and is beyond doubt. Needless to say, how many fatal cases are associated with spice poisoning. Experts are confident that the use of smoking mixtures has a negative effect on absolutely all organs and systems of the human body. The liver, reproductive and cardiovascular systems, central nervous system and the brain itself are most affected.

People who use spice experience a persistent decrease in intellectual abilities, their behavior suffers, their nervous system function is disrupted, and heart problems appear.

Most patients notice that after poisoning their time perception changes, visual and sensory hallucinations appear, chronic poor health occurs, depressive states and neuroses develop. Withdrawal syndrome is typical for many cases. [ 4 ]

Intoxication often leads to thoughts of suicide, because in such an extremely uncomfortable state a person can do almost anything to eliminate the negative and painful sensations caused by spice poisoning. Such suicide attempts are sometimes also associated with the strongest hallucinations, the fear of which "pushes" people to such a radical and ill-considered step.

In general, the most frequently recorded adverse effects of spice poisoning are:

• impairment of consciousness and thinking abilities, loss of touch with reality, frequent hallucinations;
• decreased intellectual abilities;
• the appearance of unconscious actions, memory loss;
• visual impairment;
• heart attacks, strokes;
• neuroses, depressive states;
• reproductive and sexual incapacity;
• mental disorders.

In addition, when poisoned with spice, there is always a high risk of death - both due to intoxication and dysfunction of vital organs, and due to suicide.

Diagnostics spice poisoning

The peculiarity of poisoning with spice and some other narcotics is that complaints are often made not by the patients themselves, but by their relatives or friends who have noticed the problem. At the inpatient level, anamnesis collection, examination and study of clinical manifestations can be supplemented by toxic-chemical, clinical-biochemical studies, instrumental diagnostics (ECG, endoscopy, EEG, CT of the brain, chest and cranial bone radiography, ultrasound of internal organs, etc.).

The analyses are primarily represented by qualitative methods – thin-layer chromatography, immunochromatography, as well as quantitative methods – gas-liquid chromatography, liquid chromatography, gas chromatography-mass spectrometry, enzyme immunoassay. Such studies allow detecting psychoactive substances in the patient’s biological environments (blood, urine).

Cannabinoids are detected in urine for approximately 24-48 hours, sometimes up to 1 week after smoking one spice with marijuana. If acute intoxication with herbal mixtures is suspected, IHA rapid testing is used: the absence of a positive result for other narcotic or psychoactive substances indirectly indicates spice poisoning.

Determining the level of alcohol in the blood and urine is a mandatory procedure, as it is included in the protocol for examining alcohol and drug intoxication. In addition, such a method is also necessary as part of differential diagnostics. Other laboratory tests that a doctor may prescribe:

• determination of plasma potassium and sodium levels, hematocrit;
• assessment of the total protein in the blood, urea, bilirubin, creatinine.

Instrumental diagnostics for spice poisoning may include electrocardiography, chest X-ray, ultrasound of the brain, liver and kidneys, measurement of central venous pressure and other hemodynamic parameters, and EEG to detect functional disorders in the brain. [ 5 ]

Differential diagnosis

Differential diagnostics involves three main areas:

• differentiation of spice poisoning from neurological and cardiovascular pathologies;
• differentiation from conditions caused by psychostimulant drugs, as well as from abstinence (withdrawal syndrome);
• differentiation from other intoxications.

Information obtained during anamnesis collection usually helps to differentiate poisoning from neuropathology or cardiovascular diseases. However, it should be taken into account that patients often hide their addiction to spice or are admitted with impaired consciousness.

Making a correct diagnosis and understanding the treatment is often quite difficult. Even knowing the approximate composition of spice, you cannot be 100% sure which substance caused the poisoning. Narcotic drugs often contain a number of impurities, accidentally or deliberately added to the final product. For example, unknown plant components, often poisonous, are commonly added to increase the volume and mass of the mixture.

Treatment spice poisoning

Treatment for spice poisoning is complicated, since the doctor usually cannot find out the composition of the mixture: it takes a lot of effort and time to identify it. There is no antidote to spice, and standard therapy for adrenergic syndrome and toxic psychosis is not suitable in this case, since it only worsens the patient's condition.

Most patients admitted to hospital with spice poisoning are placed under observation with monitoring of vital signs. Unconsidered use of medications can quickly worsen the patient's condition, so medications are administered only according to strict indications:

• In case of signs of psychomotor agitation and convulsions, Diazepam is used in the form of a 0.5% solution of 2-4 ml intramuscularly, intravenously, intravenously by drip (with a daily dosage of up to 0.06 g). It can be replaced with Phenazepam in tablets of 0.0005-0.001 g (with a daily dosage of up to 0.01 g). In some cases, taking tranquilizers can cause motor agitation, irritability, behavioral aggression, which must be taken into account when prescribing the drug.
• To detoxify the digestive system, gastric lavage is performed and activated charcoal is used.
• When the temperature rises due to spice poisoning, external cooling is practiced.
• High blood pressure is normalized with vasodilators, in particular, Nifedipine. In some cases, intravenous drip infusion of Nitroprusside is indicated at a rate of 0.5 to 1.5 mcg/kilogram per minute with an increase of 0.5 mcg/kilogram per minute every five minutes until the condition is normalized (with a maximum dosage of 8 mcg/kilogram per minute). If Nitroprusside is ineffective, β-blockers are prescribed.
• If signs of dehydration are present, infusion therapy is indicated at a volume of 1-2 ml/kilogram per 1 hour. Such treatment is appropriate if urine output decreases to 1-2 ml/minute.
• In case of myocardial ischemia, sedatives and nitrates, as well as calcium channel blockers (Diltiazem, Verapamil) may be prescribed. In case of myocardial infarction, acetylsalicylic acid, heparin, and sometimes thrombolytic drugs are indicated.
• In case of tachyarrhythmia, rhythm monitoring, oxygen therapy, and sedatives are indicated. Ventricular arrhythmias are eliminated with Lidocaine, sodium bicarbonate. It is important to consider that ventricular rhythm disturbance can be provoked by both the action of spice and myocardial ischemia.
• If a comatose state and respiratory depression develop, immediate tracheal intubation and artificial ventilation are performed.

In severe cases, ensure the patency of the respiratory tract, conduct hemocirculatory measures. To eliminate an acute panic attack, intravenous administration of Diazepam is optimal. Secondarily, Haloperidol can be administered - if the state of excitement does not pass, and the risks remain. In some cases, a consultation with a psychiatrist is required.

To prevent subsequent attacks of agitation, the patient's exposure to light is limited and the effects of any irritating factors are minimized.

In hypertension, peripheral vasodilators such as Phentolamine, Sodium Nitroprusside, Nifedipine are used. In case of elevated body temperature, in addition to general cooling of the body, adequate rehydration of the patient is indicated.

Treatment procedures are carried out, depending on the severity of spice poisoning: in the intensive care unit (ward), the intensive care unit, or the toxicology department.

To maintain homeostasis, intravenous infusions of sodium bicarbonate or complex salt solutions are administered. In order to prevent and eliminate cerebral and pulmonary edema, colloidal solutions are administered predominantly.

With the development of toxic hypoxic encephalopathy, hyperbaric oxygenation is included in the list of therapeutic measures. Osmotic diuretics are used to eliminate cerebral edema, in particular, Mannitol. An important role is played by drugs that optimize cerebral circulation (Cinnarizine, Cavinton), as well as antioxidants and antihypoxants that affect metabolic processes in the body (Cytoflavin, ethylmethylhydroxypyridine succinate, Glycine, etc.), nootropics (Aminolone, Piracetam).

Piracetam	Prescribed for obvious cerebrovascular disorders, asthenia, intellectual and mnestic mental disorders.	A single dose is from 400 to 1200 mg, the average daily dose is from 2400 to 3200 mg.
Γ-aminobutyric acid	Prescribed for polyneuritis and dementia.	The average daily dosage is from 3000 to 3750 mg.
Nicotinoyl γ-aminobutyric acid	It is used for anxiety, phobia, and severe irritability.	Single dose from 20 to 50 mg.
Pyritinol	Prescribed for mild depression with inhibition, adynamia, and neurosis-like disorders.	The average daily dosage is from 200 to 600 mg.

Plasma-substituting solutions and cardiovascular tonics are often indicated. Tracheal intubation is performed using atropine and muscle relaxants, as indicated.

Spice intoxication is often accompanied by an increase in the level of calcium in cells, which justifies the use of calcium channel blockers. A typical representative of such medications is Nifedipine. Despite the relative safety of this drug, when using it, one should be wary of a sharp decrease in blood pressure. In addition, such drugs are not used simultaneously with beta-blockers due to the risk of developing bradyarrhythmia and acute cardiac insufficiency.

In case of spice poisoning, antidepressants may be prescribed:

Amitriptyline	Prescribed for anxiety, depression and agitation.	25-200 mg, based on a daily dosage of 75-100 mg	Side effects: blurred vision, dry mouth, drowsiness, constipation.
Imipramine	Prescribed for asthenodepressive conditions, motor and ideational inhibition.	25-250 mg, based on a daily dosage of 75-150 mg	Side effects: headache, dizziness, increased sweating, tinnitus, dyspepsia.
Clomipramine	Used for depression, compulsive disorders and obsessions.	75-250 mg, based on a daily dosage of 75-150 mg	Side effects: accommodation disorders, constipation, urinary retention, increased intraocular pressure.

First aid for spice poisoning

If there is a suspicion of poisoning a person with spice, then the first thing to do is to call an ambulance for him. Then the victim must be isolated and provided with conditions in which he could not harm himself or other people.

Before the arrival of the medics, it is necessary to monitor the patient if possible, not to let him fall asleep, talk to him, ask about anything. If he has lost consciousness, then the victim should be laid on his side, a cushion should be placed under his head - for example, a folded piece of clothing (so that he does not choke in case of vomiting). If vomiting has already occurred, then the airway should be cleared of vomit. It is necessary to try in every possible way to bring the patient to consciousness: you can pat him on the cheeks several times, rub his ears, etc. [ 6 ]

If a person has stopped breathing, resuscitation measures will be required, such as mouth-to-mouth resuscitation and indirect cardiac massage.

Unfortunately, this is all that can be done before the ambulance arrives. Now let's talk about what you absolutely must not do:

• Never try to give a person water to drink if he is in a semi-conscious state;
• do not leave him alone and do not try to put him to sleep;
• do not offer the victim coffee or other caffeinated drinks;
• Do not perform actions that may cause aggression on the part of the poisoned person.

It is a mistake to think that a patient with spice poisoning needs to be helped in the same way as a patient with alcohol intoxication. These are fundamentally different conditions that require different types of help.

Prevention

Spice is distributed under the guise of "harmless" smoking-herbal mixtures. But this harmlessness is illusory, since any spice contains a synthetic narcotic and a number of ballast components that are not always possible to identify. The mixtures include both ordinary medicinal and non-medicinal plants, as well as a drug that is used to treat herbs before they are prepared for sale. Even the "manufacturers" of spice are not always aware of the list of components of the final product. Therefore, poisoning is quite easy to get, and in many cases intoxication can be very severe, even fatal.

General preventive measures should be widespread and cover the entire population, starting from adolescence.

It is wrong to think that poisoning can only be caused by overdosing or regular use of smoking mixtures. Experience shows that even the first dose often becomes not only toxic, but also fatal. To avoid developing an addiction to such products, it is necessary to:

• conduct accessible conversations with children and teenagers about the nature and consequences of using spice, and its mortal danger;
• protect children from suspicious connections and bad company.

Adults should always be conscientious and ensure the safety of their own family, practice trusting relationships, and promote a healthy lifestyle.

Forecast

Depending on the degree of spice poisoning, treatment is carried out:

• in mild cases in toxicology departments, within 2-3 days;
• in moderate cases with the involvement of anesthesiologists-resuscitators and subsequent transfer of the patient to the toxicology or therapeutic department, for about 5 days;
• in severe cases complicated by pneumonia, renal or hepatic failure, toxic encephalopathy for 10 or more days in the intensive care unit with further rehabilitation in the toxicology department for up to 2 weeks or more.

In many cases, relative recovery of health is observed. Partial disorders of physiological processes, dysfunction of organs or parts of organs are not excluded. Some patients develop apallic (psychoorganic) syndrome as a result of hypoxic and toxic damage to the brain. Neuritis with dysfunction of the limbs may occur. After treatment of spice poisoning, the patient is discharged home under the supervision of a doctor, or transferred to a specialized clinic (department) for further neurorehabilitation measures.