Spice poisoning

Spice is a smoking mixture of herbal ingredients impregnated with synthetic additives with a narco-psychotropic effect. The use of such mixtures has a detrimental effect on all organs and systems: blood pressure rises, memory, concentration and intelligence suffer, the work of the respiratory and cardiovascular systems is disrupted. Spice poisoning can be compared to the effect of hard drugs. In addition to intoxication, “breaking” is noted, literally destroying the body.[1]

Information about the volatile composition of spices, determining the mechanisms of their action, signs of differentiation from other narcotics, current methods of first aid in case of poisoning - all this is an urgent problem for emergency physicians and emergency departments, as well as for neurologists and neuropathologists.

Epidemiology

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

To date, the frequency of spice poisoning and the development of severe consequences exceeds all other narcotic drugs. Marijuana was present in the first spices, but the mixtures of the new generation often contain psychotropics, amphetamines, and antidepressants. Such drugs do not have a permanent composition, so they are called "designer". Common components are synthetic analogues of δ 9-tetrahydrocannabinol, the main active ingredient in cannabis. Synthetic cannabinoids are much more active than marijuana (more than 4 times), as they significantly increase the response of cannabinoid receptors.

According to the intensity and duration of action, spices are divided into three categories:

• silver - last up to 2 hours;
• gold - act 2-4 hours;
• diamond - last more than 4 hours.

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

Causes of the spice poisoning

Spice can include a variety of components, including less dangerous ones. However, as a rule, there are much more dangerous narcotic components in mixtures. For example, vegetable raw materials are often treated with cannabinoids, and initially poisonous plants, such as elephant dredge (wiry argyrea), blue water lily (lotus), narcotic sage (salvia divinorum), which have psychotropic and narcotic effects, become direct components of the total mass. Regular use of spices destroys a person mentally and physically. In addition, the production of such mixtures occurs without observing any sanitary standards, therefore, almost any impurities that can lead to poisoning and the development of adverse effects can be present in the composition.

Spice can have a very intense effect on the human body. At the same time, even their single use (smoking) can trigger the development of acute toxic psychosis with severe and prolonged neurological complications, with further irreversible disorder of mental functions. [2]

Risk factors

The mechanisms of emergence of addiction to spice are quite complex and not fully understood. However, experts talk about the presence of genetic, medical, psychological and social risk factors that directly affect the formation of a dependent need.

The craving for the use of spices is not directly inherited. But the predisposition can make itself felt, 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 a special approach is recommended for him with special upbringing and education that reduces adverse risks.

Adds danger to a woman's lifestyle during pregnancy. Bad habits, stress, as well as medical regulation of childbirth with the use of psychoactive drugs, in particular, tranquilizers, play a role.

Among the psychological risk factors are family nuances: participation in the life of the child, degree of attention, determination of the boundaries of permissibility, lack of guardianship or overprotection, etc.

Social unfavorable moments are a person's free access to spices, the practice of using drugs among close associates, etc.

Pathogenesis

Anyone who consumes such a mixture can get spice poisoning - even if this is the first time. This is due to the following factors:

• the components that make up the spice are everywhere treated with toxic substances - many of them have a very strong effect, cause poisoning and even death;
• Spice smoking is often combined with the use of other drugs or alcohol;
• smoking mixtures contain a variety of herbal and narcotic combinations, which are not always combined with each other.

In addition, it is almost impossible to know the exact composition of the mixture and choose its less dangerous dosage. The components are literally prepared “by eye”, and there can be no question of any safety. Most often, spices are made in unfavorable sanitary conditions, which only exacerbates their toxic effects.

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 the direction of excitatory mediator mechanisms (adrenergic, glutamatergic, etc.). Intoxication develops with the further occurrence 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 bloodstream. The limiting amount in the blood plasma is detected within an hour. Deposition occurs in adipose tissue, where substances are determined for another 14-21 days. Metabolism is carried out 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 inhibition of adenylate cyclase/cAFM of the secondary information system. It is this property that becomes the biochemical basis of the effect of the drug on the central nervous system.

In designer spices, the pathogenetic mechanism depends on which psychoactive substances are present in them. In fact, the mixtures are crushed plant materials treated 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 such substances:

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

Symptoms of the spice poisoning

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

• tremor of the hands, eyes (nystagmus);
• excessive reflection (especially knee reactions);
• decrease in Achilles reactions;
• dynamic and static locomotor ataxia.
• Sometimes the voice timbre changes, speech slows down.

With an average degree of spice poisoning, mental confusion, tremor, and increased sweating are noted. Among the common autonomic signs are difficulty breathing, involuntary motor skills, reminiscent of "dopamine stereotypes". Muscle tone is observed, from decerebrate rigidity to spasticity, countercontinence, etc. Convulsive and hyperkinetic syndrome, stereotypical chewing, gnashing of teeth, screams (the so-called automatisms) are possible. There are hallucinations, accompanied by bouts of panic attacks, phobias.

A severe degree of spice poisoning is characterized by impaired consciousness up to the development of a coma, changes in blood pressure, increased heart rate, and episodic respiratory arrest. Tachycardia can be replaced by a threatening slowdown in cardiac activity. The gaze is not fixed, the eyeballs “float”. Possible hyporeflexia, decreased muscle tone (including mimic muscles), bilateral ptosis. Of the non-permanent symptoms: pyramidal pathological signs, grasping reactions, oral automatism.

In the somatogenic phase of spice poisoning, emotional diversity and incontinence, hypertension against the background of tachycardia (up to threatening indicators), and frightening hallucinosis are noted. This phase can last up to several weeks. Often, hemorrhagic cerebral infarctions develop, intracranial pressure rises, resulting in a dislocation syndrome.

First signs

The impact on the body of spice 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, the general condition of the body.

As a rule, signs of intoxication occur abruptly: a person can lose consciousness (fall into a coma), his pressure suddenly decreases until he collapses.

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 malfunction in blood clotting (coagulopathy), toxic encephalopathy and myocardial dystrophy, intoxication psychosis with phobic hallucinations, and purulent-septic complications are possible.

The onset of acute spice poisoning often resembles a state of alcoholic intoxication. The patient has a certain motor and speech excitation, the appearance of vivid hallucinations is possible, there is a feeling of carelessness, relaxation. The pulse rate rises, as does the systolic blood pressure. Sometimes there are signs of a panic attack or an acute psychotic state. Toxic psychosis is characterized by a state of excitation, clouding of consciousness, loss of orientation, delirium, visual hallucinations. Violation may be accompanied by abdominal pain, headache, fear and anxiety, depression, 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 beyond doubt. Needless to say, how many deaths are associated with spice poisoning. Experts are sure that the use of smoking mixtures negatively affects absolutely all organs and systems of the human body. Most of all, the liver, reproductive and cardiovascular systems, the central nervous system and the brain itself are affected.

In people who use spice, there is a persistent decrease in intellectual capabilities, behavior suffers, the function of the nervous system is upset, and heart problems appear.

Most patients notice that after poisoning, their temporal perception changes, visual and sensory hallucinations appear, chronic poor health occurs, depressive states and neuroses develop. Many cases are characterized by withdrawal symptoms. [4]

Intoxication often leads to thoughts of suicide, because in such a highly 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 drastic and thoughtless step.

In general, the most commonly reported adverse effects of spice poisoning are:

• violation of consciousness and mental abilities, loss of connection with reality, frequent hallucinations;
• lowering of intellectual abilities;
• the appearance of unconscious actions, loss of memory;
• visual impairment;
• heart attacks, strokes;
• neurosis, depressive states;
• reproductive and sexual incapacity;
• mental disorders.

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

Diagnostics of the spice poisoning

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

The analyzes 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 make it possible to detect psychoactive substances in the patient's biological media (blood, urinary fluid).

Cannabinoids are found in the urinary fluid for approximately 24-48 hours, sometimes up to 1 week after smoking a single marijuana spice. If acute intoxication with plant mixtures is suspected, ICA 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 urinary fluid is a mandatory procedure, as it is included in the protocol for the examination of alcohol and drug intoxication. In addition, a similar method is necessary in the framework of differential diagnosis. Other lab tests your doctor may order:

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

Instrumental diagnostics for spice poisoning can be represented by electrocardiography, chest x-ray, ultrasound of the brain, liver and kidneys, measurement of CVP and other hemodynamic parameters, EEG to detect functional disorders in the brain. [5]

Differential diagnosis

Differential diagnosis involves three main areas:

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

Information obtained during the history taking usually helps to distinguish poisoning from neuropathology or cardiovascular disease. However, it should be borne in mind that patients often hide their addiction to spices, or act with impaired consciousness.

It is often difficult to make a correct diagnosis and deal with treatment. Even knowing the approximate composition of spice, one cannot be one hundred percent sure which substance led to the development of poisoning. Narcotic drugs often contain a range of impurities that are accidentally or deliberately added to the final product. For example, unknown herbal ingredients, often poisonous, are commonly added to increase the volume and mass of the mixture.

Treatment of the spice poisoning

Treatment for spice poisoning is complicated, since usually the doctor 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 the standard therapy for adrenergic syndrome and toxic psychosis is not suitable in this case, as it only worsens the patient's condition.

Most patients who are admitted to a hospital with spice poisoning are monitored with vital signs monitored. The thoughtless use of medicines can quickly aggravate the patient's condition, so medicines are administered only according to strict indications:

• With signs of psychomotor agitation and convulsions, Diazepam is used in the form of a 0.5% solution of 2-4 ml intramuscularly, intravenously, intravenously-drip (with a daily dosage of up to 0.06 g). You can replace 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, activated charcoal is used.
• When the temperature rises against the background of spice poisoning, external cooling is practiced.
• High blood pressure is normalized with the help of vasodilators - in particular, Nifedipine. In some cases, an intravenous drip infusion of nitroprusside is indicated at a flow rate of 0.5 to 1.5 mcg / kg per minute with an increase of 0.5 mcg / kg per minute every five minutes, until the condition normalizes (at a maximum dosage of 8 mcg / kilogram per minute). If nitroprusside is ineffective, then β-blockers are prescribed.
• With signs of dehydration, infusion therapy is indicated in the amount of 1-2 ml / kg per 1 hour. Such treatment is appropriate if urine output is reduced to 1-2 ml/minute.
• With myocardial ischemia, it is possible to prescribe sedatives and nitrates, as well as calcium channel blockers (Diltiazem, Verapamil). In myocardial infarction, acetylsalicylic acid, heparin, and sometimes thrombolytic drugs are indicated.
• With tachyarrhythmia, rhythm monitoring, oxygen therapy, and sedatives are indicated. Ventricular arrhythmias are eliminated by Lidocaine, sodium bicarbonate. It is important to consider that ventricular arrhythmia can be triggered by both the action of spice and myocardial ischemia.
• With the development of a coma and respiratory depression, immediate tracheal intubation and artificial ventilation of the lungs are performed.

In severe cases, they monitor the patency of the respiratory tract, carry out hemocirculation measures. To eliminate an acute attack of a panic attack, intravenous administration of Diazepam is optimally chosen. Secondly, you can enter Haloperidol - in case the state of excitement does not go away, but the risks remain. In some cases, a psychiatric consultation is required.

To prevent subsequent attacks of arousal, the patient is limited in illumination, minimizing the effect of any irritating factors.

Hypertension is treated with peripheral vasodilators such as phentolamine, sodium nitroprusside, nifedipine. At elevated body temperature, in addition to general cooling of the body, adequate rehydration of the patient is indicated.

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

To maintain homeostasis, intravenous infusions of sodium bicarbonate solution or complex saline solutions are carried out. 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. To eliminate cerebral edema, osmotic diuretics are used - 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 (Aminalon, Piracetam).

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

The use of plasma-substituting solutions, cardiovasotonics is often indicated. According to indications, tracheal intubation is performed using atropine and muscle relaxants.

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

In case of spice poisoning, it is possible to prescribe antidepressants:

Amitriptyline	Assign for anxiety and depression, agitation.	25-200 mg each, based on a daily dosage of 75-100 mg	Side effects: blurred vision, dry mouth, drowsiness, constipation.
Imipramine	It is prescribed for asthenodepressive state, motor and ideational retardation.	25-250 mg each, 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 each, based on a daily dosage of 75-150 mg	Side effects: disturbances of accommodation, constipation, urinary retention, increased intraocular pressure.

First aid for spice poisoning

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

Before the arrival of the doctors, you should, if possible, control the patient, do not allow him to fall asleep, talk to him, ask about anything. If there is a loss of consciousness, then you need to lay the victim on his side, put a roller under his head - for example, folded clothes (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, then resuscitation measures will be needed, such as mouth-to-mouth artificial respiration and chest compressions.

Unfortunately, this is all that can be done before the arrival of the ambulance doctors. Now let's talk about what you absolutely cannot do:

• in no case should you 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 and other caffeinated drinks;
• do not perform actions that can cause aggression on the part of the poisoned person.

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

Prevention

Spice is distributed under the guise of "harmless" smoking-herbal mixtures. But this harmlessness is illusory, since any spice contains a synthetic narcotic drug and a number of ballast components that are not always possible to identify. The composition of the mixtures includes both ordinary medicinal and non-medicinal plants, as well as a drug that processes herbs before preparing them for sale. Even the "manufacturers" of spices 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 is very severe, even fatal.

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

It is wrong to think that poisoning can only be obtained with an overdose or regular use of smoking mixtures. Practice shows that even the first dose often becomes not only toxic, but also fatal. To avoid the formation of addiction to such means, it is necessary:

• conduct accessible conversations with children and adolescents about the essence and consequences of the use of spices, about their mortal danger;
• protect children from suspicious relationships and bad company.

Adults should always be conscious 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 further transfer of the patient to the toxicological or therapeutic department, for about 5 days;
• in severe cases complicated by pneumonia, renal or hepatic insufficiency, toxic encephalopathy for 10 or more days in the intensive care unit with further rehabilitation in the toxicology department for up to 2 or more weeks.

In many cases, there is a relative recovery of health. Partial disorders of physiological processes, violations of the functionality of organs or parts of organs are not excluded. Some patients develop apallic (psychoorganic) syndrome as a result of hypoxic and toxic brain damage. Neuritis may occur with dysfunction of the limbs. 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.