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BACKGROUND: Illicit synthetic drugs (ISD), including synthetic cathinones (“bath salts”) and synthetic cannabinoids (“synthetic marijuana”) have become popular substances of abuse in recent years. ISD diagnoses are challenging, as new compounds are not detected by standard toxicology screens. Since 2010, ISD use has become a concern for emergency departments in Duluth, MN (population 86,000). In 2013, the Minnesota Department of Health initiated an exploratory epidemiologic investigation into the health care burden of ISD.
METHODS: The investigation utilized a case series design, with a convenience sample of people with suspected ISD use treated in EDs at two Duluth-area hospitals from January through September 2013. Cases were identified by poison center data or physician recall. Data were collected through medical record review. A positive case was defined as having ISD recorded in the medical record. A nested case series of 36 subjects was further examined for diagnosis codes.
RESULTS: Of 78 cases reviewed, 58 (74%) patients reported having used ISD: 38 (66%) used cannabinoids, 15 (26%) cathinones, and 5 (9%) used both; 58 (74%) had a history of polysubstance use; and 54 (69%) were male. The median age was 34 (range 12 to 73) years; 52 (67%) were unemployed. Most patients utilized external resources to arrive at the hospital: 36 (46%) by police escort and 23 (29%) by ambulance. The most common signs/symptoms experienced by cases included agitation, violent/bizarre behavior, anxiety, anger/aggression, hallucinations and confusion. Of hospitalized cases, 18 (23%) patients were admitted to the intensive care unit; 24 (31%) to the psychiatric unit, and 2 (3%) to general medicine. Median length of stay was 4 (range 1-39) days. Diagnosis codes were distributed disparately amongst cases, and included respiratory failure, renal failure, rhabdomyolysis, cannabis abuse and others. There were no codes for synthetic drug use.
CONCLUSIONS: At least 78 ISD cases were evaluated in a 9-month period. ISD cases were generally male, age in mid-30s, and unemployed. ISD use was associated with a high hospitalization rate, including intensive care. Symptoms for cathinones and cannabinoids overlapped and typically included agitation, violent and bizarre behavior. Most cases had a history of polysubstance use, suggesting ISD use is an indicator of an existing polysubstance use issue. Specific ISD diagnostic codes were not available, which complicated the tasks of identifying cases, and estimating incidence and healthcare burden. Strategies such as adding a code as part of the annual code updates would further enable ISD investigations.