Over the last six months, the drug K2 – or “spice” – has gained national attention both from the media and the medical community. This synthetic cannabinoid, which is completely legal in most states, is sending users to the ED with symptoms from hallucinations to seizures.
K2 is a tetrahydrocannabinol (THC) analogue, which is the psychoactive component of marijuana. Synthetic cannabinoids have been around since the 1980s, when scientists discovered receptors that bind cannabinoids and cause their effects. In fact, in search of a new analgesic, Pfizer developed their own line of synthetic cannabinoids known as the CP series. In 1994, Clemson professor John W. Huffman developed a series of synthetic cannabinoids. One of them, JWH-018, is thought to be the active ingredient in K2.
While many of us in the United States may be unfamiliar with K2, mention of the synthetic marijuana can be found on the internet dating back to 2006. The drug has gained notoriety in both Asia and Europe leading to Germany banning it in early 2009. However four weeks after it was outlawed in Germany, second-generation products were reported. In most places in the United States, K2 can be purchased over the internet or at any local head shop for about $30. A head shop is any local retail outlet that sells items such as pipes, rolling papers, or other products that can be used as drug paraphernalia. K2 is sold under many names including Spice, Spice Gold, and Spice Diamond. It is marketed as an incense or herbal preparation. In most cases the packaging states that the product is not for human use. Spice is a combination of different herbs that have been sprayed with a synthetic marijuana such as JWH-018. The user can then make it into a cigarette or place it into a bong to smoke just as they would with regular marijuana.
The average marijuana user can be envisioned as the college stoner sitting on his couch while eating junk food and laughing at children’s cartoons. Anyone that has ever treated a patient presenting after using Spice knows that they do not act like this. While undoubtedly some users have a similar experience when they use Spice as they have after smoking marijuana, an increasing amount of patients are not. While I can’t remember the last time a patient, assuming they weren’t being detained by the police or involved in a car accident, was brought to the ED because of marijuana intoxication, local poison center data do show a consistent climb in the number of calls originating from EDs regarding patients using K2. They can present drowsy and with hallucinations. However a number of them present with agitation, bad GI upset, tachycardia, hypertension, and even seizures. Marijuana used in large amounts or very high concentrations can cause some of these symptoms; but once again, when was the last time you saw multiple agitated patients after only using marijuana. Whether these symptoms are due to an inherent characteristic of K2 or just due to the concentration that is sprayed on the herbal product is unknown. Care generally involves symptomatic treatment with hydration and benzodiazepines for agitation. The standard urine drug test, while it can detect marijuana, will not detect K2. While there are some research laboratories that have equipment sensitive enough to detect K2, this technology is not available in a clinically useful manner. Little research has been conducted on possible long-term sequelae after using these drugs.
The drug has also gained the attention of law enforcement. In addition to not showing up on drug tests, part of the popularity of K2 is likely related to it being easily accessible. Its availability is a consequence of it being completely legal in most states. Kansas was the first state to outlaw K2. Missouri and Arkansas have since followed with similar legislation reported in Illinois, Louisiana, Michigan, New Jersey, New York and Texas.
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