smoking synthetic marijuana leads to seng bilateral...

6/1/2016 Smoking Synthetic Marijuana Leads to Self-Mutilation Requiring Bilateral Amputations | Orthopedics

http://www.healio.com/orthopedics/journals/ortho/2014-4-37-4/%7Be1c1de76-8467-4810-8e5f-8f18bde50169%7D/smoking-synthetic-marijuana-leads-to-self-mutil… 1/20

Smoking Synthetic Marijuana Leads to SelfMutilation Requiring Bilateral Amputations

Orthopedics

April 2014 Volume 37 · Issue 4: e391e394

Posted April 1, 2014

DOI: 10.3928/014774472014040162

Abstract

CASE REPORT FREE

Karim A. Meijer, MD; Russell R. Russo, MD; Dhaval V. Adhvaryu, MD

Synthetic cannabinoids have become a worldwide epidemic because they provide asometimes legal, easily accessible, and presumably safe alternative to marijuana. Recentlypublished reports have linked acute psychosis, myocardial infarctions, convulsions, selfharm, and even terrorist organizations to these designer substances. This case reportoutlines the first reported case of Black Diamond, a synthetic cannabis, leading to a selfinflicted burn to the bilateral upper extremities requiring a transradial amputation of theright arm and a toe transfer procedure of the left hand after loss of all digits. The patientpresented to the emergency department with selfinflicted fourthdegree burns to thebilateral hands and forearms with seconddegree burns of the face, for a total body surfacearea of 14.5%. The patient was found by firefighters with his hands aflame on his kitchenstove. With no previous medical or psychiatric history and collateral information toconfirm the patient’s mental status prior to use of Black Diamond, the patient’s acutepsychotic episode was attributed to Black Diamond. After multiple procedures and alengthy recovery, the patient completed his postgraduate education and entered theprofessional world. As orthopedic surgeons, we should be involved in educating the publicon the harm of these designer drugs, including selfmutilation. The popularity of syntheticdrugs in the United States will continue to present a major challenge to all health careproviders. Orthopedists are on the front lines of this epidemic because these drugs pushpatients into risky, traumatic behavior.

The authors are from the Department of Orthopedics (KAM, RRR), LSU Health SciencesCenter, New Orleans; and the Department of General Surgery (DVA), Baton RougeGeneral Medical Center, Baton Rouge, Louisiana.



Received: March 13, 2014Accepted: March 17, 2014

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Russell R. Russo, MD, Department ofOrthopedics, LSU Health Sciences Center, 1542 Tulane Ave, New Orleans, LA 70112 ([email protected]).

Synthetic cannabinoids have become a worldwide epidemic because they provide a sometimeslegal alternative to marijuana. First sold under the name Spice in 2004, the drug has evolvedinto many different names (eg, Black Diamond, Mojo, K2, Spice Gold, Aroma, Dream, Genie,Silver) and packaging from incense to tea bags. These designer drugs and the newer bathsalts have recently drawn the attention of both the medical and law enforcement communities.Recently published reports of recurring psychosis, myocardial infarctions, convulsions, andeven necrotizing fasciitis have been linked to these substances. This case report outlines thefirst reported case of Black Diamond, a synthetic cannabis, leading to bilateral upperextremityselfmutilation treated with a transradial amputation of the right arm and a toe transferprocedure of the left hand after loss of all digits.

1

1–6

Synthetic cannabis, like other designer drugs, masquerades as lessharmful legal herbs andincenses that are marketed under the pretense of giving a marijuanalike high without the illegaltetrahydrocannabinol (THC) chemical formula. In 2009, German scientists tested the popularsubstances and found no traces of these socalled herbs, only a chemically engineeredsynthetic THC product meant to evade regular THC screening tests. Later that year, theGerman government banned the substance and its many homologues. Since the early 2000s,these products have evaded authorities; they have only recently come under review, whenpatients began pouring into emergency departments with severe psychotic events.

7

8

Synthetic cannabinoids are chemically altered drugs designed to mimic the effects of traditionalmarijuana. Often sold in stores and on the Internet as incense, these engineered drugs canhave severe side effects, such as acute psychosis leading to selfmutilation. Many case reportsare emerging that demonstrate the powerful psychotic effects these new designer drugs canhave or the drugs’ ability to exacerbate underlying psychosis in previously susceptibleindividuals. Originally created in laboratories for the purpose of research on pain and its effectson brain function, synthetic cannabinoids have escaped the laboratory and are proliferatingacross Europe and the United States. Many states have acknowledged the dangers of thesedrugs, as well as others such as bath salts. They have been banned in 18 states since October2011. This case report serves as a warning to the medical community and orthopedicsurgeons in particular because these drugs are undetectable in routine emergency departmentscreening and have added medical concerns. These patients may need medical andpsychological treatment for their addiction, withdrawal, and recurrent psychoses.

9

1

When presented with a patient with a mangled extremity, the physician must keep in mind the



Case Report

When presented with a patient with a mangled extremity, the physician must keep in mind thewhole patient. Initial treatment should begin with the ABCs of trauma, followed by a secondarysurvey and full medical and psychosocial assessment to restore the patient’s best possiblefunctional and cosmetic result. This case report outlines the treatment of a patient who smokedBlack Diamond, a synthetic cannabis, which led to an acute psychosis. The patient deliberatelyburned his hands and face and was treated accordingly with burn resuscitation, multipledebridements, transradial amputation, toe transfer, and ultimately a myoelectric prosthesis,giving him a chance at a fulfilling life.

A healthy 26yearold man presented to the emergency department with selfinflicted

fourthdegree burns to the bilateral hands and forearms with seconddegree burns to the

face, for a total body surface area of 14.5%. The patient was found by firefighters with his

hands aflame on his kitchen stove. The smoke detectors had alerted the firefighters to the

residence, and with the patient’s hands still gripped to the stove, 6 firefighters and an

electroshock weapon were required to subdue the individual and remove him from the

flames. The patient had no previous medical or psychiatric history except for attention

deficit disorder, which had been treated with lisdexamfetamine dimesylate and kept stable

for many years. He was an intelligent and highfunctioning member of society pursuing a

postgraduate degree. His social, family, and surgical histories were otherwise

unremarkable (Figures 1–2).

Figure 1:



Initial emergency department photograph

of the dorsum of the left hand.



Figure 2:

Initial emergency department photograph of

the volar surface of the left hand.

On admission to the emergency department, standard burn protocol and fluid resuscitationwere initiated. The patient underwent urgent irrigation and debridement to identify healthytissue margins. His initial debridement required amputations of his right thumb and ringand small fingers at the level of the metacarpophalangeal joint and the index and longfingers at the level of the proximal interphalangeal joint. His left hand requiredamputations of the thumb and index, long, and ring fingers at the level of themetacarpophalangeal joint, with the long and ring fingers being amputated at the proximalinterphalangeal joint. The small finger required a transmetacarpal amputation. Over thecourse of the next month, the patient underwent multiple debridements of his bilateralupper extremities, as well as fasciotomies (Figures 3–4).



Figure 3:

Photograph showing debridement of

the right upper extremity.



Figure 4:

Photograph showing debridement of

the left upper extremity.

Once the patient was stabilized both medically and psychologically, his history was

reviewed and revealed that prior to his acute psychotic outbreak, the patient had purchased

Black Diamond, a synthetic marijuana, and smoked it to get high. Through collateral

information, the mental state of the patient was completely lucid prior to smoking Black

Diamond. The patient had just returned home from visiting a friend. Moments after



Discussion

smoking the synthetic marijuana, the patient had paranoid delusions causing him to feel hishands were going to harm him. At that point, he placed them on the stove and attempted toburn them off to “get the devil out of [him].”

The patient subsequently underwent multiple procedures, including a groin flap forcoverage of his left hand, placement of roughly 900 cm of synthetic dermal substitute tohis upper extremities, multiple skin grafts, and eventually a transradial amputation of hisright upper extremity. He was subsequently fitted with a myoelectric prosthesis and beganto return to normal activities. The patient is now in good health and attending aprofessional university, where he is progressing well with no recurrent paranoid delusions.

2

It is of note that an attempt was made after initial debridements to arrange a handtransplantation; however, the patient did not meet the requirements of the acceptingfacility.

When attempts at hand transplantation failed, the authors chose to perform a large toetransfer for pollicization. This allowed the best possible functional outcome for the patientgiven the limitations.

This case report is one of the first to elucidate a link between synthetic cannabinoids andparanoia leading to selfmutilation. Through an arduous process of multiple orthopedic,burn, and plastic surgery procedures, this patient was able to make a recovery to afunctional state in which he can lead a meaningful and productive life.

Although recently banned by both the US Drug Enforcement Agency and individual states,these drugs continue to increase in popularity. The complexity of designer drugs allowsoverseas manufacturers of these substances to evade authorities and sell them legally whilesidestepping current laws. It is possible that more patients will present as the currentpatient did with disfiguring injuries leading to loss of limb and even death. A possibleexplanation for the increased demand may be the potential for evading drug tests, whichmay shift the demographic of patients who abuse these drugs toward working professionalsor athletes who may undergo routine drug testing. Recently, urine samples collected from5956 athletes showed that 4.5% of samples had metabolites of JWH018 and/or JWH073,which are synthetic cannabinoids. Orthopedic surgeons and the medical community must10



References

1. Pierre JM. Cannabis, synthetic cannabinoids, and psychosis risk: what the evidencesays. Current Psychiatry. 2011; 10(9):49–57.https://www.procon.org/files/current_psychiatry_psychosis.pdf. Accessed: July 3, 2013.

be able to recognize the effects of such synthetic drugs because they do not appear on

routine emergency department tests. Sendout laboratory tests exist but are commonly used

only for state drug testing of workers and athletes or for postmortem diagnostic testing.

Synthetic cannabinoids produce symptoms similar to those of marijuana; however, unlike

marijuana, synthetic cannabinoids produce unexplainable psychotic symptoms in some

individuals. Multiple case reports have demonstrated this psychosis. Synthetic

cannabinoids can also aggravate existing medical and psychological conditions or cause an

outbreak of an acute psychotic episode in someone who may be healthy but who has a

family history of psychological disease or a predisposition to a psychotic break. Case

reports have illustrated a possible link, but there are no standardized largescale published

reports proving a correlation.

11,12

Because these designer drugs were only introduced in the United States in the past couple

of years, reports in the medical literature on their effects have been sparse. The first

physician encountered by patients taking the drugs may likely be an orthopedic surgeon

due to the psychotic outbreaks and patients’ subsequent dangerous behavior leading to

traumatic injuries. Orthopedic surgeons must be diligent in identifying signs of intoxication

and in aiding primary care physicians and emergency department doctors in diagnosing and

treating these patients so as to avoid recurrence of these events.

Educating the community, and specifically legislators, is the duty of physicians as patient

advocates. Physicians need to be more active with state and national leaders to protect the

community from these seemingly harmless overthecounter drugs, which have the

potential to cause serious harm. As their popularity rises, so will the devastating

consequences. It is hoped that more states formally ban designer drugs and that the federal

government takes action on the importation of these drugs. Recent news has documented

the importation of synthetic marijuana as a multimillion dollar industry for terrorist

organizations. Designer drugs are more than a danger to our health; they are also a

problem of national security. It is hoped that the current patient’s story will inspire law

changes and protect others from the dangers of designer drugs.

13


http://www.healio.com/orthopedics/journals/ortho/2014-4-37-4/%7Be1c1de76-8467-4810-8e5f-8f18bde50169%7D/smoking-synthetic-marijuana-leads-to-self-muti… 10/20

2. Rodgman C, Kinzie E, Leimbach E. Bad Mojo: use of the new marijuana substitute leadsto more and more ED visits for acute psychosis. Am J Emerg Med. 2011; 29(2):232.doi:10.1016/j.ajem.2010.07.020 [CrossRef]

3. Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of thesynthetic cannabinoid K2. Pediatrics. 2011; 128(6):e1622–e1627.doi:10.1542/peds.20103823 [CrossRef]

4. Schneir AB, Baumbacher T. Convulsions associated with the use of a syntheticcannabinoid product. J Med Toxicol. 2012; 8(1):62–64. doi:10.1007/s1318101101822[CrossRef]

5. Russo R, Marks N, Morris K, King H, Gelvin A, Rooney R. Lifethreatening necrotizingfasciitis due to ‘bath salts’ injection. Orthopedics. 2012; 35(1):e124–e127.

6. Harris CR, Brown A. Synthetic cannabinoid intoxication: a case series and review. JEmerg Med. 2013; 44(2):360–366. doi:10.1016/j.jemermed.2012.07.061 [CrossRef]

7. Stafford N. Synthetic cannabis mimic found in herbal incense. Chemistry World News.January15, 2009. http://www.rsc.org/chemistryworld/News/2009/January/15010901.asp.Accessed March 1, 2014.

8. Adams S. Teens in Britain getting legally high on synthetic cannabis banned acrossEurope. The Telegraph. February13, 2009. http://www.telegraph.co.uk/news/uknes/lawandorder/4611523/TeensinBritainGettingLegallyHighonSyntheticCannabisBannedAcrossEurope.html. Accessed March 1, 2014.

9. Fergusson DM1, Poulton R, Smith PF, Boden JM. Cannabis and psychosis. BMJ. 2006;332(7534):172–175. doi:10.1136/bmj.332.7534.172 [CrossRef]

10. Heltsley R, Shelby MK, Crouch DJ, et al. Prevalence of synthetic cannabinoids in U.S.athletes: initial findings. J Anal Toxicol. 2012; 36(8):588–593. doi:10.1093/jat/bks066[CrossRef]

11. Fattore L, Fratta W. Beyond THC: the new generation of cannabinoid designer drugs.Front Behav Neurosci. 2011; 5:60. doi:10.3389/fnbeh.2011.00060 [CrossRef]

12. EveryPalmer S. Warning: legal synthetic cannabinoidreceptor agonists such as JWH018 may precipitate psychosis in vulnerable individuals. Addiction. 2010; 105(10):1859–1860. doi:10.1111/j.13600443.2010.03119.x [CrossRef]

13. Cloherty J, Zhang S. Bath salts and other synthetic drugs making “millions” for terrorists.abcnew.com Website. http://abcnews.go.com/Politics/bathsaltssyntheticdrugsmakingmillionsterrorists/story?id=19507041. Published June 27, 2013. Accessed January 1,2014.

10.3928/014774472014040162



Abstract

Article

Received: March 13, 2014

Accepted: March 17, 2014

Ā Previous Article Next Article ā

Synthetic cannabinoids have become a worldwide epidemic because they provide a

sometimes legal, easily accessible, and presumably safe alternative to marijuana.

Recently published reports have linked acute psychosis, myocardial infarctions,

convulsions, selfharm, and even terrorist organizations to these designer substances.

This case report outlines the first reported case of Black Diamond, a synthetic cannabis,

leading to a selfinflicted burn to the bilateral upper extremities requiring a transradial

amputation of the right arm and a toe transfer procedure of the left hand after loss of all

digits. The patient presented to the emergency department with selfinflicted fourthdegree

burns to the bilateral hands and forearms with seconddegree burns of the face, for a total

body surface area of 14.5%. The patient was found by firefighters with his hands aflame on

his kitchen stove. With no previous medical or psychiatric history and collateral information

to confirm the patient’s mental status prior to use of Black Diamond, the patient’s acute

psychotic episode was attributed to Black Diamond. After multiple procedures and a

lengthy recovery, the patient completed his postgraduate education and entered the

professional world. As orthopedic surgeons, we should be involved in educating the public

on the harm of these designer drugs, including selfmutilation. The popularity of synthetic

drugs in the United States will continue to present a major challenge to all health care

providers. Orthopedists are on the front lines of this epidemic because these drugs push

patients into risky, traumatic behavior.

The authors are from the Department of Orthopedics (KAM, RRR), LSU HealthSciences Center, New Orleans; and the Department of General Surgery (DVA), BatonRouge General Medical Center, Baton Rouge, Louisiana.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Russell R. Russo, MD, Department ofOrthopedics, LSU Health Sciences Center, 1542 Tulane Ave, New Orleans, LA 70112( [email protected]).

Synthetic cannabinoids have become a worldwide epidemic because they provide a



Synthetic cannabinoids have become a worldwide epidemic because they provide asometimes legal alternative to marijuana. First sold under the name Spice in 2004, thedrug has evolved into many different names (eg, Black Diamond, Mojo, K2, Spice Gold,Aroma, Dream, Genie, Silver) and packaging from incense to tea bags. These designerdrugs and the newer bath salts have recently drawn the attention of both the medical andlaw enforcement communities. Recently published reports of recurring psychosis,myocardial infarctions, convulsions, and even necrotizing fasciitis have been linked tothese substances. This case report outlines the first reported case of Black Diamond, asynthetic cannabis, leading to bilateral upperextremity selfmutilation treated with atransradial amputation of the right arm and a toe transfer procedure of the left hand afterloss of all digits.

1

1–6

Synthetic cannabis, like other designer drugs, masquerades as lessharmful legal herbsand incenses that are marketed under the pretense of giving a marijuanalike high withoutthe illegal tetrahydrocannabinol (THC) chemical formula. In 2009, German scientiststested the popular substances and found no traces of these socalled herbs, only achemically engineered synthetic THC product meant to evade regular THC screeningtests. Later that year, the German government banned the substance and its manyhomologues. Since the early 2000s, these products have evaded authorities; they haveonly recently come under review, when patients began pouring into emergencydepartments with severe psychotic events.

7

8

Synthetic cannabinoids are chemically altered drugs designed to mimic the effects oftraditional marijuana. Often sold in stores and on the Internet as incense, these engineereddrugs can have severe side effects, such as acute psychosis leading to selfmutilation.Many case reports are emerging that demonstrate the powerful psychotic effects thesenew designer drugs can have or the drugs’ ability to exacerbate underlying psychosis inpreviously susceptible individuals. Originally created in laboratories for the purpose ofresearch on pain and its effects on brain function, synthetic cannabinoids have escapedthe laboratory and are proliferating across Europe and the United States. Many stateshave acknowledged the dangers of these drugs, as well as others such as bath salts. Theyhave been banned in 18 states since October 2011. This case report serves as a warningto the medical community and orthopedic surgeons in particular because these drugs areundetectable in routine emergency department screening and have added medicalconcerns. These patients may need medical and psychological treatment for theiraddiction, withdrawal, and recurrent psychoses.

9

1

When presented with a patient with a mangled extremity, the physician must keep in mindthe whole patient. Initial treatment should begin with the ABCs of trauma, followed by asecondary survey and full medical and psychosocial assessment to restore the patient’sbest possible functional and cosmetic result. This case report outlines the treatment of apatient who smoked Black Diamond, a synthetic cannabis, which led to an acutepsychosis. The patient deliberately burned his hands and face and was treated accordinglywith burn resuscitation, multiple debridements, transradial amputation, toe transfer, andultimately a myoelectric prosthesis, giving him a chance at a fulfilling life.

smoking synthetic marijuana leads to seng bilateral...

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