New-Onset Psychosis Linked to "Spice," Synthetic Marijuana

By: M. ALEXANDER OTTO, Internal Medicine News Digital Network

New-Onset Psychosis Linked to Synthetic Marijuana Use

HONOLULU – Synthetic marijuana, known as "spice," appears to have induced psychosis in 10 young service members in the U.S. Naval Academy, according to a case series from the Naval Medical Center in San Diego.

"These are people who never had psychosis. They were so disorganized, so out of it, we had to lock them up [on our ward]. It’s pretty scary," Dr. Donald Hurst, lead investigator on the study, reported at the annual meeting of the American Psychiatric Association.

Psychotic symptoms resolved within 8 days in seven patients. One of those patients had a past diagnosis of attention-deficit/hyperactivity disorder; the others had no psychiatric histories. Most had been daily users for weeks, months, or up to a year.

The remaining three patients still suffer lingering paranoid delusions and dysthymia after 5 months. One has a history of substance abuse and a family history of schizophrenia and had been using spice daily for a year and a half; another has a history of depression and had been using spice daily for a month. The third patient, however, has no personal or family psychiatric history and had used spice about 20 times in two months.

The men were in their early 20s. They were each hospitalized 6-10 days. Some had used alcohol, marijuana, or both, with spice. It’s unknown how much the men used during each session.

Given the potential consequences, Dr. Hurst advises discussing spice with patients if there’s cause. "Tell them how bad" results of using the substance can be, said Dr. Hurst, a lieutenant commander and third-year psychiatry resident at the medical center.

The report is the first to link spice to new-onset psychosis in patients with no psychiatric histories. There is no way to know at present how common such reactions are, he said.

After they were admitted, 7 of the 10 patients in the case series got atypical antipsychotics, usually for 4 days. Since writing the report, Dr. Hurst and his colleagues have seen about 20 additional cases and have noticed that patients – if they are going to recover – seem to do so regardless of antipsychotic use.

Because of that, "we are starting on our ward not to give them anything. You may give them an antipsychotic because behaviorally they are out of control, and we need to tone it down. But if they’re calm, we are not giving them anything, and they are still clearing up in 4-8 days," he said.

In terms of presentation, "the most common theme is confusion" along with disorganized behavior and speech. Paranoid delusions also are common, but their focus can shift from minute to minute. Symptoms wax and wane as well, with patients cycling in and out of psychosis hour by hour, sometimes even quicker, Dr. Hurst said.

Auditory and visual hallucinations, flat affect, thought-blocking, alogia, suicidal ideation, insomnia, psychomotor retardation, agitation, and anxiety also were noted in the group.

"The role of spice in inducing these symptoms was determined by military command, friend, family member and/or patient report, as well as urine drug test," Dr. Hurst noted.

Synthetic marijuana is usually a mix of cannabinoid receptor agonists. They are generally full agonists, which distinguishes them from the active ingredient in actual marijuana, tetrahydrocannabinol (THC), which is a partial cannabinoid agonist, Dr. Hurst said.

The chemicals originally were developed to help locate cannabinoid receptors and as experimental pain relievers – uses that did not pan out, he said.

Plant material is dipped into the chemicals, or sprayed with them, and sold on the Internet or in drug paraphernalia shops as K2, Blaze, RedXdawn, and other brands. Spice is usually smoked, but is beginning to be sold as a crystalline powder. Users have no way of knowing how potent a particular product is, Dr. Hurst said.

On March 1, the U.S. Drug Enforcement Agency temporarily designated five synthetic cannabinoids as Schedule I substances, pending further action, "because they pose a threat to public health," according to the order. In January 2011, seven Navy midshipmen were discharged from the Naval Academy because of spice use. In 2008, the U.S. Marine Corps banned the substance because of concern about its increased use among service members.

Dr. Hurst said that he has no disclosures.