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2. Synthetic Cannabinoids: Management of Intoxication and Withdrawal
David A. Gorelick, M.D., Ph.D., DLFAPA
Professor of Psychiatry
University of Maryland School of Medicine

3. CB1 No specific antidote Block the acute effects of cannabis
Supportive and symptomatic treatment
Taken off the market in 2008
May require hospitalization for observation and monitoring
Psychiatric side effects
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

4. Specific Symptom Treatment
Acetaminophen
Pain or fever
Short-acting benzodiazepines 
(e.g., lorazepam) 
Anxiety or agitation
Antipsychotics
Severe or persistent psychosis
Antidepressants (rarely)
Transient suicidal ideation in acute intoxication
Close evaluation for comorbid psychiatric disorder
Psychiatric symptoms > 1 week
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

5. Synthetic Cannabinoid Withdrawal Syndrome
Anxiety
&
Increased muscle tone
Muscle twitching
Depression
Insomnia
Chills and sweating
Decreased appetite
Increased drug craving
Headache
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

6. Management of Withdrawal
Schedule III medication 
Marinol
(Dronabinol)
Nausea and vomiting
Cachexia with cancer chemotherapy
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

7. No clinical trials of dronabinol to treat synthetic cannabinoid withdrawal
No approved pharmacological treatments for synthetic cannabinoid withdrawal 
No consensus clinical practice guidelines for its treatment

8. Clinical Management of Withdrawal
Observation and monitoring
Supportive and symptomatic measures
Antidepressants if:
Intravenous fluids for dehydration
Short-acting benzodiazepines for agitation or anxiety 
Depression persists more than several days
Known, independent, comorbid mood disorder
Acetaminophen for pain or headache
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

9. Substance Use Disorder
10%
Chronic, regular cannabis users
Develop cannabis use disorder ?
Synthetic cannabinoid users
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

10. Formal Diagnosis Diagnostic criteria categories
Impaired control over synthetic cannabinoid use
Social impairment due to synthetic cannabinoid use
Risky use of synthetic cannabinoids
Pharmacological dependence on synthetic cannabinoids; tolerance or withdrawal
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

11. Treatment of Synthetic Cannabinoid Use Disorder
Group
General principles
CBT
Individual
Treatment of Synthetic
Cannabinoid Use Disorder
Understand the adverse consequences
Learn better coping strategies
*No specific treatment protocol
No medication to reduce synthetic cannabinoid craving or use
Monte, A. A., Calello, D. P., Gerona, R. R., Hamad, E., Campleman, S. L., Brent, J., ... & ACMT Toxicology Investigators Consortium. (2017). Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC Database study. Journal of Medical Toxicology, 13(2),
Tait, R. J., Caldicott, D., Mountain, D., Hill, S. L., & Lenton, S. (2016). A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clinical Toxicology, 54(1), 1-13.

12. Key Points
Intoxication and withdrawal syndromes often resemble those from plant cannabis but may be more intense and longer lasting.
Treatment of intoxication and withdrawal is supportive and symptomatic, as no specific antidotes are available.

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