1. A Spike in Emergency Department Visits Associated With Synthetic Cannabinoid Use – Alaska, 2015 Sarah Shafer Public Health Associate Program Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention PHAP Spring Seminar April 5 th,2016 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

2. Samples collected from patients at the hospital. BACKGROUND What are synthetic cannabinoids?

3.  Municipality of Anchorage and emergency medical services began reporting an increase in Spice related emergencies.  Problems with Spice:  Difficult to regulate  Cheap and readily available  Not easily detected in standard drug tests  Misperceived as natural  Difficult to track  Burdens emergency medical services BACKGROUND Spice in Anchorage

4. BACKGROUND Alaska Section of Epidemiology Investigates  Purpose of investigation:  Quantify the burden on the health care system  Characterize variation in the severity of symptoms and outcomes associated with Spice use  Conduct laboratory testing on samples to characterize the chemical formulations circulating in Anchorage  Use information gleaned from the investigation to reduce the health burden of Spice use in the community

5. METHODS Preliminary Fact-Finding Investigation  Interviewed individuals, predominantly homeless  Distributed a fact sheet with warnings about the health risks  Used medical records to gather:  Severity of health complications  Clinical outcomes observed  Discharge diagnoses assigned to patients

6. METHODS (continued) Systematic Epidemiologic Characterization  Medical records were requested from 3 main hospitals  A query was run on these medical records for common diagnoses:  Acute drug intoxication, altered mental status, drug abuse, drug ingestion, drug psychosis, drug use, illicit drug use, poly-substance abuse, and substance abuse  Charts from the query were reviewed and classified as:  Self- proclaimed, Suspected, Questionable, Unrelated  Data were abstracted from charts classified as self- proclaimed and suspected

7. RESULTS Epidemiologic Characterization  The query flagged 488 emergency department visits  167 were categorized as self-proclaimed or suspected  321 were categorized as either unrelated or questionable  The 167 self-proclaimed or suspected = 167 Spice Cases  Represented 128 unique persons (25 had >1 visit)  85% (n=142) were male  Mean age of 37 years (range 12-62)  40% (n=66) homeless  Roughly half included race and were 41% (n=36) Caucasian, 31% (n=27) American Indian or Alaska Native, 22% (n=19) African American  Over 78 day period (July 15 th -September 30 th ) there were 2.1 emergency department visits per day (range 0-12)

8. RESULTS (continued) Epidemiologic Characterization  Medical Interventions and Clinical Outcomes of Spice cases  10% (n=17) were admitted from the emergency department to the hospital  7% (n=11) underwent endotracheal intubation  16% (n=26) required physical restraints  69% (n=115) involved lethargic patients  33% (n=55) involved agitated patients  22% (n=37) involved both lethargy and agitation  46% (n=75) exhibited tachypnea  29% (n=48) exhibited tachycardia

9.  The investigation confirmed anecdotal reports of a considerable spike in Spice related medical emergencies  Overall volume of patients transported and treated for Spice represented a substantial burden on time and resources  72.2% (n=873) of ambulance transports originated near downtown Anchorage, where the homeless population is concentrated. DISCUSSION

10.  Information from interviews found:  The ready availability of Spice  Spice is cheaper and easier to obtain than marijuana  Spice overdose involved a rapid onset of extreme symptoms ranging from lethargy or loss of consciousness to agitation and violence, sometimes accompanied with posturing and seizure-like activity  Because Spice is visually similar to marijuana, use could easily be and is often unintentional  It is virtually impossible for a person using Spice to know what chemicals he/she is ingesting, and in what concentration DISCUSSION (continued)

11.  Three potential and not mutually exclusive factors that may have catalyzed this outbreak include:  A change in the chemistry of synthetic cannabinoids being used  A change in the incidence (rate) of use  A change in the user population Members of the homeless population are much more likely than the general population to have underlying medical conditions DISCUSSION (cont.) What Caused the Outbreak?

12. DISCUSSION (cont.) Limitations  Lack of baseline data  Determining homelessness  Classification of cases  Investigation only included patients who were alive at presentation in the emergency department  Standard drug and alcohol testing regularly performed as part of postmortem evaluations cannot detect Spice.  Only 2 of the 3 Anchorage hospitals participated in the epidemiologic characterization investigation

13. CONCLUSION AND IMPLICATIONS FOR PUBLIC HEALTH  This investigation highlights the need for systematic surveillance and enhanced community cooperation to better mitigate the burden of this public health issue  On November 10 th 2015 the Anchorage Assembly passed an ordinance that made possessing and selling Spice a misdemeanor crime in Anchorage – a fine up to $10,000 or as much as one year in jail. Law enforcement began immediately thereafter  By the end of January 2016, the Anchorage Fire Department reported a slight decrease in Spice related medical emergencies

14. For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: OSTLTSfeedback@cdc.govWeb: http://www.cdc.gov/stltpublichealthOSTLTSfeedback@cdc.govhttp://www.cdc.gov/stltpublichealth The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Sarah Shafer YPL2@cdc.gov Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support