May 18, 2018, 03:33 pm Chris Crawford – The recent cases of severe bleeding linked to contaminated synthetic cannabinoids highlighted the advantages of a family medicine approach to managing a public health crisis, a physician in one of the hardest-hit outbreak areas told AAFP News.
As of May 9, the Illinois Department of Public Health (IDPH) has received reports of 164 cases, including four deaths, linked to an outbreak that began March 7 and caused synthetic cannabinoid users to suffer from severe bleeding possibly linked to contamination from brodifacoum.
According to an April 3 CDC Clinician Outreach and Communication Activity (COCA) outbreak alert update, additional potentially related cases were reported in Florida, Indiana, Kentucky, Maryland, Missouri, Pennsylvania, Virginia and Wisconsin.
Brodifacoum is a lethal 4-hydroxycoumarin vitamin K antagonist anticoagulant that is typically used as a rodenticide.
The CDC said its laboratory testing confirmed brodifacoum exposure in at least 60 patients. Additionally, at least seven synthetic cannabinoid product samples related to this outbreak have tested positive for brodifacoum.
Asim Jaffer, M.D., (right) precepts residents like third-year resident Nathan Gallagher, M.D., at the UnityPoint Clinic-Family Medicine in Peoria, Ill., where many of the patients affected by the recent synthetic cannabinoid poisoning outbreak were treated.
The IDPH said synthetic cannabinoids are human-made, mind-altering chemicals that are either sprayed on dried, shredded plant material so they can be smoked, or sold as liquids to be vaporized and inhaled in e-cigarettes and other devices.
These products are also known as herbal or liquid incense and have brand names such as K2, Spice, Black Mamba, Bombay Blue, Genie, and Zohai, but also may be packaged under other brand names, the department report said.
Cannabinoids contain chemicals similar to those in marijuana, and they also are called "synthetic marijuana" or "fake weed."
"Synthetic cannabinoids are part of a group of drugs called new psychoactive substances (NPS)," the IDPH said. "NPS are unregulated mind-altering substances that have become newly available on the market and are intended to produce the same effects as illegal drugs."
In its general guidance for health care professionals on synthetic cannabinoids, the CDC said these drugs first appeared for sale in Europe around 2005 and arrived on U.S. shelves in 2008.
"Poison centers receive thousands of reports of adverse health effects in persons using synthetic cannabinoids annually; 2015 was the year with the highest number of calls at 7,794," the agency said.
The CDC also said a disproportionate number of synthetic cannabinoid users are men in their 20s and 30s.
Asim Jaffer, M.D., is president of the Illinois AFP and teaches in the residency program at the University of Illinois College of Medicine at Peoria Family Medicine Residency. He practices at UnityPoint Clinic-Family Medicine, also in Peoria.
According to the IDPH, Peoria County had 35 of Illinois' 164 cases, making it the third highest concentration of cases, behind only Chicago (40) and Tazewell County (49).
Jaffer said he and his family medicine residency staff treated many of the cases that presented in Peoria using an interdisciplinary approach that included the ER, ICU and resident rounding service, as well as follow-up care at the residency center.
Jaffer said shortly before the first patients affected by this outbreak arrived at the hospital, the IDPH issued a bulletin warning there could be patients presenting with severe bleeding from synthetic cannabinoid use.
"Two days after that bulletin came out, we started seeing patients presenting with symptoms of severe bleeding, hematuria, groin pain, testicular pain, vaginal bleeding, vomiting blood, severe bloody noses and coughing up blood," he said.
"What was particularly challenging with these patients was that initially they did not respond to the traditional treatments for controlling the bleeding," Jaffer said. "A traditional patient would need a one-time, low dose of vitamin K (5 or 10 mg), which acts on the liver and helps promote the production of clotting factors. Many of these patients required 10-20 times those doses of vitamin K and needed recurrent, multiple-times-a-day dosing. That's why they call it vitamin K-dependent coagulopathy."
Taking a family medicine approach to a public health crisis means more than just managing symptoms or directing treatment in a hospital setting, he said.
"One of the reasons we did right by our patients and were successful in treating them was we had a consistent family medicine team in the hospital that saw every patient affected by this outbreak and were admitted on the medical floor, as opposed to the patients being sent to different services," Jaffer said. "By not assigning patients to different services, we could standardize our counseling and treatment plans and better understand some of the unique challenges of this difficult patient population."
For example, some of these patients had insurance and some didn't.
The CDC mentioned in its COCA outbreak alert update that repeated vitamin K treatments are expensive. An oral supply of vitamin K for two weeks of treatment can cost $8,000 and treatment might be required for months.
Jaffer confirmed that the vitamin K treatments are expensive and said his facility got around this issue by sourcing the medication from suppliers offering a lower cost and applying quickly to federal programs that helped subsidize and pay for the medication.
"It took a great deal of time and effort and coordination between the physicians, pharmacists, insurance companies and federal programs, but thank goodness we were able to do that," he said.
Without that action, the vitamin K medication would have been cost-prohibitive for most patients, Jaffer added.
During the peak of the outbreak, the facility held daily interdisciplinary meetings to discuss the affected panel of patients and any related challenges, including getting enough vitamin K medication. This group included representatives from hospital administration, the emergency department, nursing, social work, pharmacy, intensive care and the family medicine residency. And these conversations still occur today, Jaffer said, just more by phone and as needed.
After patients were stabilized and discharged from the hospital, the family medicine residency team continued to treat them during regular follow-up appointments. Each patient had their own dedicated social worker and care facilitator, as well.
"Having the same team that managed the patients in the hospital and built a trust with a patient population that often has mistrust in the health care system was beneficial," Jaffer said. "Our residents really worked overtime to build relationships with these patients -- and many times, educated them on adherence to the treatment plans and making sure there was regular follow-up, because it could really be life-threatening if they were to miss doses or appointments."
Jaffer said the patients affected by the outbreak also were told to reach out to their family and friends who might be using synthetic cannabinoids and explain the risks related to the outbreak and the availability of the family medicine residency center to check them out and treat them, if needed.
The family medicine residency center continues to treat these patients daily, Jaffer said.
"You want to get those patients in the door," he said. "You build that trust and relationship and now we can deal with more than just this poisoning. We can deal with the substance abuse issues they have, other health issues, the routine health maintenance and preventive care that should happen. For the first time now, many of these patients are established with family doctors. I think there's real value in that."
For family physicians who didn't see patients affected by the recent outbreak, Jaffer cautions that synthetic cannabinoids don't show up on standard drug screens.
"So keep them high on your list of differentials when you see bleeding or coagulopathy that's unexplained," he said, "and include that in your history-taking when you see patients who present with symptoms that don't make sense."
The CDC recommended that all patients be asked about their history of illicit drug use.
"All 'high-risk' patients (e.g., synthetic cannabinoids users), regardless of their presentation, should be screened for vitamin K-dependent antagonist coagulopathy by checking their coagulation profile (e.g., international normalized ratio and prothrombin time)," the agency said.
Jaffer closed by explaining how valuable the experience of treating these patients was for his family medicine residents.
"This slammed home the idea that this is what we do as family docs and why we can do it so well," he said. "I told them it's important to remember with these and all of our patients that we build trust and relationships by being nonjudgmental. And then we drove home that there's real value in having close follow-up and seamless transitions of care from the hospital to the clinic with our patients."
CDC Health Studies Branch: Synthetic Cannabinoids