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Drug and Alcohol Dependence
journal homepage: www.elsevier.com/locate/drugalcdep
Full length article
Synthetic cannabinoid JWH-018 and psychosis: An explorative study
Susanna Every-Palmer ∗
Te Korowai-Whāriki, A Capital and Coast District Health Board Service, Ratonga Rua O Porirua, Regional Forensic Service, Raiha Street,
P O Box 50-233 Porirua, New Zealand
a r t i c l e
i n f o
Article history:
Received 7 July 2010
Received in revised form 6 January 2011
Accepted 15 January 2011
Available online xxx
Keywords:
Cannabinoids
Psychoses, substance-induced
Designer drugs
Qualitative research
Psychotic disorders
Forensic psychiatry
Spice
JWH-018
a b s t r a c t
Background: Aroma, Spice, K2 and Dream are examples of a class of new and increasingly popular
recreational drugs. Ostensibly branded “herbal incense”, they have been intentionally adulterated with
synthetic cannabinoids such as JWH-018 in order to confer on them cannabimimetic psychoactive properties while circumventing drug legislation. JWH-018 is a potent cannabinoid receptor agonist. Little is
known about its pharmacology and toxicology in humans. This is the first research considering the effects
of JWH-018 on a psychiatric population and exploring the relationship between JWH-018 and psychotic
symptoms.
Method: This paper presents the results of semi-structured interviews regarding the use and effects of
JWH-018 in 15 patients with serious mental illness in a New Zealand forensic and rehabilitative service.
Results: All 15 subjects were familiar with a locally available JWH-018 containing product called “Aroma”
and 86% reported having used it. They credited the product’s potent psychoactivity, legality, ready availability and non-detection in drug testing as reasons for its popularity, with most reporting it had replaced
cannabis as their drug of choice. Most patients had assumed the product was “natural” and “safe”. Anxiety
and psychotic symptoms were common after use, with 69% of users experiencing or exhibiting symptoms consistent with psychotic relapse after smoking JWH-018. Although psychological side effects were
common, no one reported becoming physically unwell after using JWH-018. Three subjects described
developing some tolerance to the product, but no one reported withdrawal symptoms.
Conclusion: It seems likely that JWH-018 can precipitate psychosis in vulnerable individuals. People with
risk factors for psychosis should be counseled against using synthetic cannabinoids.
© 2011 Published by Elsevier Ireland Ltd.
1. Introduction
While cannabis use has a long history, the emergence of synthetic cannabinoids such as JWH-018 is recent. This article explores
the relationship between JWH-018 and psychotic symptoms and
reports 15 forensic inpatients’ experiences with synthetic cannabinoid containing products (SCCPs).
1.1. Background: SCCPs emerge as a new drug trend
Spice, Aroma, K2 and Dream are examples of a large
and evolving group of smokable products branded as ‘herbal
incense’, but found by users to have potent cannabis-like properties. Spice first started appearing on internet sites and in
specialized shops around 2004 (Dresen et al., 2010). Warning messages on the product stating it was not intended for
human consumption contrasted with sophisticated packaging
∗ Tel.: +64 4 385 5999; fax: +64 4 918 2477.
E-mail addresses: Susanna [email protected],
[email protected]
and marketing, promoting the product as a cannabis alternative
which was undetectable by conventional drug testing methodology.
It was not until December 2008 that researchers reported the
reason for Spice’s cannabis-like properties: Spice had been ‘laced’
with undeclared synthetic cannabinoids JWH-018 and CP 47,497
(Auwärter et al., 2009). It is believed that these synthetic cannabinoids were dissolved in a solvent which was then sprayed on a
plant-derived base for delivery (Vardakou et al., 2010). The herbal
ingredients cited on Spice’s packaging did not appear to contribute
to its psychoactivity; in fact they were not even present in most of
the samples tested (Piggee, 2009).
Since being identified in “herbal” products JWH-018 and CP
47,497 and have been banned in a number of European countries
and some American States (Vardakou et al., 2010). Three weeks
after CP-compounds and JWH-018 were banned in Germany,
second generation products (e.g., analogues such as JWH-073)
appeared on the market, suggesting the manufacturers had
anticipated prohibition and had already synthesized an array
of alternatives (Lindigkeit et al., 2009). Currently “headshops”
and the internet offer an ever-expanding array of synthetic
cannabinoids originating from 3 chemically distinct groups
0376-8716/$ – see front matter © 2011 Published by Elsevier Ireland Ltd.
doi:10.1016/j.drugalcdep.2011.01.012
Please cite this article in press as: Every-Palmer, S., Synthetic cannabinoid JWH-018 and psychosis: An explorative study. Drug Alcohol Depend.
(2011), doi:10.1016/j.drugalcdep.2011.01.012
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(JWH-, CP- and HU-compounds), alongside oleamide, a fatty acid
with cannabinoid-like activity (EMCDDA, 2009; Hudson et al.,
2010; Lindigkeit et al., 2009; Uchiyama et al., 2009; United States
Drug Enforcement Administration, 2009).
The rapid proliferation of synthetic cannabinoid products over
the last 4 years has been labeled the “Spice phenomenon”
(EMCDDA, 2009). Griffiths et al. (2010) consider the Spice phenomenon to be a “case study” of how existing models of drug
control and response are being challenged by globalization, internet technology and innovation in the drug market.
1.2. Synthetic cannabinoids and psychosis
Little data is available on the psychological and other risks of
synthetic cannabinoids.
Psychotic relapses following the use of a JWH-018 product in 5
patients in our forensic service have already been reported (EveryPalmer, 2010). There is one published case report of tolerance and
withdrawal phenomena in the literature (Zimmermann et al., 2009)
and another of drug induced psychosis (Müller et al., 2010). Both
these cases were attributed to Spice, which at the time contained
JWH-018 and CP 47,497.
There is also an increasing number of reports describing patients
presenting for emergency medical care after using “Spice” products.
Common features of many of these presentations have included
anxiety symptoms, agitation, tachycardia, paranoia and hallucinations (Banerji et al., 2010; Bebarta et al., 2010; Piggee, 2009;
Vearrier and Osterhoudt, 2010). Inter-batch variation in the type
and quantity of cannabinoids present has also resulted in accidental
overdosing requiring hospitalization (Auwärter et al., 2009).
A number of self-reports of users experiencing anxiety and
psychotic symptoms following the use of JWH-018 and other
cannabinoids can be found on the internet (e.g., http://www.
erowid.org/experiences/subs/exp JWH018.shtml#Train Wrecks
& Trip Disasters).
1.3. Synthetic cannabinoid use in New Zealand
JWH compounds (e.g., JWH-018, JWH-015 and JWH-073) are
currently unregulated in New Zealand and are widely available in
‘headshops’ and over the internet.
New Zealand may be a particularly opportune market for
cannabimimetic drugs with an annual prevalence of cannabis use
at 14.6%, one of the highest in the world (United Nations Office
on Drugs and Crime, 2010). Cannabis use is particularly prevalent
in criminal populations with 55% of New Zealand prison inmates
qualifying for lifetime diagnoses of cannabis abuse or dependence
(New Zealand Department of Corrections, 1999).
In forensic psychiatric services, substance use is prohibited, and
abstinence is monitored by urine drug screens. However, the arrival
of unregulated synthetic cannabinoids into the market is posing
new challenges to forensic and other mental health services.
2. Methodology
2.1. The sample
Subjects were recruited from a Regional Forensic and Rehabilitation service.
Inclusion criteria were patients between the ages of 18 and 65 who were able to
give informed consent and were residing in a low security forensic inpatient unit,
or waiting placement in such a setting. Clients who were considered high risk of
assault or too unwell to be interviewed alone were excluded for safety reasons.
The author is a forensic psychiatrist and patients currently or previously under
her care were excluded from the study, due to potential conflicts of interest.
Fifteen subjects were recruited over a two week period from a pool of 21 patients
meeting the inclusion criteria. Two of the original 21 were excluded from the study
as they were absent during the data collection period and 4 patients declined to
participate.
Five of the 15 subjects recruited had previously been identified by staff as experiencing psychotic relapses in the context of synthetic cannabinoid use, becoming
objectively agitated, disorganized and delusional after smoking the product.
The study had ethical approval from the New Zealand Central Regional Ethics
Committee.
2.2. Recruitment
The interviewer visited the two inpatient units where the research was conducted on 7 occasions. A brief explanation of the study was provided to patients.
Subjects who were interested in participating were individually provided with written and oral information about the study and informed oral consent was obtained.
2.3. Interviews
Semi-structured interviews were conducted by the author in a private interview
room within the inpatient units. The interview explored the subjects’ experience
with synthetic cannabinoids, including knowledge, personal use, subjective experience and their observations of how these substances appeared to have affected
others. A formal inquiry into each subject’s current mental state was not conducted,
but the interviewer noted her observations of the subject’s presentation immediately after the interview, including whether the subject seemed thought disordered.
Interviews took place in March and April 2010.
2.4. Data collection and analysis
Short-hand notes recording the subjects’ responses were taken during the interview. Patients were not willing to consent to audio recording due to the sensitive
nature of the material discussed, and fears about confidentiality. Following the interview, short-hand notes were transcribed into long-hand and were annotated with
the interviewer’s observations from the interview. The transcripts were analyzed
manually in order to identify key themes and recurrent ideas. Data were coded
and indexed in terms of similarity and contrast of content. All data recorded was
de-identified to preserve confidentiality.
Quotations in Section 3 are used to illustrate emergent trends. Interviewee
quotes are identified by: (a) a number between 1 and 15 to differentiate among
respondents, and (b) the letter N, O or H to denote the subject’s reported frequency
of synthetic cannabinoid use over the preceding year (N: never, O: occasional-less
than weekly, H: high use-daily or weekly).
2.5. Urinalysis
All patients had been subject to regular random urine drug testing for cannabinoids, opiates, opioids, amphetamines and benzodiazepines.1 The urine drug screen
results from the last 18 months were reviewed.
3. Results
3.1. Patient demographics
All 15 participating subjects were male. At the time of the study
the service had a 5:1 male to female ratio, and no female patients
met the inclusion criteria.
All patients had a history of psychotic illnesses and had been
compulsorily treated with therapeutic doses of antipsychotic medication, with active monitoring of compliance, for at least 6 months
prior to the study. Five patients were also taking mood stabilizers.
They had all achieved stable mental states prior to the decompensations reported in this study. The demographics of the subjects are
summarized in Table 1.
All subjects had been within the service for some years, and
had been referred to a low security rehabilitation facility as their
mental states had improved. They all had unescorted leave off the
unit, although in three cases leave privileges had been temporarily
revoked due to the patients’ recent deterioration in mental state.
All participants had used cannabis in the past. None of the participating patients had tested positive for THC in their most recent
urine drug screens. Review of urine drug screens for the cohort
over the previous 18 months showed a positive result for cannabinoids was a low probability event. Of 153 urine tests, only 7 (from
1
Random drug screening used an immunoassay technique, based on the KIMs
method.
Please cite this article in press as: Every-Palmer, S., Synthetic cannabinoid JWH-018 and psychosis: An explorative study. Drug Alcohol Depend.
(2011), doi:10.1016/j.drugalcdep.2011.01.012
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Table 1
Summary of subject demographics.
Feature
Sex
Male
Female
Age range
Diagnosis
Schizophrenia
Schizoaffective disorder
Bipolar affective disorder with psychotic features
Current treatment with antipsychotic medication
Index offence
Serious violent offence (as defined by NZ
Sentencing Act)
Non violent offence or violent offence not
regarded as serious
Lifetime prevalence of cannabis use
Positive urine drug screen for cannabis in the last
18 months
Number (%) [n = 15]
15 (100%)
0 (0%)
Early twenties to
mid-forties, mean
34, sd 7.9
10 (67%)
4 (27%)
1 (7%)
15 (100%)
10 (67%)
retails at NZ$20/g compared to a cannabis street price of approximately NZ$13.2/g [Wilkins and Sweetsur, 2006]). Patients credited
Aroma’s legality, easy availability, product consistency, nondetection in drug tests and perceived safety as reasons to favour
it over marijuana.
“Aroma has cancelled out all the cannabis here. No one smokes
cannabis anymore. Why would you? It [Aroma]’s a good substitute,
its legal, it’s not in urine and it’s easier to go to [name of local
shop that sells Aroma] than to go down to a tinny house [cannabis
dealer].” (8-H)
3.2.2. Psychoactivity. All 13 patients who acknowledged having
smoked Aroma said that they used it as a cannabis substitute.
“[Aroma]’s like marijuana, but health wise it’s better. . ..It’s strong.
It gets you real whacked and makes you high.”(2-H)
5 (33%)
15 (100%)
4 (27%)
4 different patients) were positive for cannabinoids. No patient
tested positive for amphetamines or opioids, and positive tests for
benzodiazepines and opiates correlated with prescribed medicine.
3.2. Trends
On analysis and coding of the interview transcripts four common
themes were identified relating to the use of synthetic cannabinoids
in the service: their popularity, psychoactivity, effects on mental
state and pleasurable feelings of rebellion associated with their use.
Results are summarized in Table 2.
3.2.1. Popularity. All subjects were familiar with a locally available
SCCP, Aroma. Four patients had some historical experience with
similar products called Kronic Skunk, Dream and Spice. All these
products consist of a base of unidentified plant matter which has
been shown to contain JWH-018 (personal correspondence. Mark
Heffernan, Senior Policy Analyst, National Drug Policy, New Zealand
Ministry of Health).
Of the patients surveyed 87% (13/15) reported having used
Aroma over the last year. Of the two clients who denied ever trying
SCCPs, one was spontaneously identified by two other clients as
being a co-smoker and ‘middleman’ provider of the product to others, casting some doubt over his credibility. Five patients reported
high use (daily or almost daily), one reported using weekly, and
seven reported infrequent or occasional use (20 times or less in the
last year).
Most patients reported that SCCPs were more popular than
cannabis in the service despite being more expensive (Aroma
3
Five subjects commented that they preferred Aroma to cannabis
due to its potency. One subject preferred cannabis and the others
were indifferent. A common complaint was that the SCCPs “did not
last as long as cannabis”, with the psychoactive effects being consistently described as having a rapid onset of action and a duration
of 1–2 h following inhalation.
Patients did not know what conferred Aroma its psychoactive
properties. Three patients correctly speculated that it ‘had been
sprayed with chemicals’, the others were either unsure or described
it as a “natural” or “herbal” product. A number of patients commented that it was “safe”, this assumption seemingly based on its
legality and easy availability.
“I used to smoke marijuana, but I don’t do that when I’m on medication. Aroma won’t interfere with medication. . ..It’s a better buzz
than marijuana. It’s quite safe” (10-O)
3.2.3. Effects on mental state. Five patients reported experiences
consistent with a psychotic relapse within 24 h of smoking Aroma
which lasted “2 days” to “several weeks”. Two of these patients
also reported pronounced anxiety symptoms. They attributed these
symptoms to Aroma. However, of the 5 patients in this study who
had previously been identified by clinical staff as suffering a probable JWH-018-induced psychotic relapse (Every-Palmer, 2010), only
1 subjectively acknowledged the effects Aroma had on their mental state. The other 4 had little insight into their mental illnesses
and denied being adversely affected by SCCPs, for example one
man who objectively became floridly psychotic and aggressive after
admittedly smoking Aroma reported:
“Staff say we’re not allowed to smoke it, because it would cause
risks, but they don’t know. It doesn’t cause risks to me. It just makes
me cool, calm and collected. . . to clients who are sick, it causes risks
to them.”(3-O)
Table 2
Summary of subjects’ experiences with synthetic cannabinoid containing products (SCCPs).
Experience
Of all subjects who participated in the study (n = 15)
Familiar with synthetic cannabinoid containing products (SCCPs)
Admitted using SCCPs over the last year
Admitted using SCCP ‘Aroma’ over the last year
Admitted using other SCCPs (e.g., Kronic Skunk, Dream, Spice,)
Of the subjects who reported SCCP use (n = 13)
Described psychoactive effects from SCCP
Considered SCCP a “herbal” or “natural” product
Reported or exhibited psychotic symptoms following SCCP use
Reported observing psychotic symptoms in others following SCCP use
Reported experiencing anxiety symptoms following SCCP use
Reported tolerance (requiring increasing amounts to achieve the same effects)
Reported withdrawal symptoms
Yes
No
Unsure
15/15 (100%)
13/15 (87%)
13/15 (87%)
4/15 (27%)
0/15 (0%)
2/15 (13%)
2/15 (13%)
10/15 (67%)
0/15 (0%)
0/15 (0%)
0/15 (0%)
1/15 (7%)
13/13 (100%)
7/13 (54%)
9/13 (69%)
7/13 (54%)
2/13 (15%)
3/13 (23%)
0/13 (0%)
0/13 (0%)
3/13 (23%)
3/13 (23%)
5/13 (38%)
10/13 (77%)
10/13 (77%)
13/13 (100%)
0/13 (0%)
3/13 (23%)
1/13 (7%)
1/13 (7%)
1/13 (7%)
0/13 (0%)
0/13 (0%)
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Table 3
Patients describe their experience with SCCPs.
“I can’t touch it, it makes me real paranoid. . . I smoked a big doobie. Nothing happened for a while. I walked down the street, then started feeling real sick, shaking, dizzy. My
heart was pounding and I was freaking out. Then I felt that something bad was leaping out at me. I tried to escape, stumbled onto the road and was almost hit by a car. I was
real fucked up.” (10-O)
“It made me feel wasted. It made me not feel like myself. I was having psychotic thinking... Wanting to do evil things. It made me think it would be cool to have rocket launches
and weapons and stuff. . . In all I smoked under 11[times]. Every time it made me feel not good and those thoughts started coming back. . . I don’t smoke it anymore. . . It’s no
good for your brains.” (11-O)
“It made me feel like my world was closing in. It made me feel anxious and worried and my heart was pounding. . . It felt weird, I was really warm, really hot, I had never felt that
hot before, even in summer. . . I just felt paranoid. . . I smoked cannabis years ago. This was kind of similar, but cannabis never made me feel hot and anxious. I think Aroma’s
dangerous.” (15-O)
“X and Y used to smoke it with me. They would freak out. He got real paranoid. She used to go off her nut, scream and yell and totally freak out. That would bring the heat on us.”
(3-O)
“One client, I smoked with him a few times, he’d be completely normal at the start, then he’s just sitting there with his lips moving, talking to someone who’s not even there. Some
people take it- they get sick, you know, straight away.” (8-H)
Overall 9/13 (69%) of the Aroma users experienced or exhibited
psychotic symptoms after using this synthetic cannabinoid. Seven
patients also reported that they had noticed other patients become
unwell after using Aroma. Descriptions of these experiences are
reported in Table 3.
3.2.4. Rebellion. All the patients knew psychoactive substances
including SCCPs were prohibited in the service. A number of
patients discussed the high level of supervision and loss of autonomy associated with their forensic status, and how they felt that
using SCCPs allowed them to reassert their control.
“It doesn’t stink, people can’t tell you’ve been smoking it. It never
turns up in their tests, so we get away with it, no problems. You can
smoke it anywhere. We were smoking it right here, in front of all
the nurses. It’s classic, (laughs) they just think its tobacco.” (3-H)
3.2.5. Other themes. Some patients felt SCCP use had negatively
affected the atmosphere of the unit. Two non-users talked about
other patients spending all their money on SCCPs and then coercing
their peers to share cigarettes. Several patients alluded to an ‘ingroup, out-group’ dynamic between users and non-users. A black
market had also evolved, with some clients purchasing SCCPs and
selling them to others at a profit.
4. Discussion
4.1. Limitations of the study
This was a small study (n = 15) of a highly select patient group.
The participants were all men with serious mental illness with risk
profiles mandating intensive supervision in a forensic service. This
group is particularly vulnerable to psychosis, but paradoxically may
also currently have some degree of protection (compared to vulnerable people in the community), as all subjects were receiving
assertive treatment and environmental support. The experiences
of this group cannot necessarily be extrapolated to a wider population, particularly those without mental illness, females and
adolescences.
This study describes only the subjective experiences that subjects chose to share with the interviewer and as such is subject
to bias including selection bias, under-reporting and exaggeration.
Although patients and staff report deteriorations in the subjects’
mental states in relation to synthetic cannabinoid use, this study
only suggests, but does not prove a causal link.
4.2. Discussion of findings
In this cohort of forensic inpatients in a low-secure setting all
the subjects were familiar with synthetic cannabinoids and 86%
Table 4
Psychoactive compounds detected in Aroma.
Compound
Concentration
Cannibicyclohexanol (mg/g)
JWH-018 (mg/g)
Oleamide (mg/g)
Other psychoactive compounds
Not detected
27.91 ± 1.09
210.90
Not detected
Source: Uchiyama et al. (2010); Personal correspondence Ruri Kikura-Hanajari,
8 October 2010.
reported having used them. They credited the products’ potent psychoactivity, legality, ready availability and non-detection in drug
testing as reasons for their popularity, reporting they had replaced
cannabis as the drugs of choice in our service. Synthetic cannabinoids do not appear in conventional urine drug testing so users
could evade detection and sanction by their care team. This had
engendered a conspiratorial culture in which users took some pleasure in small acts of insurrection, in an environment where the
balance of power usually resides on the side of the health professionals.
Furthermore, most patients assumed SCCPs were “herbal”,
“natural” and “safe”. This may be due to by their legality,
easy availability and marketing as “organic”. However, synthetic
cannabinoids are not herbal, natural nor safe. Nine patients experienced symptoms consistent with a psychotic relapse after using
JWH-018 containing products (5 self reported, 4 reported by health
professionals). Three patients reported tolerance, but nobody
endorsed withdrawal symptoms.
Substance abuse is a robust predictor of an increased probability of violence and criminality in the mentally disordered (Soyka,
2000). Whether JWH-018, like cannabis, is a potential mediator of
antisocial behaviour is at this stage unclear, but the unfettered use
of psychoactive compounds in high risk patients is concerning for
both individual and societal reasons.
4.3. Pharmacology of Aroma
All patients were smoking the same product, a SCCP marketed
as Aroma. This product comprises a dried herb material which is
a vehicle for high concentrations of JWH-018 and oleamide. Of 46
products tested by Uchiyama et al. (2010) Aroma contained the
highest concentration of oleamide and the second highest concentration of JWH-018. (See Table 4.)
4.4. JWH-018 and psychosis
Although to date there is little data about the possible psychiatric sequelae of synthetic cannabinoids, the link between
cannabis and psychosis is well established and has been extensively
reviewed (e.g., Henquet et al., 2005; Fergusson et al., 2006; Moore
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et al., 2007; Murray et al., 2007). Cannabis contains at least 90
different cannabinoids, with THC being the primary psychoactive
ingredient (Gaoni and Mechoulam, 1964). In experimental studies, THC produces transient and dose related psychotic symptoms
(D’Souza et al., 2004) and impaired memory (Solowij and Michie,
2007). Consumer surveys (e.g., Thomas, 1996) provide further evidence that cannabis intoxication can produce transient psychotic
experiences. Large prospective epidemiological studies (e.g., van Os
et al., 2002; Zammit et al., 2002; Arseneault et al., 2002) show a link
between cannabis use and the development of chronic psychotic
illnesses such as schizophrenia.
All the patients in this study had established psychotic illnesses.
Cannabis use in such patients is common (Green et al., 2004;
Boydell et al., 1999) and has been associated with poor clinical and
functional outcomes including: an earlier disease onset (Foti et al.,
2010); more positive symptoms (Bühler et al., 2002; Mauri et al.,
2006); a higher relapse rate (Swofford et al., 1996), and a reduced
treatment response (Foti et al., 2010). In first-episode schizophrenia cannabis use is associated with a greater reduction in cerebral
grey matter volume in users compared with non users over time
(Rais et al., 2008).
It cannot be assumed that the psychiatric risks of synthetic
cannabinoids will equate to those associated with cannabis, however, it is hypothesized that JWH-018 may pose comparable or even
greater risks due to the following observations:
1. JWH-018 produces similar effects to THC in animal experiments
(EMCDDA, 2009).
2. There are an emerging number of reports of users experiencing psychotic symptoms in the context of JWH-018 use on the
internet and in the literature (Müller et al., 2010; Every-Palmer,
2010).
3. The pharmacological profile of JWH-018 raises the theoretical
possibility of increased cognitive and psychiatric side effects
compared to cannabis.
(a) In vitro data suggests that JWH-018 possesses approximately
a four-fold higher affinity to the CB1 receptor and ten-fold
affinity to CB2 receptor compared with THC (Aung et al.,
2000; Huffman et al., 2005). CB1 receptors are abundant in
central nervous system, particularly in the basal ganglia, hippocampus and cerebellum (Howlett et al., 2004; Fergusson
et al., 2006). These receptors regulate the release of several
key neurotransmitters, including dopamine and serotonin.
It is thought that cannabis may lead to psychosis through
THCs’s effects on dopaminergic and serotonergic pathways
via CB1 receptors (Fergusson et al., 2006). While THC exerts
only partial CB1 agonism, JWH-018 is a full and potent agonist
at CB1 receptors (Atwood et al., 2010).
(b) Unlike cannabis, SCCPs do not contain cannabidiol.
Cannabidiol and THC are the two major components of
cannabis, and they exhibit opposing pharmacological and
physiological actions. Cannabidiol is a CB1 and CB2 antagonist which appears to have antipsychotic (Leweke et al.,
2009; Zuardi et al., 2006; Morgan and Curran, 2008) and
anxiolytic properties (Guimarães et al., 1990) and may be
neuroprotective in humans (Hermann et al., 2007; Morgan
et al., 2010). While cannabidiol may afford cannabis users
some inherent protection against psychotic symptoms
(Morgan and Curran, 2008) and cognitive impairment
(Morgan et al., 2010) this protection is lacking in SCCPs.
(c) Some SCCPs like Aroma also contain oleamide, a fatty
acid demonstrated to functionally activate CB1 cannabinoid
receptors in vitro (Leggett et al., 2004), which may have
potentiating effects.
4. SCCPs may appeal to vulnerable populations who might not
otherwise smoke cannabis including those who have suf-
5
fered adverse effects from cannabis or have been warned
against using cannabis (e.g., a possible predisposition to
psychotic illness) and those being monitored for drug use
(e.g., in prisons, forensic hospitals). There are increasing
reports of young people using SCCPs (e.g., EMCDDA, 2009;
http://www.stuff.co.nz/national/4279640/Parents-worried-bylegal-weed). In the forensic population studied in this research,
the base rate of ongoing cannabis use was low due to institutional deterrents and education regarding the risks of cannabis.
However, those disincentives did not exist to the same extent
with SCCPs, which were being consumed in greater quantities
than cannabis had previously been. Although it is likely that
most people who smoke SCCPs will not experience psychotic
symptoms, the risks are much higher for these vulnerable
populations.
4.5. Management
It is known that in forensic populations drug treatment programs associated with the best outcomes are assertive and use
some form of leverage, such as mandatory drug testing (Lamb et al.,
1999). Currently there are no widely available drug testing methods to identify JWH-018 use, although laboratory techniques have
recently been developed for identifying JWH-018 in serum (Teske
et al., 2010) and JWH-018 metabolites in urine (Sobolevsky et al.,
2010). Until these techniques become more widely available clinicians will need to rely on clinical skills. These include: specifically
asking patients about “herbal highs”; being alert to the physiological and effects of SCCP use such as conjuctival injection and
tachycardia (Auwärter et al., 2009; Sobolevsky et al., 2010) and
having a high index of suspicion in the context of an unexplained
deterioration in mental state in the context of a negative urine drug
screen. Health professionals need to be cogniscant and responsive
to novel drug trends in order to counsel their clients appropriately.
In countries where synthetic cannabinoids remain legal, there
needs to be ongoing review and monitoring of their safety at a
national level. Discussion also needs to be held around the accurate labeling of products containing psychoactive compounds, so
that users are aware of the potential risks.
5. Conclusion
Synthetic cannabinoids pose difficult social, political and health
challenges. There are more than 100 known compounds with
cannabinoid receptor activity, and no doubt more will be synthesized in the future. Almost nothing is known about the
pharmacology and toxicology of compounds such as JWH-018,
however, it seems that they can cause psychosis in vulnerable
individuals. Health professionals need to maintain a high degree
of vigilance for novel substance use, and the possible psychiatric
consequences. People with risk factors for psychosis should be
counseled against using synthetic cannabinoids.
Role of funding source
Nothing declared.
Conflict of interest
No conflict declared.
Acknowledgements
With grateful thanks to all the subjects who gave up their time
to participate in this research, to Mark Heffernan from the New
Please cite this article in press as: Every-Palmer, S., Synthetic cannabinoid JWH-018 and psychosis: An explorative study. Drug Alcohol Depend.
(2011), doi:10.1016/j.drugalcdep.2011.01.012
G Model
DAD-4024;
No. of Pages 6
6
ARTICLE IN PRESS
S. Every-Palmer / Drug and Alcohol Dependence xxx (2011) xxx–xxx
Zealand Ministry of Health who peer reviewed this manuscript
and to Dennis Klue, Nigel Fairley, Dr Justin Barry-Walsh, Dr Joanna
MacDonald and Professor Pete Ellis for their support.
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