What was the cause behind a 2018 multistate outbreak of hemorrhaging among synthetic cannabinoid users? The latest issue of Clinical & Forensic Toxicology News (CFTN) reveals that brodifacoum, a second-generation long-acting anticoagulant rodenticide (LAAR) in the warfarin family, may have been the culprit.

CFTN is a quarterly AACC/College of American Pathologists (CAP) educational newsletter for toxicology laboratories and individuals with an interest in toxicology. Each issue highlights topics of interest to the clinical and forensic toxicology fields. Headlining this month’s issue, an article by Minh-Ha Tran, DO, Ingrid Perez-Alvarez, MD, and Bridgit O. Crews, PhD, delves into the association between synthetic cannabinoids and LAAR poisoning and how to identify and treat cases of severe coagulopathy caused by tainted drugs.

As many as 84 different forms of synthetic cannabinoids exist, but little is known about their ingredients or the toxicity or physiological effects they inflict on users. In 2018, the Centers for Disease Control and Prevention issued an outbreak alert after healthy individuals in five states started presenting with serious bleeding problems. An investigation by the Illinois Department of Public Health revealed a link between synthetic cannabinoid users and hemorrhaging, and test samples found evidence of brodifacoum contamination.

Brodifacoum inhibits vitamin K reductase reactions and has a high oral toxicity. Poisoning effects can manifest as hematuria (34%), gingival bleeding (30%), epistaxis (24%), gastrointestinal bleeding (23%), and spontaneous ecchymoses (22%), according to a recent review. This has specific implications for blood banks, given that several patients in the outbreak had previously donated blood or plasma. “Acute, life-threatening bleeding requires rapid supplementation of factors through infusion of fresh-frozen plasma or prothrombin complex concentrates. In addition, high-dose, long-term therapy with vitamin K is required given the long half-lives (weeks to months) of LAARs in humans,” wrote Tran, Perez-Alvarez, and Crews.

The March CFTN also features two articles by Matthew D. Krasowski, MD, PhD, that delve into two very different topics: vitamin D toxicity and “predatory journals.” In the latter, Krasowski warns of publications, meetings, and conferences that try to solicit goods from researchers and scientists. Promising rapid review and publication, these publications offer little in the way of peer review. Spam journals and meetings generally deliver poor-quality material that has low scientific value. Predatory journals affect all areas of science, including forensics and toxicology, he cautioned.

“It is important to perform due diligence when considering submission to an unfamiliar journal or attendance at a conference,” wrote Krasowski. In his other article, he discussed the growing incidence of vitamin D toxicity due potentially to wider use of supplements. Dosing confusion with liquid preparations may be contributing to symptomatic vitamin D toxicity, pointing to a need to standardize liquid vitamin D formulations.

CFTN is an educational service of the Forensic Urine Drug Testing Accreditation Program co-sponsored by AACC and CAP. Individual subscriptions are also available; the regular price is $65, and AACC members pay $45. Subscribers are eligible to receive four ACCENT continuing education credits per year, one credit per quarterly issue.