Notes from the Field : Acute Poisonings from a Synthetic Cannabinoid Sold as Cannabidiol — Utah, 2017–2018, Roberta Z. Horth et al., 2019

Notes from the Field : Acute Poisonings from a Synthetic Cannabinoid Sold as Cannabidiol — Utah, 2017–2018

Roberta Z. Horth, Barbara Crouch, B. Zane Horowitz, Amelia Prebish, Matthew Slawson,  Jennifer McNair, Chris Elsholz, Stephen Gilley, Jenny Robertson, Ilene Risk, Mary Hill, Linnea Fletcher, Wei Hou, Dallin Peterson, Karlee Adams, Dagmar Vitek, Allyn Nakashima, Angela Dunn

MMWR / May 25, 2018 / Vol. 67 / No. 20

US Department of Health and Human Services/Centers for Disease Control and Prevention


On December 8, 2017, the Utah Poison Control Center (UPCC) notified the Utah Department of Health (UDOH) of reports of emergency department visits associated with reported exposure to products labeled as CBD (cannabidiol), a nonpsychoactive compound derived from Cannabis sativa, the
marijuana plant. Five patients experienced adverse reactions, including altered mental status, seizures, confusion, loss of consciousness, and hallucinations. These reactions were inconsistent with known CBD effects (1), which prompted concern for potential adulteration with a synthetic cannabinoid (2). CBD is being studied as a treatment for several health conditions* (3); however, the Food and Drug Administration has not approved any CBD product for the treatment of any condition, and the U.S. Department of Justice Drug Enforcement Administration considers CBD as a Schedule I drug.† Sale
of CBD is currently illegal in Utah, although CBD is readily available online and in shops.

State and federal health and law enforcement officials established a task force on December 11 to investigate cases and identify the source product. A suspected case was defined as the occurrence after October 1, 2017, of adverse reactions inconsistent with known CBD exposures after ingestion, inhalation, or sublingual consumption of a product labeled as CBD or hemp oil. Hospitals and law enforcement agencies or persons experiencing CBD-associated reactions were asked to report any CBD-associated cases to UPCC. Concomitantly, public health investigators searched UPCC’s database and Utah’s Syndromic Surveillance system as part of CDC’s National Syndromic Surveillance Program for CBD-related * CBD is used in treating spasticity from multiple sclerosis and Dravet syndrome, a severe form of childhood epilepsy, for which it has shown efficacy. † A Schedule I drug, defined by the U.S. Department of Justice Drug Enforcement Administration, is a drug with no currently accepted medical use and a high potential for abuse. events.§ UDOH interviewed patients by telephone, using a survey adapted from a synthetic cannabinoid investigation (4). Available blood and urine obtained at emergency departments
and product samples obtained from patients were submitted for chemical analysis using liquid chromatography and tandem mass spectrometry at the Utah Public Health Laboratory and the Utah Department of Public Safety crime laboratory.

By the end of January 2018, suspected cases were identified in 52 persons. Nine product samples (including one unopened product purchased by investigators from a store and brand reported by a patient) were found to contain a synthetic cannabinoid, 4-cyano CUMYL-BUTINACA (4-CCB), but no
CBD.¶ Eight of the tested products were branded as “Yolo CBD oil” and indicated no information about the manufacturer or ingredients. Blood samples from four of five persons were positive for 4-CCB. Press releases were distributed to media outlets December 19–21, 2017, with a warning regarding the dangers of using the counterfeit product; information with a description of the product and associated symptoms was disseminated to health care providers and law enforcement. The number of reported cases peaked during this outreach and dropped shortly thereafter. Thirty-four suspected cases were reclassified as confirmed if the person reported use of a Yolo product or laboratory testing found 4-CCB. Approximately
one quarter of persons were aged <18 years, nearly three fourths had vaped the CBD product, and approximately 60% were seen at an emergency department (Table). The top three symptoms experienced were altered mental status, nausea or vomiting, and seizures or shaking. Rapid identification and a coordinated response among state and local agencies contributed to control of the outbreak. This investigation highlights the hazards of consuming unregulated products labeled as
CBD. States could consider regulating products labeled as CBD and establishing surveillance systems for illness associated with products labeled as CBD to minimize the risk for recurrences of this emerging public health threat (5).