Inhaled synthetic cannabinoids laced with long-acting anticoagulant rodenticides: a clear and present worldwide danger

Keywords:

• Brodifacoum
• hemorrhage
• coagulopathy
• Israel
• Florida
• synthetic cannabinoids
• vitamin K

To the Editor,

In 2016 we wrote a forward looking commentary about possible malicious exposure of people in the U.S. to second generation, long-acting (months) anticoagulant rodenticides (LAAR’s), such as brodifacoum, bromadiolone and difenacoum, and the need to develop effective countermeasures to mitigate their prolonged toxic effects [1]. Our prediction materialized in March 2018, when more than 400 people in the U.S. were poisoned and developed severe coagulopathy and bleeding after inhaling synthetic cannabinoids laced with LAAR’s with 11 reported deaths [2, 3]. In September 2021 a similar outbreak was reported from Israel where 95 people who inhaled synthetic cannabinoids laced with brodifacoum have been hospitalized with severe coagulopathy and bleeding with 3 deaths reported so far [4] (Lurie Y. Personal communication). During December 2021, 45 mostly homeless individuals in Hillsborough County, Florida were hospitalized with severe coagulopathy and bleeding after inhaling synthetic cannabinoids laced with brodifacoum with 2 deaths reported so far [5] (Mulay PR. Personal Communication).

Given informal input we have received from people involved with these global outbreaks, the medical community and policy makers are presently faced with ongoing challenges in delivering appropriate care to poisoned victims. First, there is lack of rapid, sensitive, point-of-care laboratory testing to detect the offending LAAR(s); development of quantitative, liquid chromatography tandem mass spectrometry methods which can simultaneously measure multiple LAARs in under 10 min would provide health care providers with objective means to address this need [6]. Second, there is an inadequate supply of inexpensive vitamin K₁ to counter prolonged coagulopathy. In view of the long duration and dose of oral vitamin K₁ therapy required to maintain INR within the normal range, current cost estimates to treat one poisoned patient in the U.S. can amount to ∼$50,000 per month [7, 8]. Third, there is no established intervention(s) to increase clearance of the offending LAAR(s) from the human body. Finally, previous experience indicates that long-term monitoring of victims after hospitalization is inefficient [9]. In order to contain similar global outbreaks in the future, we propose that these shortcomings must be addressed and resolved soon through cohesive collaborations among all stakeholders.

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Additional information

Funding

This work was supported, in part, by VA Research Career Scientist award 5IK6BX004852 (DLF); and by grant T32AT010131 from NIH National Center for Complementary and Integrative Health (RvB).