title: Analysis and clinical findings of cases positive for the novel synthetic cannabinoid receptor agonist MDMB-CHMICA.
abstract: BACKGROUND
  MDMB-CHMICA is a synthetic cannabinoid receptor agonist which has caused concern due to its presence in cases of adverse reaction and death.
  
  
  METHODS
  43 cases of suspected synthetic cannabinoid ingestion were identified from patients presenting at an Emergency Department and from post-mortem casework. These were subjected to liquid-liquid extraction using tertiary-butyl methyl ether and quantitatively analysed by Electrospray Ionisation Liquid Chromatography-tandem Mass Spectrometry. For positive samples, case and clinical details were sought and interrogated.
  
  
  RESULTS
  11 samples were found positive for MDMB-CHMICA. Concentrations found ranged from <1 to 22 ng/mL (mean: 6 ng/mL, median: 3 ng/mL). The age range was 15-44 years (mean: 26 years, median: 21 years), with the majority (82%) of positive results found in males. Clinical presentations included hypothermia, hypoglycaemia, syncope, recurrent vomiting, altered mental state and serotonin toxicity, with corresponding concentrations of MDMB-CHMICA as low as <1 ng/mL. Duration of hospitalisation ranged from 3 to 24 h (mean: 12 h, median: 8 h).
  
  
  CONCLUSIONS
  The concentration range presented in this case series is indicative of MDMB-CHMICA having a high potency, as is known to be the case for other synthetic cannabinoid receptor agonists. The age range and gender representation were consistent with that reported for users of other drugs of this type. The clinical presentations observed were typical of synthetic cannabinoid receptor agonists and show the difficulties in identifying reactions potentially associated with drugs of this type.
  
  
  CONCLUSIONS
  The range of MDMB-CHMICA concentrations in Emergency Department presentations (n = 9) and post-mortem cases (n = 2) was reported. No correlation between the concentration of this drug and clinical presentation or cause of death was reported in this sample. However, the potential for harm associated with low concentrations of MDMB-CHMICA and the symptoms of toxicity being non-specific were highlighted.
authors.affiliation: a Department of Forensic Medicine and Science , University of Glasgow , Glasgow , UK ;
authors.forename: Alice
authors.initials: A
authors.lastname: Seywright
authors.affiliation: a Department of Forensic Medicine and Science , University of Glasgow , Glasgow , UK ;
authors.forename: Hazel J
authors.initials: HJ
authors.lastname: Torrance
authors.affiliation: a Department of Forensic Medicine and Science , University of Glasgow , Glasgow , UK ;
authors.forename: Fiona M
authors.initials: FM
authors.lastname: Wylie
authors.affiliation: a Department of Forensic Medicine and Science , University of Glasgow , Glasgow , UK ;
authors.forename: Denise A
authors.initials: DA
authors.lastname: McKeown
authors.affiliation: b Glasgow Royal Infirmary , Glasgow , UK ;|c Academic Unit of Anaesthesia, Pain and Critical Care Medicine , School of Medicine, University of Glasgow , Glasgow , UK.
authors.forename: David J
authors.initials: DJ
authors.lastname: Lowe
authors.affiliation: b Glasgow Royal Infirmary , Glasgow , UK ;
authors.forename: Richard
authors.initials: R
authors.lastname: Stevenson
mesh_terms: D000293:Adolescent; D000328:Adult; D063386:Cannabinoid Receptor Agonists / Q000097:blood* / Q000506:poisoning; D005260:Female; D053593:Forensic Toxicology; D006801:Humans; D013287:Illicit Drugs / Q000097:blood* / Q000506:poisoning; D007211:Indoles / Q000097:blood* / Q000506:poisoning; D008297:Male; D011041:Poisoning / Q000097:blood / Q000401:mortality / Q000628:therapy; D021241:Spectrometry, Mass, Electrospray Ionization; D015813:Substance Abuse Detection / Q000379:methods*; D053719:Tandem Mass Spectrometry; D006113:United Kingdom; D055815:Young Adult
chemical_list: D063386:Cannabinoid Receptor Agonists; D013287:Illicit Drugs; D007211:Indoles; C000610109:methyl 2-(1-(cyclohexylmethyl)-1H-indole-3-carboxamido)-3,3-dimethylbutanoate
keywords: Blood analysis; MMB-CHMINACA; NPS; legal highs