title: "Zombie" Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York.
abstract: New psychoactive substances constitute a growing and dynamic class of abused drugs in the United States. On July 12, 2016, a synthetic cannabinoid caused mass intoxication of 33 persons in one New York City neighborhood, in an event described in the popular press as a "zombie" outbreak because of the appearance of the intoxicated persons.
  
  
  
  We obtained and tested serum, whole blood, and urine samples from 8 patients among the 18 who were transported to local hospitals; we also tested a sample of the herbal "incense" product "AK-47 24 Karat Gold," which was implicated in the outbreak. Samples were analyzed by means of liquid chromatography-quadrupole time-of-flight mass spectrometry.
  
  
  
  The synthetic cannabinoid methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoate (AMB-FUBINACA, also known as MMB-FUBINACA or FUB-AMB) was identified in AK-47 24 Karat Gold at a mean (±SD) concentration of 16.0±3.9 mg per gram. The de-esterified acid metabolite was found in the serum or whole blood of all eight patients, with concentrations ranging from 77 to 636 ng per milliliter.
  
  
  
  The potency of the synthetic cannabinoid identified in these analyses is consistent with strong depressant effects that account for the "zombielike" behavior reported in this mass intoxication. AMB-FUBINACA is an example of the emerging class of "ultrapotent" synthetic cannabinoids and poses a public health concern. Collaboration among clinical laboratory staff, health professionals, and law enforcement agencies facilitated the timely identification of the compound and allowed health authorities to take appropriate action.
authors.affiliation: From the Clinical Toxicology and Environmental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) - both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Office of Diversion Control, Drug and Chemical Evaluation Section, Drug Enforcement Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Homeland Security, Washington, DC (M.S.).
authors.forename: Axel J
authors.initials: AJ
authors.lastname: Adams
authors.affiliation: From the Clinical Toxicology and Environmental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) - both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Office of Diversion Control, Drug and Chemical Evaluation Section, Drug Enforcement Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Homeland Security, Washington, DC (M.S.).
authors.forename: Samuel D
authors.initials: SD
authors.lastname: Banister
authors.affiliation: From the Clinical Toxicology and Environmental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) - both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Office of Diversion Control, Drug and Chemical Evaluation Section, Drug Enforcement Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Homeland Security, Washington, DC (M.S.).
authors.forename: Lisandro
authors.initials: L
authors.lastname: Irizarry
authors.affiliation: From the Clinical Toxicology and Environmental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) - both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Office of Diversion Control, Drug and Chemical Evaluation Section, Drug Enforcement Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Homeland Security, Washington, DC (M.S.).
authors.forename: Jordan
authors.initials: J
authors.lastname: Trecki
authors.affiliation: From the Clinical Toxicology and Environmental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) - both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Office of Diversion Control, Drug and Chemical Evaluation Section, Drug Enforcement Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Homeland Security, Washington, DC (M.S.).
authors.forename: Michael
authors.initials: M
authors.lastname: Schwartz
authors.affiliation: From the Clinical Toxicology and Environmental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) - both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Office of Diversion Control, Drug and Chemical Evaluation Section, Drug Enforcement Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Homeland Security, Washington, DC (M.S.).
authors.forename: Roy
authors.initials: R
authors.lastname: Gerona
mesh_terms: D000328:Adult; D002186:Cannabinoids / Q000009:adverse effects* / Q000097:blood / Q000652:urine; D004196:Disease Outbreaks; D055808:Drug Discovery; D006801:Humans; D013287:Illicit Drugs / Q000009:adverse effects*; D007191:Indazoles / Q000009:adverse effects* / Q000097:blood / Q000652:urine; D053609:Lethargy / Q000139:chemically induced* / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009519:New York City / Q000453:epidemiology; D014633:Valine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000097:blood / Q000652:urine
chemical_list: D002186:Cannabinoids; D013287:Illicit Drugs; D007191:Indazoles; C000613980:methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoate; D014633:Valine