Fake “CBD Oil” Laced With a Synthetic Cannabinoid Poisoned 52 People in Utah

On December 8, 2017, the Utah Poison Control Center told the Utah Department of Health about emergency department visits linked to products labeled CBD (cannabidiol) — a compound from Cannabis sativa, the marijuana plant, that doesn't produce a high. Five patients had reactions CBD isn't known to cause: altered mental status, seizures, confusion, loss of consciousness and hallucinations. That raised the suspicion that the products had been spiked with a synthetic cannabinoid.

Background on CBD at the time

• CBD was being studied for several conditions, and had shown efficacy against spasticity from multiple sclerosis and against Dravet syndrome, a severe childhood epilepsy.
• But the FDA had approved no CBD product for any condition, and the Drug Enforcement Administration treated CBD as a Schedule I drug — one with no accepted medical use and a high potential for abuse.
• Selling CBD was illegal in Utah, yet it was easy to buy online and in shops.

The investigation

On December 11, state and federal health and law-enforcement officials formed a task force to find cases and the product responsible.

• Suspected case: after October 1, 2017, a reaction inconsistent with CBD after swallowing, inhaling or holding under the tongue a product labeled CBD or hemp oil.
• Hospitals, police and people who'd had reactions were asked to report to the poison center. Investigators also searched the poison center's records and Utah's syndromic surveillance data (part of CDC's National Syndromic Surveillance Program), using CBD slang and brand names rather than symptoms, which weren't specific enough.
• Patients were interviewed by phone with a questionnaire adapted from an earlier synthetic cannabinoid investigation.
• Blood, urine and product samples went to the Utah Public Health Laboratory and the Utah Department of Public Safety crime lab for liquid chromatography–tandem mass spectrometry.

What they found

By the end of January 2018, 52 people had been identified as suspected cases.

• Nine product samples — one of them an unopened product investigators bought from a store and brand a patient had named — contained the synthetic cannabinoid 4-cyano CUMYL-BUTINACA (4-CCB) and no CBD.
• Eight of the tested products were sold as "Yolo CBD oil," with no information about who made them or what was in them.
• Blood from four of five people tested was positive for 4-CCB.
• 34 cases were confirmed, based on reported use of a Yolo product or a lab finding of 4-CCB.

4-CCB had been identified in Europe since 2016, when samples were intercepted as synthetic cannabinoids. It is chemically related to other indazole-based synthetic cannabinoids, the NACA derivatives, seen in other U.S. clusters.

Who was affected (all 52)

The reactions

Among those with information, reactions began a median of 1 minute after use (35 people) and lasted a median of 72 minutes (27 people).

The response

On December 19–21, 2017, officials sent press releases warning about the counterfeit product, and sent a description of it and its symptoms to health care providers and police. Reports peaked during that outreach and fell soon after. Quick identification and coordinated work among state and local agencies helped bring the outbreak under control.

Takeaway

Products labeled CBD but unregulated can be dangerous. States could consider regulating CBD-labeled products and setting up surveillance for illnesses linked to them, to lower the risk of this emerging threat recurring.

Sources

Based on Horth RZ, Crouch B, Horowitz BZ, et al., "Notes from the Field: Acute Poisonings from a Synthetic Cannabinoid Sold as Cannabidiol — Utah, 2017–2018," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The imported copy was cut off mid-paragraph; the rest of the report and its table were taken from the same report's full text in PubMed Central (PMC6433338).