Synthetic cannabinoid intoxication

Essential (Required) Features:

• Transient and clinically significant disturbances in consciousness, cognition, perception, affect, behaviour, or coordination that develop during or shortly after the consumption or administration of synthetic cannabinoids.
• The symptoms must be compatible with the known pharmacological effects of synthetic cannabinoids, and their intensity is closely related to the amount of synthetic cannabinoids consumed.
• Presenting features of Synthetic Cannabinoid Intoxication may include inappropriate euphoria, impaired attention, impaired judgment, perceptual alterations (such as the sensation of floating, altered perception of time), changes in sociability, increased appetite, anxiety, intensification of ordinary experiences, impaired short-term memory, and sluggishness. Physical signs include conjunctival injection (red or bloodshot eyes), dry mouth, and tachycardia.
• The symptoms of intoxication are time-limited and abate as synthetic cannabinoids are cleared from the body.
• Symptoms are not better accounted for by another medical condition (See below) or another mental disorder, including another Disorder Due to Substance Use (e.g., Withdrawal from a different substance).

Examples of Medical Conditions That May Present with Symptoms Similar to Substance Intoxication

• Head injury (with or without cerebral contusion or intracranial haemorrhage or haematoma)
• Meningitis and encephalitis
• Diabetic ketoacidosis or hypoglycaemia
• Hepatic or other metabolic encephalopathy
• Wernicke’s encephalopathy
• Electrolyte disturbance
• Hypoxia or hypercapnia
• Systemic infection

Severity of Intoxication Specifier:

Depending on the specific clinical situation and the information available, Substance Intoxication may be classified according to the level of severity as mild, moderate, or severe. The level of intoxication is usually related to the dose, route of administration, half-life, and duration of action of the substance. Severity of intoxication is also affected by individual variability (e.g., differences in body weight, substance metabolism, or tolerance). Susceptibility to substance intoxication may also be greater in individuals with comorbid medical conditions affecting drug pharmacokinetics (e.g., renal or hepatic insufficiency).

For some substances, there are specific tests for detecting and determining the concentration of substances in bodily fluids (e.g., blood, urine), which can be important tools for clinical management. However, severity of intoxication should be determined on the basis of clinical assessment, as specified below, and not solely based on the presence and level of the substance in bodily fluids.

The level of medical attention that may be required in response to substance intoxication varies according to the severity of intoxication and the substance involved, and varies from precautionary observation to urgent intervention to prevent death or permanent harm (e.g., administration of antagonist treatment; intubation).

The severity of intoxication is classified using the following Extension (X) Codes in addition to the appropriate intoxication category. Extension codes are attached to the category to which they apply using an ampersand (&).

XS5W Mild

Mild substance intoxication is a state in which there are clinically recognizable disturbances in psychophysiological functions and responses (e.g., motor coordination, attention and judgement) that vary by substance, but there is little or no disturbance in the level of consciousness.

The code for Synthetic Cannabinoid Intoxication, mild is 6C42.3&XS5W.

XS0T Moderate

Moderate substance intoxication is a state in which there are marked disturbances in psychophysiological functions and responses (e.g., motor coordination, attention and judgement) that vary by substance, with substantial impairment on tasks that require these functions. There is some disturbance in level of consciousness.

The code for Synthetic Cannabinoid Intoxication, moderate is 6C42.3&XS0T.

XS25 Severe

Severe substance intoxication is a state in which there are obvious disturbances in psychophysiological functions and responses (e.g., motor coordination, attention and judgement) that vary by substance, with marked disturbance in level of consciousness. There is severe impairment to the extent that the person may not be capable of self-care or self-protection, and may be unable to communicate or cooperate with assessment and intervention.

The code for Synthetic Cannabinoid Intoxication, severe is 6C42.3&XS25.

Additional Clinical Features:

• The principal psychoactive cannabinoid is cannabis is δ-9- tetrahydrocannabinol (THC). Disturbances in consciousness, cognition, perception, affect, behaviour, or coordination typical of Cannabis Intoxication are primarily attributable to levels of THC, although various other cannabinoids are also present in cannabis preparations (e.g., dried leaves and buds, hashish, cannabis oil).
• Synthetic Cannabinoid Intoxication may cause Delirium or acute psychosis.
• Regular intoxication with synthetic cannabinoids may be associated with increased long-term risk for psychosis.
• Psychoactive substances, whether of the same or a different pharmacological class, may interact such that they exacerbate or modify the features of intoxication. In cases of multiple psychoactive substance use in which more than one specific substance can be identified as a cause of the intoxication, it is recommended that the corresponding specific Substance Intoxication categories for each relevant substance should be assigned (e.g., 6C40.3 Alcohol Intoxication and 6C42.3 Synthetic Cannabinoid Intoxication) rather than 6C4F.3 Intoxication Due to Multiple Specified Psychoactive Substances.
• Synthetic Cannabinoid Intoxication may occur in the presence of medical conditions that cause impairment of levels of consciousness, cognition, perception, affect, behaviour, or coordination, which should be diagnosed separately. Determination of the aetiology of the disturbances in psychophysiological functions or responses may require longitudinal assessment.

Boundary with Normality (Threshold):

• Measurement of the presence or concentration of a substance in breath, blood, saliva, urine or other body fluids may be an important tool in the clinical management of Substance Intoxication. However, detection of a psychoactive substance in body fluids does not constitute a presumptive diagnosis of Substance Intoxication.

Course Features:

• The onset of Substance Intoxication varies according to the route of administration, the absorption of the substance and other pharmacokinetic factors. Generally, inhalation (smoking) and intravenous injecting routes lead to more rapid onset of intoxication, though oral ingestion may also lead to intoxication within minutes, depending on the substance.
• Substance Intoxication is a transient condition, with the duration of intoxication depending on multiple factors including: (1) the dose of the substance taken, (2) the half-life and duration of action of the particular substance, and (3) the formulation of the substance taken (e.g., for pharmaceutical preparations, whether a controlled-release drug has been taken). Intoxication may last from a few minutes up to several days following the episode of use. The intensity of intoxication lessens with time after reaching a peak of absorption, and the effects eventually disappear in the absence of further use of the substance.

Culture-Related Features:

• The degree and characteristics of intoxication displayed for a given amount of a psychoactive substance varies considerably with circumstances, with beliefs and expectations about the effects of the substance, and with the cultural acceptability of displaying these effects. These factors result in cultural differences in the extent and manifestations of intoxication.
• There are also genetic differences in susceptibility to intoxication with specific psychoactive substances associated with certain ethnic groups. Cultural and ethnically linked genetic factors have been better documented for alcohol than for other substances.

Developmental Presentations:

• Naïve users including adolescents can show features of intoxication at lower levels of use, reflecting lower physical and learned tolerance.
• Older adults may have a lower tolerance than younger people to the effects of substances.

Sex- and/or Gender-Related Features:

• The amount of substance and duration of use necessary to cause intoxication differs by sex, reflecting differences in body weight and composition.
• Behaviour while intoxicated may vary by gender, reflecting not only physiological differences, but also cultural differences and role expectations.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Episode of Harmful Use of Synthetic Cannabinoids and Harmful Pattern of Use of Synthetic Cannabinoids: In Episode of Harmful Use of Synthetic Cannabinoids and Harmful Pattern of Use of Synthetic Cannabinoids, consumption or administration of synthetic cannabinoids results in damage to the person’s physical or mental health (including a Synthetic Cannabinoid-Induced Mental Disorder) or in behaviour leading to harm to the health of others. Recovery from Synthetic Cannabinoid Intoxication is generally complete. Complications due to such effects of intoxication such as injury, the effects of prolonged hyperactivity or inactivity, or other tissue damage should be diagnosed as Episode of Harmful Use of Synthetic Cannabinoids or Harmful Pattern of Use of Synthetic Cannabinoids, as appropriate. If relevant at the time of the clinical encounter (e.g., in emergency settings), Synthetic Cannabinoid Intoxication can be given as an associated diagnosis, with Episode of Harmful Use of Synthetic Cannabinoids or Harmful Pattern of Use of Synthetic Cannabinoids as the primary diagnosis.
• Boundary with Synthetic Cannabinoid Dependence: Episodic or continuous intoxication with synthetic cannabinoids is a typical feature of Synthetic Cannabinoid Dependence. If all diagnostic requirements of both conditions are met for the same episode of care, Synthetic Cannabinoid Dependence should be assigned as the primary diagnosis, with an associated diagnosis of Synthetic Cannabinoid Intoxication.
• Boundary with Synthetic Cannabinoid Withdrawal: Synthetic Cannabinoid Withdrawal occurs upon cessation or reduction of synthetic cannabinoids in the context of physiological dependence or when synthetic cannabinoids have been taken for a prolonged period or in large amounts. In contrast, the onset of Synthetic Cannabinoid Intoxication occurs immediately or shortly after the consumption of synthetic cannabinoids. Moreover the intoxication and withdrawal syndromes for synthetic cannabinoids are typically quite distinct.
• Boundary with Synthetic Cannabinoid-Induced Delirium: Delirium is characterized by disturbances in attention, orientation, and awareness that develop within a short period of time with symptoms that are transient and may fluctuate depending on the underlying aetiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. Disturbance of the sleep-wake cycle may also be present. Delirium can be caused by intoxication or withdrawal from substances. When symptoms of Delirium are attributable to Synthetic Cannabinoid Intoxication, an associated diagnosis of Synthetic Cannabinoid-Induced Delirium should be assigned in addition to the diagnosis of Synthetic Cannabinoid Intoxication.
• Boundary with other Synthetic Cannabinoid-Induced Mental Disorders: Mental or behavioural symptoms that arise during Synthetic Cannabinoid Intoxication should only be used as a basis for diagnosing a Synthetic Cannabinoid-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of Synthetic Cannabinoid Intoxication and the symptoms are sufficiently severe to warrant specific clinical attention.
• Boundary with other medical conditions: A variety of medical conditions may produce symptoms that are similar to those of Synthetic Cannabinoid Intoxication. Some of these medical conditions are life-threatening requiring immediate intervention. Evidence of synthetic cannabinoid use (e.g., positive laboratory results) does not rule out the possibility of a comorbid medical condition. These alternative diagnoses must be considered in assessing Synthetic Cannabinoid Intoxication. Certain medical conditions may also augment or prolong the duration of intoxication. Symptoms of intoxication that persist after they can no longer be reasonably attributed to the pharmacological effects of synthetic cannabinoids may suggest the presence of another medical condition. If it is determined that Synthetic Cannabinoid Intoxication is comorbid with a medical condition, both diagnoses should be assigned.
• Boundary with overdose: When consumption or administration of psychoactive substances results in symptoms of overdose (e.g., coma; life-threatening cardiac or respiratory suppression), it is typically more appropriate to apply a diagnosis from the grouping of Harmful Effects of Substances in the chapter on Injury, Poisoning or Certain Other Consequences of External Causes rather than Substance Intoxication.