To some, the spread of marijuana legalization across the United States might look like a sign that synthetic cannabinoid drugs like K2 and Spice are bound to decline in popularity. But in fact, they’re a growing problem that drug users and doctors alike are at a loss for how to deal with. In a new report commissioned by the Office of National Drug Control Policy, researchers explain why doctors are so ill-equipped to deal with this problem.

When patients arrive at an emergency room with a suspected overdose from synthetic cannabinoids, an effective diagnosis — which includes a drug test — is crucial to determining how to treat them. But because new synthetic cannabinoids are created in labs almost every week, doctors and drug test manufacturers simply can’t keep up. In the report, published Tuesday, a team of emergency doctors and forensic toxicologists in Maryland show that even their best efforts are no match for the rate that new drugs are appearing on the streets.

“We thought we were really on top of it because we were testing for 26 synthetic cannabinoid metabolites,” Eric Wish, Ph.D., director of the Center for Substance Abuse Research at the University of Maryland and the principal investigator on the new study, tells Inverse. “Out of the 169 substances, one was positive for synthetic cannabinoids, so we said, ‘What in the hell is going on here? We must be missing whatever’s out there.’”

A package of K2, also known as Spice.
A package of K2, also known as Spice. Synthetic cannabinoid mixtures have so many new chemicals in them that doctors simply can't test for them all.

The study was performed on 175 samples taken from patients who had been admitted to either Prince George’s Hospital Center (PGHC) or the University of Maryland Medical Center (UMMC) for suspected synthetic cannabinoid overdoses. Because the first battery of tests that Wish mentioned wasn’t able to identify synthetic cannabinoids in the samples, over the next year the team modified the original test to identify 20 additional synthetic cannabinoid metabolites. But when the new tests were run on the original samples, only one-quarter tested positive for synthetic cannabinoids.

The tests clearly could not keep up with new synthetic cannabinoids, but they did show all sorts of other drugs. For instance, 47 percent of patients from PGHC tested positive for PCP, and 78 percent of patients from UMMC tested positive for opioids. Two-thirds of patients had multiple drugs in their systems, and some tested positive for as many as six different drugs.

“Even though the doctors and the patients thought they had taken synthetic cannabinoids — this was during an outbreak around Baltimore, with synthetic cannabinoids — they were actually using different drugs,” says Wish. “The results were quite unexpected and amazing.”

urinalysis
To conduct this study, researchers used urine samples that the hospitals were going to throw away.

In his decades of research, Wish has identified emerging drug trends before most people were even aware the drugs existed. By retesting urine samples from hospitals and jails that have already been processed for basic drugs, Wish and his team have found evidence of synthetic cannabinoids, prescription and illicit opioids, and other designer drugs. As in the new study, he has often found that the initial tests conducted by hospitals or the probation system failed to catch what people are really using; while those institutions usually test for fewer than 10 drugs, his team tests for over 200. For better or worse, that level of testing now seems to be necessary in order to keep up with the rapidly changing drug scene nationwide.

“We were surprised to know that the patients and the doctors didn’t know what the people had actually taken,” says Wish. “We can’t keep up with what’s on the street, and the consumer doesn’t have any idea what they’re taking.” He notes that researchers no longer call things like Spice and K2 “synthetic marijuana” because they act so differently from marijuana, despite stimulating the brain’s cannabinoid receptors. “What you’re using is new chemicals that no one has ever tested to see what the effect is on a human being.”

To help doctors stay on top of new drugs, Wish and his team are working on the NIH-sponsored Drug Outbreak Testing Service, a program in which medical examiners and treatment programs can send up to 20 urine specimens at a time for more thorough drug testing. The hope is that the results will give doctors a better idea of what drugs people in their area are taking, helping public health officials to understand what they’re dealing with. The opioid epidemic, which has received the most media attention in recent years, is only one dimension of a far broader drug problem, he says.

“Everywhere we looked, whether it’s people who died from what was believed to be a fentanyl overdose or it was people who came into a drug treatment program, what you find is that these people have a large number of drugs in their urine. In other words, the opioid is only the tip of the iceberg of what they’re using,” he says.

“If we think that all we have to do is treat their fentanyl problem or their heroin problem, we’re going to miss the problem that’s much bigger than those drugs. The person needs to get services and help that focuses on the entire drug-using behavior, not just those couple of drugs that we hear about so much.”