{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,14]],"date-time":"2026-05-14T10:10:17Z","timestamp":1778753417768,"version":"3.51.4"},"reference-count":6,"publisher":"California Digital Library (CDL)","issue":"2","license":[{"start":{"date-parts":[[2020,4,23]],"date-time":"2020-04-23T00:00:00Z","timestamp":1587600000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Introduction: Heroin can be adulterated with various substances that may or may not have pharmacological effects. Here we report a case series of 8 patients who presented to the emergency department after overdose with intravenous heroin preparation adulterated with the synthetic cannabinoid methyl 2-(1-(5-fluoropentyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate (5F-MDMB-PINACA).\n\nCase Series: Except for one patient, all of them presented with a typical initial opioid toxidrome consisting of central nervous system and respiratory depression along with pinpoint pupils. Naloxone was given to them, triggering severe agitation and combative behavior along with overlapping features of anticholinergic and sympathomimetic toxidrome. All patients required multiple doses of benzodiazepines. Three were successfully treated with physostigmine.\n\nDiscussion: 5F-MDMB-PINACA is a synthetic cannabinoid that was added to heroin in samples obtained from patients reported in this case series. Patients demonstrated significant agitation after receiving naloxone for opioid toxidrome, presumably because of the removal of the depressant effect of opioids, which unmasked the excitatory effects of the synthetic cannabinoids. Three patients required physostigmine along with the benzodiazepines for control of their agitation, urine retention and abnormal vitals, suggesting the possibility of an anticholinergic toxidrome to have developed in these patients.\n\nConclusion: Heroin contaminated with 5F-MDMB-PINACA exhibits variable severities of anticholinergic effects, some on presentation and others only after opiate antagonism.<\/jats:p>","DOI":"10.5811\/cpcem.2020.2.45060","type":"journal-article","created":{"date-parts":[[2020,5,5]],"date-time":"2020-05-05T22:20:17Z","timestamp":1588717217000},"page":"121-125","source":"Crossref","is-referenced-by-count":5,"title":["Heroin Adulterated with the Novel Synthetic Cannabinoid, 5F-MDMB-PINACA: A Case Series"],"prefix":"10.5811","volume":"4","author":[{"given":"Muhammed","family":"Ershad","sequence":"first","affiliation":[{"name":"Drexel University College of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maricel","family":"Dela Cruz","sequence":"additional","affiliation":[{"name":"Drexel University College of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed","family":"Mostafa","sequence":"additional","affiliation":[{"name":"Drexel University College of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Muhammad","family":"Khalid","sequence":"additional","affiliation":[{"name":"Drexel University College of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ryan","family":"Arnold","sequence":"additional","affiliation":[{"name":"Drexel University College of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard","family":"Hamilton","sequence":"additional","affiliation":[{"name":"Drexel University College of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"29705","published-online":{"date-parts":[[2020,4,23]]},"reference":[{"key":"ref0","doi-asserted-by":"publisher","unstructured":"Hamilton RJ, Perrone J, Hoffman R, et al. A descriptive study of an epidemic of poisoning caused by heroin adulterated with scopolamine. Clin Toxicol. 2000;38(6):597-608.\u00a0","DOI":"10.1081\/clt-100102008"},{"key":"ref1","doi-asserted-by":"publisher","unstructured":"Le Boisselier R, Alexandre J, Lelong-Boulouard V et al. Focus on cannabinoids and synthetic cannabinoids. Clin Pharmacol Ther. 2017;101(2):220-9.","DOI":"10.1002\/cpt.563"},{"key":"ref2","doi-asserted-by":"publisher","unstructured":"Schwartz MD, Trecki J, Edison LA et al. A common source outbreak of severe delirium associated with exposure to the novel synthetic cannabinoid ADB-PINACA. J Emerg Med. 2015;48(5):573-80.","DOI":"10.1016\/j.jemermed.2014.12.038"},{"key":"ref3","doi-asserted-by":"publisher","unstructured":"Zhang MW and Ho RC. The cannabis dilemma: a review of Its associated risks and clinical efficacy. J Addict Med. 2015;2015:707596.","DOI":"10.1155\/2015\/707596"},{"key":"ref4","doi-asserted-by":"publisher","unstructured":"Angerer V, Jacobi S, Franz F et al. Three fatalities associated with the synthetic cannabinoids 5F-ADB, 5F-PB-22, and AB-CHMINACA. Forensic Sci Int. 2017;281:e9-15.","DOI":"10.1016\/j.forsciint.2017.10.042"},{"key":"ref5","doi-asserted-by":"publisher","unstructured":"Krotulski AJ, Mohr ALA, Logan BK. [Ahead of Print]. Emerging synthetic cannabinoids: development and validation of a novel liquid chromatography quadrupole time-of-flight mass spectrometry assay for real-time detection. J Anal Toxicol. January 7, 2020.","DOI":"10.1093\/jat\/bkz084"}],"container-title":["Clinical Practice and Cases in Emergency Medicine"],"original-title":[],"deposited":{"date-parts":[[2020,7,20]],"date-time":"2020-07-20T20:36:49Z","timestamp":1595277409000},"score":1,"resource":{"primary":{"URL":"https:\/\/escholarship.org\/uc\/item\/6fz2q2tm"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,4,23]]},"references-count":6,"issue-title":["Clinical Practice and Cases in Emergency Medicine"],"journal-issue":{"issue":"2","published-online":{"date-parts":[[2020,4,1]]}},"URL":"https:\/\/doi.org\/10.5811\/cpcem.2020.2.45060","relation":{},"ISSN":["2474-252X","2474-252X"],"issn-type":[{"value":"2474-252X","type":"electronic"},{"value":"2474-252X","type":"print"}],"subject":[],"published":{"date-parts":[[2020,4,23]]}}}