Catatonia may also present as part of a primary psychotic disorder, general medical condition, or relating to substance abuse.This case describes a catatonic state associated with psychosis and mania postulated to be induced by vaping cannabis oil. We acknowledge that it is difficult torule out an underlying BPD in this case and that his cannabis use could have induced a mood episode or was simply incidental to the presentation, especially given that catatonia is seen most commonly in BPD mood episodes. In addition, it is more likely for patients experiencing a manic episode to engage in risky behavior such as substance use, and the patient may not have noticed the onset of mania when he began to engage in cannabis use. However, we still fifind his case to be compelling in that he never experienced psychosis, mania, or catatonia outside of episodes of high-potency THC use, which the patient reported preceded the start of his acute psychiatric symptoms. In addition, it is atypical for a patient with BPD to have never experienced a depressive episode or not have a family history of mood disorders. Ultimately, it would be difficult to diagnose BPD in this patient unless he has future mood episodes in the absence of precipitating substance use. There were no general medical conditions found that we could contribute to the development of catatonia. He also had no residual symptoms of psychosis that would be expected of a primary psychotic disorder in the periods between his two admissions. Lastly, the patient denied that he had used any illicit substances other than cannabis before either hospital admission that could have contributed to the development of catatonia. Regarding cases of cannabis-induced catatonia, the literature draws from scattered case reports only. One case was found involving a 17-year-old patient with cannabis dependence and catatonia who eventually was diagnosed with schizophrenia.11 Another case published in 2011 touts itself as the “only report of cannabis-induced catatonia” found at that time in the literature. This case involved a 30-year-old patient with increased use of pot for growing marijuana for three weeks before admission for catatonia. This patient had a history of five prior episodes of catatonia with no interepisode psychiatric symptoms, several of which were associated with increased cannabis use.
Catatonia has also been associated with abrupt withdrawal of heavy cannabis use in one case report. In this case, a 32- year-old man who reportedly smoked approximately 20 g of cannabis daily for many years was incarcerated. Three weeks later, he was admitted for catatonia after he had ceased talking and eating and had a Bush-Francis catatonia rating scale score of 30. He required six weeks of treatment before his symptoms fully resolved.13 Although cannabis use is common in patients with BPD, the association between cannabis use and bipolar symptomology remains equivocal. This is also a point of interest given that individuals with BPD have increased rates of cannabis use compared with patients with other psychiatric disorders and the general population. Cannabis use disorder prevalence is also higher in patients with BPD, specifically 7.2% in patients with BPD compared with 1.2% in the general population.14 Authors of a 2018 review on cannabis use and mood disorders concluded that there is moderate evidence to support earlier onset and increased exacerbations of BPD symptoms in patients with problematic cannabis use.15 However, a more recent review from 2020 concluded that some studies found a significant association between cannabis use and BPD onset and progression, whereas other studies did not, highlighting the need for more longitudinal research in this area.16 While the general body of literature regarding the effects of high potency cannabis remains limited, we do have a possible model in the form of synthetic cannabinoids . One recent case report links the use of SCs to the development of catatonia in two patients.17 Similar to our patient, these two patients also experienced psychosis and related catatonic symptoms. These compounds, commonly called K2 or spice, bind as full agonists to CB1 and CB2 and elicit cannabimimetic effects similar to those of THC. However, SCs have been shown to bind to cannabinoid receptors with potencies 2–100 times greater than traditional herbal cannabinoids and are associated with greater risks of adverse psychiatric symptoms such as agitation and psychosis.
Moreover, SCs do not contain any psychoprotective CBD, which is also similar to high-potency THC products. One could postulate that despite the difference in binding potentials, receptor saturation through high-potency herbal THC products may result in similar symptoms experienced with SCs. It would follow that higher rates of psychosis and catatonia seen in SC users may also be seen in those vaping highpotency cannabis oil.Our review of published literature found five case reports of hospitalizations associated with cannabis oil vaping. Of particular interest, one patient also developed catatonia and was treated with lorazepam similar to our case. However, this patient had been administered antipsychotics, which itself can be a risk factor for the development of catatonia. Four cases reported prominent symptoms of psychosis, includingcommand auditory hallucinations, persecutory and paranoid delusions, incoherent speech, and poor selfcare. In four of the cases, clinicians attempted treatment with risperidone. Interestingly, two cases reported cardiotoxicity with diaphoresis, hypertension, and tachycardia. In one case, the patient required sedation becuase of seizures. Psychiatric disorders are cited as one of the most common reasons for using medicinal cannabinoids. However, a recent systematic review and meta-analysis found that there is insuffificient evidence to suggest that cannabinoids improve depression, anxiety, or psychosis. In fact, it is well established that cannabis use, especially of products with highly concentrated THC, increases the likelihood of developing psychotic disorders in individuals at risk and predicts higher psychosis relapse rates.A recently published large multicenter case-control study of patients with first-episode psychosis found that the greatest risk factors for psychosis were daily use of cannabis and use of high-potency cannabis .
The odds of developing psychosis among daily low-potency cannabis users were 2.2 times higher than for never users. The odds of psychosis among users of daily high-potency cannabis users were 4.8 times higher than for never users. Assuming cannabis use caused these patients’ psychosis, the study investigators estimated that 20% of new cases of psychotic disorders could have been prevented if daily cannabis use were abolished.24 Furthermore, there is ample evidence that initiation of cannabis use in adolescence is associated in a dose-dependent fashion with the emergence andseverity of psychotic symptoms. Those adolescents who initiate use earlier and use at higher frequencies show more significant symptoms of psychosis and poorer treatment outcomes. These associations are more robust for those patients with a strong family history of psychotic disorders.25 One concern highlighted extensively by the media is the rise in vaping-related lung injuries. National and state data from patient reports and product sample testing show THC-containing e-cigarette or vaping products are linked to most e-cigarette or vaping product use– associated lung injury cases. As of February 4, 2020, a total of 2758 hospitalized e-cigarette or vaping product use–associated lung injury cases and 64 deaths had been reported to the US Centers for Disease Control and Prevention. Among these cases reported to the Centers for Disease Control and Prevention , 82% reported using THC-containing products with 33% using THC-containing products exclusively. Of these cases, 52% were younger than the age of 24 years.Owing to this large rise in vaping product use among adolescents,container for growing weed the US Food and Drug Administration issued an enforcement policy in January 2020, which prohibits the production, distribution, and sale of all flflavored cartridge-based e-cigarettes with the exception of menthol and tobacco flflavors. In accordance with the FDA, the change is an attempt to limit the alarming rise in the use of e-cigarettes by teens, who overwhelmingly prefer flflavors. However, to date, the FDA’s efforts to improve the safety of vaping devices has focused only on the regulation of nicotine vaping products.
Our case raises concerns about the potential for increased psychiatric toxicity from vaping highly concentrated THC products. Numerous studies continue to show the relationship between cannabis use and the development of psychosis; however, there is currently no clear relationship between the onset and progression of BPD owing to cannabis use or the development of catatonia. Based on our case, one could hypothesize that the use of highly concentrated THC products could result not only in psychosis but also episodes of mania and catatonia that may have not been seen in the past when lower-potency THC use was more the norm. High-potency cannabis use may result in more severe psychiatric side effects, similar to SCs in which several cases of catatonia have been documented. There is currently no available research to guide the public about what level of THC is benefificial for any medical condition or what level may result in medical and psychiatric toxicity, though it is apparent that daily use and high-potency THC use result in higher psychosis risk.This is alarming in light of recent data showing increasing numbers of adolescents and adults initiating and using cannabis products daily.8 The vaping of concentrated cannabis oils is also growing, especially among adolescents, further increasing exposure to high-potency THC. Current evidence suggests that this trend will likely lead to more cases of psychosis and need for acute psychiatric treatment.4 More education about these risks should be made available to the public and legislators should consider regulations to limit the concentrations of THC and types of cannabis products offered in dispensaries until more research is available regarding their safety. Our case also highlights the need for more research into the potential medical and psychiatric complications from the use of newer, highly concentrated THC products. More attention should also be given to the possible negative medical consequences of vaping THC products such as e-cigarette or vaping product use– associated lung injury. We propose based on our case that high-potency cannabis products may have signififi- cantly more psychiatric toxicity than traditional lower potency products, and future research should be aimed at clarifying this potential association.Modern civilization has extensive utilization of multiple pharmaceutical drugs such as Non-steroidal anti-inflflammatory drugs for the reprieve of pain, as analgesics and antipyretics, sex hormones, antiepileptic , blood lipid-lowering and b-blocker agents.
NSAIDs are the class of drugs that are used more abundantly because these are over the counter drugs and can be easily purchased from the market without specific prescription. More common drugs in this class are acetylsalicylic acid, paracetamol, ibuprofen, naproxen and diclofenac.Moreover, many common pharmaceuticals are available with extensive utilization in medical care having paracetamol as a base ingredient and are used with different formulations and considered safe, except for high dosage. The structural formula is given in Scheme 1. As the use of these drugs is unavoidable and these pharmaceutical compounds are excreted in urine and other biological wastes as active metabolites, either directly or indirectly, in high fractions. These wastes are constantly being discharged into municipal wastewaters which results in contaminated aquatic surroundings, surface and ground waters, and finally into the drinking water supplies. Despite their very low concentrations, these are hazardous for human beings especially for infants, and cannot be removed employing conventional water treatment techniques such as chlorination. Advanced oxidations, reverse and forward osmosis can be used to remove these contaminants but these processes are expensive; hence, large scale application for municipal water treatment is uneconomical. Up to now, membrane fifiltration, UV-degradation, ultrasonic degradation and electrochemical degradation are the reported processes for the removal of NSAIDs from surface or drinking water. The combination of catalytic decomposition along with ultrasonic degradation was studied by Soltani et al.,.Results elucidated that the dispersion of stonewaste improved the pore volume and specific surface area of ZnO catalyst which significantly improved the paracetamol degradation effificiency up to 98.1%. Mirzaee et al., investigated the electrochemical decomposition of paracetamol in an ultrasound environment. Using Iron anode improved the degradation potential of the modified hybrid process as compared to individual processes.