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Short report
Are the last grade medical students aware of the danger of synthetic
cannabinoids?
Nazim Ercument Beyhun
a
,
*
, Gamze Can
a
, Murat Topbas
a
, Sertac Cankaya
a
,
Huseyin Cetin Ketenci
b
a
Karadeniz Technical University Medical Faculty, Dep. of Public Health, 61080 Trabzon, Turkey
b
Trabzon Branch of The Council of Forensic Medicine, Trabzon, Turkey
article info
Article history:
Received 30 August 2015
Received in revised form
3 November 2015
Accepted 15 November 2015
Available online 26 November 2015
Keywords:
Synthetic cannabinoids
Internship
Awareness
Social media
Medical student
abstract
Synthetic cannabinoids are drugs which are increasingly used by especially adolescents and young
people. In recent years hospital admissions even concluding with deaths have been observed. Therefore,
the awareness of medical students, who will be in challenge with this new drug abuse, is an important
issue. The aim of this study is to figure out the awareness of the last grade medical students and its
correlates. This is a questionnaire based descriptive study with the participation of 148 students at
Karadeniz Technical University Medical Faculty, Turkey. An awareness score was produced to measure
awareness (cronbach alpha ¼0.67). The 17.6% (26/148) of students who reported not knowing what
synthetic cannabinoids were and hearing the name for the first time in this study. The 16.4% of students
assumed that synthetic cannabinoid use was legal, and 16.2% assumed that synthetic cannabinoids are
not drugs. The internet (including social media) (48.6%) and pharmacology lectures (40.5%) were iden-
tified as the most stated sources of information. The students who have synthetic cannabinoid user
friends and social media account have significantly higher awareness scores (p <0.05 for both). Last
grade medical students have a lack of awareness towards synthetic cannabinoids which is an increasing
threat that they have to challenge.
©2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
1. Introduction
Synthetic cannabinoids (SCs) are compounds which have been
increasingly used by young people and young adults in particular in
recent years.
1,2
The SCs are compounds that mimic the effects of
cannabis which have various types of chemical structures. There
are many synthetic cannabinoid compounds like HU, AM, JWH,
XLR, CP, UR, AKB, APICA, APINACA.
1,3,4
Clinical effects observed to
date include hallucinations, anxiety, paranoia, psychosis, agitation,
confusion, seizures, nausea, vomiting, tachycardia, dyspnea, acute
kidney failure, ST elevation at ECG, myocardial infarction, self-
harming behaviors, suicide and death.
1,5 e9
SCs, originally produced for medical purposes, are now also
manufactured in clandestine laboratories, mixed with herbal
products and sold under various names in attractive, bright pack-
aging likely to be attractive to young people. They are frequently
rolled up like cigarettes and inhaled. They are easily available in gas
stations, places known as head shops and on the internet. The
packaging may give the impression that they are harmless, natural
products. They may even be sold as nail polish remover, incense or
deodorants.
1,5,6
SCs which entered the European market under the name of
‘Spice’and ‘K2’in America have been sold under the names of
‘Bonzai’in Turkey since 2009.
10e13
SCs, which are already on the
lists of prohibited substances in the U.S. and Europe, are also ban-
ned in Turkey.
10,13
Although they are banned, producers employ an
interesting technique and are able to alter the chemical structures
of SCs to enable users to avoid detection at toxicology scans.
Forensic laboratories are constantly striving to keep up with new
substances. The possibility of detection at toxicology tests used in
hospitals is even lower. This fact enables users to perceive SCs as
easily used drugs without being detected, thus it causes the com-
mon use.
1,5,8
Lifetime use among university students in the U.S. ranges be-
tween 1.1% and 9.0% while the level of use among high school
*Corresponding author. Karadeniz Teknik Universitesi Tip Fak, Halk Sagligi AD,
61080 Trabzon, Turkey. Tel.: þ90 5386650288.
E-mail addresses: ebeyhun@yahoo.com (N.E. Beyhun), gcanktu@yahoo.com
(G. Can), murattopbas@yahoo.com (M. Topbas), drsertaccankaya@gmail.com
(S. Cankaya), hcketenci@gmail.com (H.C. Ketenci).
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine
journal homepage: www.elsevier.com/locate/jflm
http://dx.doi.org/10.1016/j.jflm.2015.11.014
1752-928X/©2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 38 (2016) 1e5
students in the previous year was 6.4%.
8,14
There are no prevalence
studies for Turkey, but according to Turkish Drug Report, 780 kg of
SCs were seized in 2013, much more than the levels for 2011 and
2012.
12
They may be popular among young people for reasons such
as curiosity, relaxation and feeling better, perceptions of avoiding
legal sanctions and easy accessibility.
2,8,15
They are particularly
used together with cannabis and alcohol.
2,8,14,16
Presentations to hospital due to SC use have increased in recent
years. According to the U.S. Drug Abuse Warning Network, there
were 11,406 SC-related presentations in 2010, 3/4 of which involves
the 12e29 age group.
1
As the usage of SCs increases, the diverse
health effect reports also increase. Law et al. noted that diverse
health effect reports due to SCs increased by 330% between
JanuaryeApril 2015 in United States.
17
Recent publications in Turkey particularly report hospital pre-
sentations in the adolescent age group.
18
The question therefore
naturally arises of how aware physicians are on this subject. The
only study of physician awareness was performed in Chicago and
reported low awareness and a need for education.
19
Education in
medical faculties in Turkey lasts 6 years. At the Karadeniz Technical
University Medical Faculty, where this study was performed, the
final year consists of internships and students attend all the theo-
retical classes as well as practical medicine. The increasing use of
SCs and associated hospital presentations mean that medical stu-
dents therefore need to have greater experience and preparation.
No studies have to date investigated medical students’awareness of
this subject.
The purpose of this first study in the literature on the subject
involving medical students was therefore to determine the levels of
awareness of SCs among the last grade medical students and the
factors affecting that awareness.
2. Methods
This descriptive, questionnaire-based research was performed
with the participation of last grade medical students of Karadeniz
Technical University Medical Faculty (N ¼164). It was completed
with 148 interns (coverage ¼90.2%).
Participation in the study was voluntary, and questionnaires
were completed anonymously. At the beginning of the question-
naire, students were informed of the purpose of the study, and
completion of the form was interpreted as consent. Approval for the
study was granted by the Karadeniz Technical University Medical
Faculty Management Board (Approval No. 2015-5/3).
The research data were collected by using a questionnaire in
AprileMay 2015. The questionnaire consisted of four parts. The first
part contained questions inquiring into sociodemographic charac-
teristics (age, sex) and habits (smoking, alcohol use). The second
part inquired into drug use, what the substance was if the subject
used or experienced any, whether the subject had any friends who
used drugs, if so what substances they used, whether any family
members used drugs, and if so what they used. Students were next
asked two multiple select questions. The first question asked which
of a list of substances (amphetamine, marijuana, cocaine, heroin,
morphine, ecstasy and the SCs Bonzai, K2, Spice, Jamaica and JWH)
were drugs, and the second one was which of these were SCs. Blank
spaces were also provided for participants to write down the names
of the substances they knew other than in the list. In order to
determine students’clinical knowledge of SCs, that same section
also inquired into whether students had ever seen patients with
drug intoxication, if so what substance was involved, and how SCs
can be used (orally, inhalation, intramuscularly, intravenously or by
the rectal route). Students were next asked whether they knew
about the effects of SCs, and were asked to select one of three op-
tions; 1) I do not know, this research is the first time I have heard of
them, 2) I have heard of them, but I do not know their effects or 3) I
know them. If the students reported that they knew, they were
asked to list the effects they were familiar with. This was followed
by a multiple select question intended to elicit the sources of that
information (medical faculty pharmacology classes, the internet,
TV or medical textbooks). The first of the last two questions in this
section asked whether students had encountered reports of SC use
on the social media (facebook, twitter, youtube, tumblr, instagram
etc.), and the second one inquired into whether they asked patients
about SCs when taking anamnesis. The final part of the question-
naire contained 15 propositions and students were asked to
respond to these propositions on a 5-point Likert-type scale
(completely agree, partly agree, do not know, disagree and
completely disagree). Subjects responding completely agree or
agree, and those responding disagree or completely disagree were
combined, while the do not know option was preserved. The
propositions are shown in Table 1.
An awareness score was calculated on the basis of answers to 9
questions. Eight of these were scored according to responses to the
first 8 prepositions shown in Table 1 (with the exception of the 2nd
question, 1 point was given for expression of agreement, while in
the 2nd question 1 point was given for expression of disagreement.
No points were given for saying ‘do not know’or for leaving a
question blank). These items had a Cronbach Alpha score of 0.67.
Finally, 1 point was given to the students who marked the correct
options for the question in the second part of the questionnaire
asking about the SCs that subjects were familiar with, and who did
not incorrectly mark other substances. An awareness score out of 9
was thus calculated for each subject.
Statistical analysis was performed on SPSS 13.0 (Chicago, USA)
software. Descriptive statistics were expressed as number, per-
centage, mean, median, standard deviation, minimum and
maximum. Normal distribution of awareness scores was assessed
using the KolmogoroveSmirnov test. The ManneWhitney U test
was used to determined factors affecting awareness scores. Bon-
ferroni adjustment was used where required. The reliability of the
awareness score was calculated with Cronbach-alpha.
3. Results
Sociodemographic characteristics and habits of the participants
are shown in Table 2. Awareness of known synthetic cannabinoid
brands and JWH on the market was presented at Fig. 1.
The 17.6% (26/148) of students reported not knowing what SCs
were and hearing the name for the first time in this study, while
49.3% (73/148) stated that they heard the name but were unfamiliar
with the effects. Additionally, 34.5% (51/148) of students said they
had seen patients with drug intoxication and 19.6% (29/148) re-
ported having seen bonzai intoxication. Asked whether they
inquired into SC use when taking anamnesis, 43.2% (64/148) of
students said they had never asked, 40.5% (60/148) reported that
they only asked when they knew or suspected that the patient has
psychiatric disease and/or substance dependence, while 16.2% (24/
148) stated that they asked all patients.
Asked about modes of SC use, 41.9% (62/148) of students cited
the oral route, 40.5% (60/148) inhalation, 33.1 (49/148) the intra-
venous route, 12.2% (18/148) the intramuscular route and 4.1% (6/
148) the rectal route. A total of 30.4% (n ¼45) stated the effects of
SCs. When asked to write the effects down, the five most common
were hallucination (10.1%, 15/148), coma (6.8%, 10/148), impaired
consciousness (6.8%, 10/148), tachycardia (6.8%, 10/148) and nausea
(6.1%, 9/148).
When students were asked the source of their information
about SCs, 48.6% (72/148) cited the internet including social media,
N.E. Beyhun et al. / Journal of Forensic and Legal Medicine 38 (2016) 1e52
40.5% (60/148) cited pharmacology lectures, 32.4% (48/148) cited
TV and 18.9% (28/148) cited medical books.
Responses of students to propositions concerning SCs are given
in Table 1.
Students' mean awareness score was 4.7 ±1.7 out of 9, with a
median of 5.0 (min ¼0emax ¼8). Medical students who have a
social media account and stated to encounter messages about SC on
the social media have significantly higher awareness scores
(p <0.05). Factors affecting students’awareness are shown in
Table 3.
4. Discussion
This is the first study intended to determine medical faculty
students’awareness of SCs. The fact that the use of SCs is increasing
both worldwide and in Turkey, where this study was performed,
makes the awareness of last grade medical students, who will be
encountering such cases, very important.
SC use in Turkey was made illegal under a law passed in 2011.
Nonetheless, 16.4% of students thought that SC use was legal, and
16.2% thought that SC is not a drug. The young people thought SCs
were legal and regarded SCs as safer than other drugs.
8
However,
since the target group in our study consisted of students, who
would soon be physicians, a higher level of this basic awareness
might have been expected. Another striking finding was that 17.6%
of students said they had never heard of SCs before this research.
SCs are generally known by brand names. The best known names in
Europe and the USA are Spice and K2.
1,4 e6
Similar as in other
markets, SCs have various different brand names in Turkey. Bonzai,
Jamaica, Yucatan Fire, Jamaican Gold, Smoke XXX are example
brand names. However, most commonly they are known as ‘Bon-
zai’.
11,13,20
The same picture also emerged in our study. Almost all
students stated that Bonzai is a drug but dramatically, almost half of
them did not know that Bonzai is a SC (Fig. 1). This deficiency can be
overcome, and the awareness of physicians who will be directly
serving the community can be increased by discussing SCs together
with the brand names during medical training. However, the brand
names can change on a constant basis. For example, the level of
hearing the name ‘Jamaica’was much lower. Instructors must also
adapt to the rapid changes introduced by manufacturers.
One important component of students' awareness is their
knowledge of the clinical effects of SCs and their modes of use, and
their approaches to patients. In our study, students were asked to
write down the effects of SCs they were acquainted with using an
open-ended question. Only 10% and %6.8 of students even put
down hallucinations and coma as effects of SCs and others lower
than these proportions.
1,9,20
This finding shows a gap in knowledge
of SCs. To increase the awareness, lecturers should give more
attention to the clinical effects of SCs and should ask questions in
exams. Although, in agreement with the literature, inhalation was
reported as the most common mode of use, students described the
oral, i.m. and i.v routes, which are almost never encountered (apart
from in one case), as being commonly used.
1,6,8,15
Additionally,
74.3% of students reported feeling inadequately prepared to deal
with a patient using SCs (Table 1). A similar level of 80% was re-
ported in a study of emergency physicians in America.
19
In the light
of this information it is very important for awareness of how to
approach patients using SCs to be enhanced, especially during
pharmacological, psychiatric and emergency education. We found
that the students who stated to take care of a patient intoxicated
with SCs previously did not have higher awareness scores than
Table 1
Students' awareness of synthetic cannabinoids and their responses to propositions concerning attitudes (5-point Likert scale).
Agree Disagree No idea
1. Synthetic cannabinoid use is illegal (n ¼146) 83.6 8.2 8.2
2. Synthetic cannabinoids do not count as drugs (n ¼148) 16.2 74.3 9.5
3. Synthetic cannabinoids are easily available substances (n ¼148) 71.6 9.5 18.9
4. Synthetic cannabinoids' chemical strictures are constantly being altered by manufacturers (n ¼148) 37.8 7.4 54.7
5. They cause more medical effects than marijuana (n ¼146) 45.2 9.6 45.2
6. Synthetic cannabinoids can cause death (n ¼148) 85.8 5.4 8.8
7. Even if synthetic cannabinoids are used it is hard to detect them in blood or urine tests (n ¼148) 12.2 52.0 35.8
8. A patient using synthetic cannabinoids should also be assessed for other substance addictions (n ¼148) 88.5 6.8 4.7
9. There is no harm in using synthetic cannabinoids occasionally for recreational purposes (n ¼148) 12.2 81.8 6.1
10. I have heard more about synthetic cannabinoids recently (n ¼148) 85.8 6.8 7.4
11. I think that synthetic cannabinoid use is widespread among young people (n ¼148) 83.8 8.1 8.1
12. I do not think that synthetic cannabinoids use is as serious a public health problem as depicted (n ¼148) 10.1 81.1 8.8
13. I feel inadequate in terms of approaching a patient using synthetic cannabinoids (n ¼148) 12.8 74.3 12.8
14. I think that the social media can be used as a tool for reducing synthetic cannabinoid use in society (n ¼148) 74.3 20.9 4.7
15. I think that reports concerning synthetic cannabinoids in the social media and on TV increases curiosity about
narcotic substances (n ¼148)
68.9 23.0 8.1
16. The content concerning synthetic cannabinoids reaching me on the social media is largely about their health effects (n ¼147) 37.2 39.2 23.0
Table 2
Some sociodemographic characteristics and habits of students.
Characteristics n %
Gender (n ¼148)
Male 69 46.6
Female 79 53.4
Age (n ¼148) (mean ±SD/median) 25.1 ±1.1/25.0
Cigarette use (n ¼148)
Never 79 53.4
Tried 28 18.9
Occasionally 25 16.9
Regularly 16 10.8
Alcohol use (n ¼148)
Never 84 56.8
Tried 24 16.2
Occasionally 37 25.0
Regularly 3 2.0
Drug use (n ¼148)
Never 133 89.9
Tried 8 5.4
Occasionally 7 4.7
Regularly ee
Drugs used (n ¼15)
Marijuana 6 4.0
Marijuana þAmphetamine 1 0.7
Marijuana þEcstasy 1 0.7
Missing 7 4.7
Friends using drugs (n ¼148)
Yes 45 30.4
Friends using synthetic cannabinoids 22 14.9
Members of family using drugs (n ¼147)
Yes 5 3.4
N.E. Beyhun et al. / Journal of Forensic and Legal Medicine 38 (2016) 1e53
students who did not see SC intoxicated patient (p ¼533, Table 3).
This additionally indicates that near bed clinical trainings should be
more carefully designed by taking this lack of awareness of stu-
dents into consideration. Besides this findings also may indicate the
knowledge gap of lecturers about SCs also.
The factors affecting awareness need to be known in order to
improve it. The students who have synthetic cannabinoid or any
kind of drug user friends have higher awareness scores (p <0.05 for
both, Table 3). The presence of a ‘user’friend has also been reported
as an enhancing factor in another study.
2
Considering that the
mean age of the students in our study was 25 in addition to rep-
resenting the last grade medical students, this group was a young
one, and presence of a ‘user’friend also increased awareness. The
internet (including social media) was also identified as most stated
source of information. Similarly, the previous study of emergency
physicians in America also reported non-medical sources and the
internet as important sources of information.
19
However, since in-
formation obtained from friends, the internet and TV may be
misleading, accurate information obtained during medical training
is very important. Students in our study also cited pharmacology
classes and medical text books as sources of information, but at
levels lower than the internet. This information suggests that in-
structors should attach greater prominence to SCs in determining
educational content and SCs should be much more discussed in
pharmacology lectures and readings.
We identified one important finding not mentioned in any other
study, medical students who have social media account have
significantly higher awareness scores (Table 3). The question now
arises of whether the social media might represent a tool in the
fight against substance addiction. Pechman et al. reported that the
social media represented grounds for optimism in the fight against
smoking.
21
Indeed, 74.3% of students regard the social media as an
important means of raising awareness. Only 37.2% of students re-
ported that the information reaching them on the subject via the
social media concerned the health effects of SCs, and 68.9% re-
ported that the social media provoked curiosity on the subject, and
curiosity is one important reason for SC use (Table 1). From that
perspective, the social media represent a risk as well being capable
of use as an awareness raising tool. If judicial institutions interested
in the uncontrolled social media and those involved in the fight
against drugs can be properly and effectively used by the Ministry
of Health, this can represent an important source of accurate in-
formation for society.
4.1. Strengths and limitations
This study is the first one that tries to find the awareness of
synthetic cannabinoids with the participation of medical students.
One of the limitations of this study is that although students’names
were not taken in the questionnaires, since the subject matter is a
Fig. 1. Awareness of known synthetic cannabinoid brands and JWH on the market (n ¼148).
Table 3
Factors affecting students’awareness of synthetic cannabinoids.
Awareness score
(mean ±sd) Median (minemax) Z P
Have a friend who uses drugs 2.4 0.018
Yes (n ¼45) 5.2 ±1.6 5 (2e8)
No (n ¼103) 4.5 ±1.7 5 (0e8)
Have a friend who uses SCs 2.1 0.032
Yes (n ¼22) 5.4 ±1.3 5.5 (3e8)
No (n ¼126) 4.6 ±1.7 5 (0e8)
Have you ever cared for a patient with SC intoxication? 0.6 0.533
Yes (n ¼29) 5.0 ±1.7 5 (2e8)
No (n ¼119) 4.7 ±1.7 5 (0e8)
Have you encountered reports about SC use in the social media?
I do not use the social media (n ¼13) - a 3.4 ±1.6 4 (0e6) aeb1.4 0.172
a
I use the social media but I have never encountered any reports about SC (n ¼38) eb 4.1 ±1.6 4 (1e8) bec3.4 0.001
a
Yes, I have encountered messages about SC on the social media (n ¼96) ec 5.1 ±1.6 5 (0e8) aec3.7 0.000
a
a
Bonferroni adjustment, p values under 0.016 are significant.
N.E. Beyhun et al. / Journal of Forensic and Legal Medicine 38 (2016) 1e54
socially sensitive one the reported level of SC use may be lower
than the true figure, with no students stating they had used SCs.
Another limitation is that it contained retrospective questions, thus
raising the question of the memory factor.
5. Conclusion
This is the first study of the literature concerning SCs involving
medical students and it's found that among last grade medical
students there is a low level of awareness and a lack of information
about SCs. It is important to raise awareness of SCs and to be trained
with accurate information. The social media is a significant factor in
increasing awareness and can be used by the people who are
engaged in the fight against drugs as a way of enhancing this
awareness.
Conflict of interest
None declared.
Funding
None declared.
Ethical approval
None declared.
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