In “Emerging synthetic cannabinoids and the risk of psychosis: a growing concern for public health,”¹ the authors discussed the emergence of synthetic cannabinoid (SC), also called synthetic cannabinoid receptor agonist,² consumption in Brazil, describing its complex mechanisms of action and its strong association with psychosis and psychotic symptoms.

However, despite their clear harmful effects and higher addiction potential than other stimulants, SCs have not been regarded as a threat to public health in Brazil. The restricted availability and higher prices of SCs have so far acted as protective factors, limiting access in disadvantaged populations. For similar reasons, Brazil has largely avoided the opioid crisis experienced by many Western nations. Unfortunately, the low consumption rates of heroin and synthetic opioids cannot be attributed to better regulation of the rapidly growing pharmaceutical industry or to more conscientious prescription practices. Instead, they are due to the extremely low price of its competitors: cocaine and crack cocaine, which dominate Brazil’s drug market. The persistent affordability of crack cocaine stems from longstanding production and distribution pathways that have been firmly controlled by organized criminal networks in Brazil.³ This has also contributed to the emergence of open drug use in most Brazilian cities, where severe crack cocaine use disorder is deeply intertwined with social inequality. It is precisely within the complex landscape of open drug use that SC consumption has gained recent public attention. While reports of SC use in Brazil can be traced back to 2015, the perceived health risk of these substances has been insignificant until now. The likelihood of seeking emergency medical treatment following SC use was a main finding of the Global Drug Survey,⁴ which has been a leading information source on the topic since it was first conducted in 2015.⁵ The Survey found that SC use involves a significant risk of dependence and withdrawal, presumably higher than natural cannabis products. Brazil has actively participated in the Global Drug Survey since 2015, joining over 50 other nations in the survey that year. Although the survey’s data are not representative, 1.8% of the Brazilian respondents (103 of 5749) reported using SC in 2015.

There appears to have been a surge in SC consumption in recent months in Brazil. This phenomenon has been widely reported in the media and by health care services, which have documented anecdotal cases of fatalities.

Inaugurated in April 2023, the Hub de Cuidados em Crack e outras Drogas (Care Hub for Crack and Other Drugs) is a public service that provides offering addiction treatment and social care in São Paulo’s largest open drug scene, known as “Crackland.” During the first 12 months of operation, the facility has already received 3,759 patients reporting SC use (i.e., street names commonly attributed to SC, such as: Spice, K2, K9, and K12), which is 37.8% of all 9,945 patients interviewed for addiction treatment. Surpassing anecdotal evidence, these figures indicate a notable shift in SC accessibility, particularly among the most vulnerable segments of Brazil’s population. Easy access to SCs in the most prominent open drug scene in Brazil’s most populous city has led to a distinct set of challenges and risks. These preliminary data highlight the pressing need to promptly address this issue and have resulted in the Care Hub’s implementation of a toxicology surveillance program. The facility has recently added toxicology analysis to its service protocol to detect and identify SC metabolites in an effort to pinpoint the specific SCs used by this socially vulnerable population.⁶ The strategy involves systematic collection of 10 to 20 hair samples on a quarterly basis from individuals who report SC consumption during clinical assessment. The first batch is currently in analysis. The main challenge is to determine whether the substances commonly referred to as “K drugs” are indeed SCs, given that 221 new synthetic drugs have been identified as cannabinoid receptor agonists.⁷ Studies have shown that different types of SCs involve different levels of risk, which could be due to chemical variability or mixture with different compounds.^2,6 Hence, the insights derived from systematic screening could lead to tailored therapeutic approaches for emergency cases and more effective symptom management for abstinence syndrome. The surveillance program will also determine the presence of other synthetic drugs, such as amphetamine-type stimulants (phenethylamines, synthetic cathinones), synthetic opioids, ketamine, and gamma-hydroxybutyrate. Furthermore, potentially lethal adulterants to crack cocaine, such as strychnine can be identified. Recognizing the increasing availability and consumption of SCs in the largest open drug scene in the country,⁸ in addition to more accurate identification of the drugs in circulation has key significance for health care professionals and policy makers alike.