Substance Abuse



Medical marijuana was legalized in the state of Colorado in 2009, and over the next few years, the number of medical marijuana licenses had grown exponentially.  In 2012, Colorado voted to legalize the commercial sale and personal use of recreational marijuana beginning on January 1, 2014.  Coincidentally, emergency departments (ED) in the state have seen an increase in the number of patients presenting with acute marijuana intoxication. With an increasing number of states expressing interest in legalizing medical or recreational marijuana, there is a critical need to evaluate the impact of increased marijuana availability both on individual health and on the health systems.  The goal of the Monte-Saben Research Program is to develop a database of patient health data from individuals treated at the UCHealth University Hospital ED for marijuana-related reasons and begin to analyze this population data to understand the impact of marijuana liberalization in Colorado.

Novel Drugs of Abuse


Novel psychoactive substances (NPS) are the fastest growing class of abused illicit drugs in the world. These drugs are inherently difficult to detect due to the molecular infidelity amongst drug classes, and even within drugs with the same street names. Additionally, lack of cross reactivity of traditional drug screens to detect NPS and infrequent capture of biologic samples from drug abusers makes it difficult for clinicians to match clinical syndromes with the causative agent. The Monte-Saben Research Program focuses on: 1) collecting and analyzing de-identified biological specimens from individuals who present to the emergency department (ED) with clinical syndromes associated with NPS use, 2) obtaining de-identified clinical health information from the ED visits linked to the samples to understand the clinical outcomes associated with NPS, and 3) gathering ethnographic information from these patients around their drug use to help inform intervention and educational material for NPS abuse.


Public Health Effects of Marijuana Policy Liberalization


Public Health Effects of Marijuana Policy Liberalization:  The purpose of this research project is to assess the impact of marijuana tourism on emergency departments (EDs) before and after the legalization of medical marijuana in 2009 and recreational marijuana in Colorado in 2012. We hypothesize that the number of ED visits due to acute marijuana intoxication substantially increased after recreational marijuana legalization, both in Colorado and non-Colorado residents. Retrospective analyses of electronic health records of patients treated in the UCHealth University Hospital ED for marijuana related illness from 2012 until 2016 are complete and make up the database used for this study.   We utilize this database to monitor emerging illnesses associated with cannabis liberalization in Colorado.



  1. Population characteristics of marijuana-associated ED visits

  2. Marijuana-related visits associated with edible verses non-edible marijuana use

  3. Hospital admissions associated with marijuana-related ED visits

  4. ICD9 codes associated with marijuana-related ED visits

  5. Cannabinoid hyperemesis syndrome (CHS)



  1. Hall KE, Monte AA, Chang T, Fox J, Brevik C, Vigil DI, Van Dyke M, James KA. Mental Health-related Emergency Department Visits Associated With Cannabis in Colorado. Acad Emerg Med. 2018 May;25(5):526-537. doi: 10.1111/acem.13393. Epub 2018 Apr 10. PubMed PMID: 29476688; PubMed Central PMCID: PMC5980767.

  2. Kim HS, Hall KE, Genco EK, Van Dyke M, Barker E, Monte AA. Marijuana Tourism and Emergency Department Visits in Colorado. N Engl J Med. 2016 Feb 25;374(8):797-8. doi: 10.1056/NEJMc1515009. PubMed PMID: 26933869; PubMed Central PMCID: PMC4878119.

  3. Kim HS, Monte AA. Colorado Cannabis Legalization and Its Effect on Emergency Care. Ann Emerg Med. 2016 Jul;68(1):71-5. doi: 10.1016/j.annemergmed.2016.01.004. Epub 2016 Feb 24. PubMed PMID: 26921970; PubMed Central PMCID: PMC4939797.

  4. Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. JAMA. 2015 Jan 20;313(3):241-2. doi: 10.1001/jama.2014.17057. PubMed PMID: 25486283; PubMed Central PMCID: PMC4404298.

  5. Bell C, Slim J, Flaten HK, Lindberg G, Arek W, Monte AA. Butane Hash Oil Burns Associated with Marijuana Liberalization in Colorado. J Med Toxicol. 2015 Dec;11(4):422-5. doi:10.1007/s13181-015-0501-0. PubMed PMID: 26289652; PubMedCentral PMCID: PMC4675612.

  6. Kim HS, Anderson JD, Saghafi O, Heard KJ, Monte AA. Cyclic vomiting presentations following marijuana liberalization in Colorado. Acad Emerg Med. 2015 Jun;22(6):694-9. doi:10.1111/acem.12655. Epub 2015 Apr 22. PubMed PMID:25903855; PubMed Central PMCID: PMC4469074.

  7. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. In Reply: "The importance of recognizing cannabinoid hyperemesis syndrome from synthetic marijuana use". J Med Toxicol. 2017 Jun;13(2):201. doi:10.1007/s13181-017-0613-9. Epub 2017 Apr 5. PubMed PMID:28382464; PubMed Central PMCID: PMC5440326.

  8. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. In Response to Letter to the Editor Regarding: Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. J Med Toxicol. 2017 Jun;13(2):198. doi: 10.1007/s13181-017-0610-z. Epub 2017 Mar 10. PubMed PMID:28283940; PubMed Central PMCID: PMC5440323.

  9. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. J Med Toxicol. 2017 Mar;13(1):71-87. doi: 10.1007/s13181-016-0595-z. Epub 2016 Dec 20. Review. PubMed PMID:28000146; PubMed Central PMCID: PMC5330965.

  10. Monte AA, Shelton SK, Mills E, Saben J, Hopkinson A, Sonn B, Devivo M, Chang T, Fox J, Brevik C, Williamson K, Abbott D. Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study. Ann Intern Med. 2019 Mar 26. doi: 10.7326/M18-2809. [Epub ahead of print] PubMed PMID: 30909297.



Colorado Department of Public Health and Environment: April 2017 – March 2018

P-SCAN (Psychoactive Surveillance Consortium and Analysis Network)


The Psychoactive Surveillance Consortium and Analysis Network (P-SCAN) is a group of committed Medical Toxicologists from across the United States that collect de-identified clinical data and biologic samples. This group has collected over 100 samples from patients intoxicated with new psychoactive substances, primarily synthetic cannabinoids (SCs), presenting to emergency departments.  Locally, this results in 5-10 additional blood and urine samples collected from SC intoxicated patients every month from the University of Colorado and allows for testing of de-identified samples obtained from other sites. Samples are analyzed for drug metabolites in a research laboratory coordinated by Dr. Roy Gerona at the University of California, San Francisco. Dr. Gerona has the most comprehensive panel of SCs available for targeted drug identification (225 reference standards are available, compared to 43 through NMS) using HPLC-MS. Therefore, P-SCAN seeks agile and real time identification of new drugs of abuse to prevent progression of clinical illness.



  1. Brandehoff N, Adams A, McDaniel K, Banister SD, Gerona R, Monte AA. Synthetic cannabinoid "Black Mamba" infidelity in patients presenting for emergency stabilization in Colorado: a P SCAN Cohort. Clin Toxicol (Phila). 2018 Mar;56(3):193-198. doi:10.1080/15563650.2017.1357826. Epub 2017 Sep 1. PubMed PMID: 28862050; PubMed Central PMCID: PMC5786486.

  2. Fox J, Smith A, Yale A, Chow C, Alaswad E, Cushing T, Monte AA. Drugs of Abuse and Novel Psychoactive Substances at Outdoor Music Festivals in Colorado. Subst Use Misuse. 2018 Jun 7;53(7):1203-1211. doi: 10.1080/10826084.2017.1400067. Epub 2017 Nov 17. PubMed PMID:29148866; PubMed Central PMCID: PMC5935531.

  3. Monte AA, Calello DP, Gerona RR, Hamad E, Campleman SL, Brent J, Wax P, Carlson RG; ACMT Toxicology Investigators Consortium (ToxIC). Characteristics and Treatment of Patients with Clinical Illness Due to Synthetic Cannabinoid Inhalation Reported by Medical Toxicologists: A ToxIC Database Study. J Med Toxicol. 2017 Jun;13(2):146-152. doi:10.1007/s13181-017-0605-9. Epub 2017 Apr 10. PubMed PMID: 28397128; PubMed Central PMCID: PMC5440319.

  4. Monte AA, Bronstein AC, Cao DJ, Heard KJ, Hoppe JA, Hoyte CO, Iwanicki JL, Lavonas EJ. An outbreak of exposure to a novel synthetic cannabinoid. N Engl J Med. 2014 Jan 23;370(4):389-90. doi:10.1056/NEJMc1313655. PubMed PMID: 24450915; PubMed Central PMCID: PMC3983965.

  5. Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012 Oct;60(4):435-8. doi:10.1016/j.annemergmed.2012.03.007. Epub 2012 May 9. PubMed PMID: 22575211.



  • Currently in progress

Ethnography of Synthetic Cannabinoid Abusers to Target Substance Abuse Intervention


Synthetic cannabinoids (SC) are increasingly abused in military communities.  These drugs are more dangerous than traditional drugs of abuse due to higher potency, unpredictable dosing, and the inability to detect the drugs by traditional laboratory drug screens, which mitigates the ability to counsel users. The most common demographic to use these drugs are young men hoping to evade detection by traditional drug screens making active military high risk for SC abuse. Eleven percent of an active-army substance abuse cohort reported SC use in the preceding 90 days. Sixty-six percent of these reported that SCs were their primary drug of choice. We are conducting a cross sectional ethnographic survey, capturing knowledge, attitudes, beliefs, and practice domains, paired with biologic sample collection. We have focused this work on three at risk populations at the San Antonio Military Medical Center (SAMMC) and the University Of Colorado Hospital. The three populations studied are 1) active soldiers 2) family members presenting with altered mental status to base emergency departments and 3) veterans treated for substance abuse disorders.


  • Department of Defense April 2017 – March 2019

Assay for Synthetic Cannabinoids


Novel psychoactive substances have flooded the marketplace over the past decade. Synthetic cannabinoids (SCs), known as K2 or spice, are the most commonly abused novel psychoactive drug. SCs cause kidney failure, seizures, and death. SCs cause severe clinical illness and are preferred by users due to poor ability to detect them on standard drug screens. Detection of patients that use these drugs is difficult because the molecules are regularly altered with small chemical substitutions making them invisible to traditional immunoassays. Thus drug makers are constantly ahead of the detection methods. The best clinically available assay can only detect 30 SCs while over 100 SCs are known to exist and a new SC molecule is discovered every few months. Therefore, a new paradigm in drug testing is needed. Rather than focusing on detection of single drug molecule using immunoassays, we are developing a functional assay that detects the drug potency that elicits the euphoric drug effect.



CU Skaggs School of Pharmacy and Pharmaceutical Sciences –PharmD Student Research Program, 2018