bleeding caused by a synthetic cannabinoid contaminated with brodifacoum, a rat poison that causes bleeding. illinois was hit the hardest and on april 5, 2018, the cdc issued a clinical action alert to health care providers across the united states advising of 89 confirmed cases of "serious unexplained bleeding" in illinois. the cases are still being studied; however, 63 of the patients reported synthetic cannabinoid use, and laboratory analysis confirmed brodifacoum was present in at least 18 patients. as of april 24, 2018, 153 cases, including four deaths, linked to this outbreak have been reported to the illinois department of public health (idph) since march 7, 2018. on september 18, 2018, the wisconsin department of health services confirmed 16 more cases, bringing the total number of people affected by the outbreak in wisconsin to 80 people since march 2018, including one death in july 2018. in august 2018, there were almost one hundred overdose cases reported over two days in new haven, connecticut from a bad batch of k2. the synthetic cannabinoid was believed to have been mixed with fentanyl, although no fentanyl was identified in samples of the drug tested by the dea. in september 2018, at least 10 people overdosed on a synthetic cannabinoid, either amb-fubinaca or ab, in christchurch, new zealand over two days. some of the people are in critical condition in the intensive care unit. from september 21–22, 2018, almost 50 people overdosed and two people died in the kensington area of philadelphia. officials believed the cause to be a combination of heroin or fentanyl and a synthetic cannabinoid. this same area in philadelphia had 155 people overdose and 10 people die from a combination of heroin, fentanyl, and a synthetic cannabinoid called 5f-adb over one weekend in july 2018. the department of public health released that they believe "5f-adb was the primary cause of the cluster of patients with these adverse drug reactions." on december 10, 2021, the hillsborough county, florida department of health reported cases of "rat poison" contaminated synthetic blends linked to symptoms associated with coagulopathy, a condition where the blood's ability to clot is impaired. 2 deaths and over 41 hospitalizations have been directly linked to this specific outbreak as of december 16, 2021. research vaping-associated pulmonary injury synthetic cannabinoids have been speculated to be involved in vaping-associated pulmonary injury (vapi). legal restrictions and regional availability austria the austrian ministry of health announced on december 18, 2008, that spice would be controlled under paragraph 78 of their drug-law on the grounds that it contains an active substance that affects the functions of the body, and the legality of jwh-018 is under review. germany jwh-018, cp 47,497 and the c6, c8, and c9 homologues of cp 47,497 have been illegal in germany since january 22, 2009. since november 26, 2016 about 80-90% of the substances belonging to the group of synthetic cannabinoids are illegal in germany as the law does not cover all chemical structures. france jwh-018, cp 47,497 (and its homologues), and hu-210 were all made illegal in france on february 24, 2009. ireland from june 2010, jwh-018, along with a variety of other designer drugs, has been illegal. latvia a store selling synthetic cannabinoids in riga in 2012 jwh-018, jwh-073, cp 47,497 (and its homologues), and hu-210 as well as leonotis leonurus have been all banned in latvia since 2005. after the first confirmed lethal case from the use of legal drugs in late 2013, parliament significantly increased the number of temporarily banned substances used in spice and similar preparations. on april 3, 2014, parliament made selling of the temporarily banned substances a criminal offense. poland jwh-018 and many of the herbs mentioned on the ingredient lists of spice and similar preparations were made illegal in may 2009. the bill was passed by polish sejm and polish senat and was signed by the president. romania spice was made illegal in romania on february 15, 2010. as on 12 september 2018 spice was made legal for personal use. a new law is being discussed to make spice illegal for personal use again. russia on april 9, 2009, the chief medical officer of the russian federation issued a resolution on reinforcing control over the sales of smoking-blends. these blends, marketed under the trade names am-hi-co, dream, spice (gold, diamond), zoom, ex-ses, yucatán fire and others, have been declared to contain salvia divinorum, hawaiian wood rose, and blue lotus, and are prohibited to be sold. these substances have been found to have "psychotropic, narcotic effects, contain poisonous components and represent potential threat for humans". the resolution does not mention jwh-018 or other synthetic cannabinoids. on january 14, 2010, the russian government issued a statement including 23 synthetic cannabinoids found in smoking blends hawaiian rose and blue lotus on the list of prohibited narcotic and psychotropic substances. about 780 new psychoactive substances were added to the list from 2011 to 2014. the drug-makers avoided all the bans by making slight changes to the drugs. in the autumn of 2014, more than two-thousand spice consumers in russia sought medical attention, one-thousand were admitted to hospitals, and 40 people died on october 30, 2014, president vladimir putin brought in a bill that increased the penalty for selling or consuming smoking blends from a fine to up to eight years in prison. slovakia spice is legal in slovakia. the national anti-drug unit is considering adding it to the list of controlled substances. the latest anti-drug law version (468/2009) valid since january 2010 does not mention active compounds of spice. spain spice is unregulated in spain. for this reason, spice is available in grow shop stores or cannabis related stores, and it can be bought and shipped online without any legal impediment from those kind of stores. sweden cp 47,497-c6, cp 47,497-c7, cp 47,497-c8, cp 47,497-c9, jwh-018, jwh-073, and hu-210 were all made illegal in sweden on september 15, 2009. the bill was accepted on july 30, 2009, and was put in effect on september 15, 2009. switzerland spice has been banned in switzerland. turkey spice, which is colloquially called bonzai in turkey, was added to the list of drugs and psychotropic substances on july 1, 2011, by the law numbered as 2011–1310 b.k.k. (february 13, 2011 and the official gazette no. 27845). united kingdom the uk controls synthetic cannabinoids by analog under the misuse of drugs act, 1971 as class b drugs. until 2016, synthetic cannabinoids were legally sold in head shops, although the exact compounds available changed over time based on the legislation. the uk saw three generations of synthetic cannabinoids within five years where the second and third generations emerged in response to amendments to the misuse of drugs act, 1971, order 2009 and order 2013, which classified many first and second generation synthetic cannabinoids as class b drugs. there were two additional amendments in 2016 and 2019, which included in the analog controls many of the most popular synthetic cannabinoids circulating at the time. in may 2016, the psychoactive substances act was enacted, which made illegal the production, distribution, sale, supply, and possession in correctional institutions of any substance for human consumption with psychoactive effects. this stopped the open sale of synthetic cannabinoids in head shops, although they are still found in use. canada spice is not specifically prohibited in canada, but synthetic cannabis mimics are listed as a schedule ii drug. schedule ii to the controlled drugs and substances act makes reference to specific synthetic compounds jwh-xxx and am-xxxx, although is not limiting to those identified. health canada is debating the subject. schedule ii has consisted entirely of synthetic cannabinoids since october 2018; these remain illegal following the removal from the schedule of cannabis and its constituents derived from nature. united states