We conducted a qualitative retrospective online market surveillance study to assess whether Diamond Shruumz products continued to be marketed and made available for purchase online (see Figure 1 for a summary of the study’s methods). This included conducting structured and automated search queries on social media platforms (Instagram, Reddit, Telegram, Tumblr, and X [formerly known as Twitter]), cannabis product listings originating on e-commerce platforms (Dutchie, Leafly, and Weedmaps), and website hyperlinks generated from popular search engine results (Bing, DuckDuckGo, and Google). Automated searches were conducted from June 22 to June 27, 2024, immediately preceding the manufacturer-initiated recall (see Multimedia Appendix 1).

A qualitative review of social media posts, e-commerce product listings, and websites generated from search queries was conducted to identify active direct-to-consumer sale of any of the Diamond Shruumz products that were subject to recall. Where possible, we also attempted to assess if a seller was licensed by their respective state licensure board (eg, state cannabis control board). For websites actively advertising the sale of Diamond Shruumz products, analysis also included an assessment of any age verification processes and web forensics for internet sites using the Internet Corporation for Assigned Names and Numbers (ICANN) WHOIS look-up tool.

Finally, simulated test purchases in the period following the announcement of the recall were conducted to identify websites continuing to sell the products [8]. Simulated test purchases involved selecting a Diamond Shruumz product from an identified online seller that utilized traditional e-commerce tools (eg, hosted website, shopping cart, payment processing), placing it in an e-commerce shopping cart, proceeding through the purchase process, and simulating the purchase transaction using a credit card number generator that has been used in previous studies for e-commerce testing and test buy purposes [9-11]. Completion or denial of the transaction was documented. Qualitative data analysis and simulated purchases were performed on July 12, 2024, 2 weeks after the manufacturer initiated the recall notice.

This study utilized publicly available data and did not involve human participants or any personally identifiable information from individuals or online sellers; it therefore did not require ethics approval. All information collected from this study was from the public domain and the study did not involve any interaction with users. Any identifiable user information was aggregated and removed from the study’s results.

Market surveillance detected a total of 4117 Diamond Shruumz product listings available across all parts of the internet monitored. Product listings potentially selling Diamond Shruumz products were found in 1600 (38.86%) social media posts and comments, 11 (0.27%) cannabis e-commerce websites, and 2509 (60.94%) hyperlinks from internet search queries from the period immediately preceding the initiation of the recall (see Table 1 for a summary of the platform breakdown results, Table 2 for examples of active selling posts detected after the initiation of recall, and Table S1 in Multimedia Appendix 1 for the deidentified results of simulated test purchases).

Automated search queries on select social media platforms (Instagram, Reddit, Telegram, Tumblr, and X) identified 1600 Diamond Shruumz product listings, where 96.25% (n=1540) originated from user-generated posts and 3.75% (n=60) were from user-generated comments across only 2 platforms (Instagram and Reddit). Direct-to-consumer advertisements with links or contact information that users could use to directly purchase the products made up 3.06% (n=49) of posts, of which 67.35% (n=33) originated from Instagram, 28.57% (n=14) from X, and 4.08% (n=2) from Telegram. Simulated purchases were conducted on the social media posts, where only 1 social media advertisement, detected on X, was still actively selling Diamond Shruumz products after recall initiation.

Structured search queries on cannabis e-commerce product listing websites (Dutchie, Leafly, and Weedmaps) detected a total of 8 product listings (belonging to 4 unique cannabis vendors) that advertised Diamond Shruumz products via these platforms. Cannabis e-commerce platform vendor breakdown of these listings included Dutchie (n=1, 12.5%), Leafly (n=5, 62.5%), and Weedmaps (n=2, 25%). All vendor listings on Dutchie and 1 vendor listing from Weedmaps were linked to the same licensed cannabis retailer in Alaska. The remaining Weedmaps listing was linked to an expired licensed cannabis retailer in Oklahoma. Leafly store listings were linked to 2 shops: one in Hawaii that was verified to have an active cannabis license and one in Wisconsin that could not be verified due to lack of access to publicly available state licensure data. Post-recall simulated purchases identified the Alaska storefront as still actively selling Diamond Shruumz products.

For internet search queries, a total of 2509 hyperlinks, comprising 237 unique domain names, were collected; 67 (28.27%) domains were identified as actively selling Diamond Shruumz products prior to recall. From the sellers with sufficient information to cross-reference available state cannabis licensure data, none were linked to a valid retail cannabis state license. All websites that were actively selling Diamond Shruumz went through web forensics analysis. The majority (n=41, 61.19%) included registrant information located in the United States (including Arizona, Pennsylvania, and California as the top 3 states), followed by Canada and Iceland, with 2 websites also using domain privacy services to hide their information. Slightly over half (n=37, 55.22%) of the reviewed sites had a form of age verification, with those that did requiring a single, nonrestricted click confirming that a user was over the age of 18 years (or 21 years, based on applicable laws). Post recall, 67.16% (n=45) of re-reviewed websites continued to advertise the sale of Diamond Shruumz product. One-third (n=15, 33.33%) of those websites continued to offer the direct sale of a product (ie, where transaction and simulated purchase was successful) while two-thirds (n=30, 66.66%) of transactions failed to process (ie, payment not accepted, used robust account verification).

Results from this study indicate that the time period immediately preceding the manufacturer-initiated recall (a period when the US FDA, America’s Poison Centers, and CDC identified initial concerns about illnesses associated with consuming these products and actively provided updates to the public) had a relatively high number of product advertisements available across multiple parts of the internet that likely led to high consumer exposure to these products. Following the recall notification, the number of online access points appeared to decrease; however, we nevertheless identified at least 47 active sellers across social media, cannabis e-commerce, and website platforms.

Similar to prior studies examining online availability of psilocybin [12], there were a high number of continued access points that originated from search engine results that linked to websites selling direct-to-consumer products, two-thirds of which were found to be actively advertising even during the post-recall period. For approximately one-third of those websites, we were able to successfully complete a simulated test purchase, and some vendors actively reached out through email seeking to complete a cancelled order we initiated through this process.

The Diamond Shruumz product recall notification exemplifies some of the ongoing challenges of consumer harms associated with new and emerging substances that become readily available on the internet; in this case, novel edible mushroom-containing nootropics. This incident also has a similar fact pattern to the 2019 outbreak of e-cigarette or vaping product use–associated lung injury, which ended with a total of 2807 hospitalized cases (68 of which were deaths) attributed to vitamin E acetate in tetrahydrocannabinol (THC)-containing nicotine products [12]. In the case of Diamond Shruumz, interest in psychedelics and psilocybin therapy is growing [13-15], though psilocybin remains illegal, and products mimicking psychedelic effects or possibly containing microdoses of psychoactive properties appear to be available via direct-to-consumer sales, despite unknown potential health risks.

To capitalize on the growing interest but also the slow path of potential legalization of psychedelics, manufacturers may be experimenting with undeclared and unlabeled synthetic analogues for human consumption, such as 4-acetoxy-DMT [3,16]. Further, the FDA has warned food manufacturers that A. muscaria’s extracts and certain constituents, as found in Diamond Shruumz samples tested by the FDA, do not meet Generally Recognized as Safe (GRAS) standards, are not authorized for use as ingredients in foods, and may be harmful [2,17]. Alarmingly, Diamond Shruumz products also included appealing marketing of diverse edible forms (eg, gummies, bars, cones) and flavors (eg, chocolate, birthday cake, various fruit flavors) found with other increasingly publicly acceptable substances, such as cannabis and nicotine products, which may be attractive to children and young adults [18].

Continued availability of these products, which we observed in the early stages of initiation of this recall, highlights the challenges of effectuating recalls in a diverse e-commerce landscape for a novel product that has legal ambiguity (ie, A. muscaria is legal and 4-acetoxy-DMT is unscheduled, but DMT and psilocybin are scheduled and prohibited by the US Drug Enforcement Administration). Reflecting these challenges, the FDA announced that it was working with the National Association of Convenience Stores and the National Smoke Shop Association to raise consumer awareness about the recall and warn consumers about purchasing or consuming Diamond Shruumz [2,19-21].

Limitations of this study include the relatively short time period after recall initiation to conduct market surveillance and simulated test purchases, legal and ethical limitations that restricted our ability to conduct real-world test buys of actual products that necessitated simulated purchasing instead, and lack of complete licensure data to assess all vendor status. Future studies should address these limitations by assessing the practicality of conducting legally authorized test purchases that involve package and analytical chemical testing analysis as has been done in prior studies for other types of medications [22,23].

This paper aimed to conduct a rapid market surveillance study to identify ongoing consumer and public health risks associated with the recall of Diamond Shruumz products that were sold throughout the United States via a variety of online channels. The public health urgency of these findings is emphasized by other observations we had, such as our detection of 12 social media user-generated posts discussing purported adverse events, including a self-reported hallucination and severe adverse health experience after consuming 2 Diamond Shruumz chocolate bars by one online user (see Figure S1 in Multimedia Appendix 1). This emphasizes the need for continued surveillance in a post-recall period, particularly in the context of the concerning safety profile of A. muscaria and its toxic compounds, such as muscimol, which was detected in Diamond Shruumz products and has the potential for serious adverse events [15]. Further, there is a need for novel and persistent online marketplace monitoring approaches coupled with proactive postmarket surveillance (eg, pharmacovigilance, nutravigilance, and cannabis product surveillance), particularly for consumer groups who may purchase online and not report their adverse event experiences to poison control centers or do not end up hospitalized [19-21,24]. Customized approaches using artificial intelligence and multiplatform analysis will be key to these efforts as new products emerge in virtual spaces.