After evaluating this article participants will be able to:
1. Recognize the toxic syndrome for common hallucinogens, resulting in more accurate toxicologic agent identification.
2. Reocgnize the potential complications associated with hallucinogens, resulting in more effective patient management.
3. Be familiar with common delivery systems and activities associated with hallucinogen exposure, resulting in more accurate diagnoses.
A 22-year-old male is brought to a stadium first aid station after being found running around naked at a Grateful Dead concert. He was noted to be agitated, paranoid, and visually hallucinating requiring full leather restraints. Friends of the patient claimed he ingested several “magic shrooms and blotter acid” prior to the concert.
The patient had the following vital signs: pulse 120/min; blood pressure 130/80mmHg; respiratory rate 32/min, and temperature 100.5 F. The patient’s pupils were equal and dilated. Heart exam revealed a regular tachycardic rate, lungs were clear to auscultation, abdomen was soft and nontender. Extremity exam demonstrated no needle tracks with good distal pulses. The neurological exam was nonfocal. His skin was noted to be flushed with a “Dead Head” tattoo prominently displayed on his left buttock.
Hallucinogenic or psychedelic drugs are any group of substances that produce distorted sensory perceptions, an altered sense of awareness, with a mental state characterized by hallucinations and feelings of euphoria or despair.
Hallucinogenic mushrooms as described in the case above include the species Psilocybin and Gymnophilis. The toxin has an LSD-like effect. Clinical effects include visual hallucinogens and gastrointestinal distress. Treatment is primarily supportive by providing a calm environment and benzodiazepine administration. More combative behavior may result if the mushrooms are “laced” with adulterants such as phencyclidine (PCP).
LSD was discovered in 1938 by Dr. Albert Hofmann. According to Hofmann “At home I lay down and sank into a not unpleasant intoxicated-like condition, characterized by an extremely stimulated imagination. In a dreamlike state, with eyes closed (I found the daylight to be unpleasantly glaring), I perceived an uninterrupted stream of fantastic pictures, extraordinary shapes with intense, kaleidoscopic play of colors.”
LSD is a tasteless, colorless, and odorless powder that can be dissolved in water and distributed on various carrier vehicles such as gelatin squares (“window panes”), sugar cubes, or colored paper (“blotter acid”). Although its popularity has waxed and waned since the 1960s, it is still produced illegally and used predominantly by high school and college students. A study of patients treated during Chicago-area rock concerts in the mid 1990s found that LSD use was highly prevalent during concerts featuring the Grateful Dead.
LSD has sympathomimetic effects that can precede the onset of perceptual distortions. These include tachycardia, tachypnea, hypertension, mydriasis, and hyperthermia. The acute perceptual effects of LSD include a heightened sense of sound, shape, and color. Lights and other objects may seem to be surrounded be halos. Moving objects may leave a trail of discrete afterimages in the visual field. An unusual perceptual change is synesthesia, the illusion that stimulation of one of the five senses is experienced through another sensory modality. For example, sound may be experienced as shifting patterns of light and color.
Acute psychiatric reactions caused by LSD include severe anxiety and panic attacks. Ordinary thoughts and perceptions can seem grandiose or profound. Sensations of paranoia, depersonalization, and ego fragmentation can be terrifying, leading to the so-called “bad trip”. Typically, the user is alert, oriented, and aware that the perceptual distortions and illusions are the result of drug ingestion.
Flashbacks are perceptual distortions and hallucinations that occur in a user of LSD after the acute drug effects have worn off. Often, they repeat the user’s previous hallucinogenic experience with LSD, and have been reported to occur several years after acute drug use. They can be persistent and may be precipitated by stress, illness, SSRI use, and the use of ethanol or marijuana. A more recent term for this phenomenon is hallucinogen persisting perception disorder (HPPD).
The effects of LSD are usually not life threatening unless mixed with other drugs of abuse. When morbidity or mortalities occur, they typically result from self-induced trauma. The drugs of choice for a patient agitated after taking a hallucinogen who cannot be “talked down” are benzodiazepines and when severe, haloperidol (aka- the Haldol blow dart).
MeO-DIPT is a synthetic tryptamine with structure and effects similar to those of psilocybin. It is currently classified as a Schedule I controlled substance. It has the street names “foxy-methoxy” or “foxy”, most likely because of its reputed aphrodisiac properties. It has gastrointestinal and neurological effects, including nausea, vomiting, diarrhea, restlessness, and mydriasis. Larger doses cause perceptual effects similar to LSD. “Waxiness and plasticity” of the extremities has been described. It has been supplied as a “purple haze” tablet, a capsule, or on a sugar cube or blotting paper.
Nexus is a 2C-B- a psychedelic phenethylamine. According to one user “When I take Nexus, I merge with the music, become one with the crowd, and fuse with the whole of Planet Earth. This isn’t a drug, it’s a trance-dance sacrament.” In regard to its effects, another young man described it as “a cross between the warm, lovey-dovey feeling produced by Ecstasy and the visual patterning you get when you take magic mushrooms”.
Nutmeg (Myristica fragrans) is a mild hallucinogenic most commonly used experimentally by teenagers and college students. (Parental guidance is advised when adding to one’s holiday eggnog). GI toxicity and abdominal pain has been reported. “Nutmeg liver” with hepatotoxicity has also been described.
Salvia divinorum is a newer “legal” hallucinogenic with opioid receptor activity. Mitragyma speciosa (Kratom) is now popular in Africa and Asia, particularly in Thailand and Malaysia. Morning glory and moon glow seeds are widely distributed hallucinogenic botanicals in the US with an LSD-like effect. Hawaiian wood rose is popular in the Pacific islands.
Absinthe is an extract of Artemesia absinthum, (oil of wormwood). This drug was popularized during the 1800’s in Paris, among impressionist artists like Vincent Van Gough as a euphoriant beverage, referred to as “the Green Fairy” due to its bright green color and mind altering properties. Due to the toxin thujone, seizures can result after high doses. Absinthe bars and drinks are sold in Europe and via the Internet. An Americanized version is now available but typically contains no thujone.
Hallucinogenic or toxic toads have been popularized by the act of “toad licking” or injecting the secretions of cane toads (Bufo marinus) containing the toxin bufotenine. This exotic psychedelic agent also possesses dangerous cardioglycoside (digitalis-like) side effects that can be fatal in toxic doses.
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