POTD: Less Commonly Abused Hallucinogens

We’ve reviewed the most commonly abused hallucinogens in previous POTD, but how do you recognize and treat a patient that has “licked a toad”? And how would you treat a college student who got high off nutmeg?  Here we discuss several less commonly abused hallucinogens:

Salvia
    ▪    Salvia divinorum
    ▪    a.k.a, “Salvia” “Sally” “Magic Mint”
    ▪    Smoked or chewed
    ▪    Not currently regulated under the U.S. Controlled Substances Act
    ▪    Symptoms/Effects: Visual hallucinations, object and body distortions, dysphoria, incoordination, dizziness, slurred speech
    ▪    Duration: Up to 30 minutes
    ▪    Treatment: Supportive

Bufotoxins
    ▪    bufotenine and 5-methoxy-dimethyltryptamine from venomous toads
    ▪    also contains cardioactive steroids, and catecholamines
    ▪    a.k.a., “love stone” “rock hard”
    ▪    Obtained from extract or “licking a toad”
    ▪    Symptoms/effects: Powerful psychedelic, GI irritation, salivation, n/v, cardiac toxicity similar to acute digoxin poisoning, hyperkalemia, bradycardia, AV block, Vtach, Vfib, cardiac arrest
    ▪    Serum digoxin immunoassay often positive
    ▪    Treatment: Atropine for bradyarrhythmias, may require pacemaker; antiarrhythmics for ventricular arrhythmia; dig-Fab Ab treatment has been effective

Morning Glory Seeds
    ▪    Ipomoea violacea, Ipomoea tricolor, etc
    ▪    Contain compounds similar to LSD
    ▪    Seeds ingested for their hallucinogenic effects
    ▪    Symptoms/effects: Similar to LSD
    ▪    Treatment: Reassurance, benzodiazepines in severe cases

Nutmeg
    ▪    Myristica fragrans
    ▪    Active compound: myristicin
    ▪    Large amounts of nutmeg (1-3 nutmeg seeds) can cause delirium with hallucinations
    ▪    Symptoms/effects: Hallucinations, tachycardia, flushing, dry mouth, nausea, abdominal pain
    ▪    May resemble anticholinergic poisoning, but pupils are small or normal
    ▪    Duration: 6 to 24 hours
    ▪    Treatment: Supportive

Jimson weed and Angel’s Trumpet
    ▪    Datura stramonium and Datura candida, respectively
    ▪    Contain atropine, scopolamine, and hyoscyamine
    ▪    Seeds/other parts of plant ingested or smoked
    ▪    Symptoms/effects: Delirium, hallucinations, seizures, anticholinergic effects
    ▪    GI emptying delayed and small seeds can become trapped in GI folds after ingestion
    ▪    Treatment: Consider GI decontamination in select cases with whole bowel irrigation for large ingestions, avoid anticholinergic medications, may try physostigmine

Source: Tintinalli’s Emergency Medicine, 9th Edition, Chapter 188: Hallucinogens pp 1247-1248