AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Hallucinogens comprise a unique collection of substances that are ingested to induce alterations of consciousness. A variety of substances with differing chemical structures is known to induce hallucinations when ingested in nontoxic doses. Hallucinations are usually visual, auditory, and tactile, in varying combinations, depending on the substance ingested, the setting, and the experiences of the person using them.

Hallucinogenic substances have been used worldwide for centuries to induce altered states for religious and spiritual purposes. Throughout history, abuse of such substances probably was limited because of the moral and religious significance of their uses.

Hallucinogens can be classified and grouped by chemical structure and the compound from which they are derived. Chemically related substances tend to exhibit similar effects. Many other agents can be classified as pseudohallucinogens because they produce psychotic and delirious effects without the classic visual disturbances of true hallucinogens.

One system groups hallucinogens into 4 major classes that include indole alkaloids, piperidines, phenylethylamines, and cannabinoids. The following is a partial list of the hallucinogens by chemical derivation:

• Indole alkaloids
• • Lysergic acid diethylamide (LSD)
  • Lysergic acid amide (LSA)
  • Psilocin
  • Psilocybin
• Piperidines
• • Atropine and scopolamine
  • Cocaine
  • Phencyclidine (PCP)
  • Ketamine
• Phenylethylamines
• • Mescaline
  • 3,4-methylene dioxymethamphetamine (MDMA)
  • Methylene dioxyamphetamine (MDA)
  • 3-methoxy-4,5-methylene dioxyamphetamine (MMDA)
  • 3,5-dimethoxy-4-methylamphetamine (STP)
  • 2,5-dimethoxy-4-methylamphetamine (DOM)
• Cannabinoids
• • Delta-9-tetrahydrocannabinol (THC, the active substance in marijuana)

A number of naturally occurring hallucinogens can be found in plants and mushrooms and grow in many locations in the United States. Many of these substances have been involved in ritualistic medicine for a long time, and some are emerging agents of abuse. Included in these naturally occurring substances are dimethoxytryptamine (DMT), psilocybin and psilocin, mescaline, salvinorin A, LSA, and atropine and scopolamine.

LSD and LSA

LSD first appeared in the United States in 1949. Because of its potent psychotomimetic effects, it was believed to be useful in producing model psychosis for evaluation. As an experimental drug in the 1950s, LSD was used by psychiatrists and psychologists for the treatment of alcoholism and many neuroses.

LSD use also was believed to enhance creativity and promote well-being. By the late 1950s, use of LSD had been proposed as a way to achieve intellectual and spiritual awakening and enlightenment. Initial studies in the early 1960s concluded that the drug was safe. By the mid 1960s, reports of increasing illicit abuse and adverse effects in patients treated with LSD led the federal government to begin regulation and restriction of its use.

Although overall hallucinogen use remains fairly constant, LSD use and street sales of many substances marketed as LSD have increased. Since LSD first appeared on the street, its use and popularity have risen and fallen cyclically.

LSA is a naturally occurring hallucinogen that is a close analog to LSD. LSA is found in a variety of plants, most notably Ipomoea violacea (morning glory), Argyreia nervosa, and Stipa robusta.

Phencyclidine and ketamine

PCP and ketamine are piperidine derivatives with potent anesthetic properties and illusionogenic properties. PCP was initially marketed as an anesthetic but was withdrawn from use because of widespread reports of postanesthetic dysphoria, delirium, and psychotic behavior.

PCP was introduced as a veterinary anesthetic in the late 1960s and, beginning in California, soon became a major drug of abuse. The "peace pill," as it was dubbed in San Francisco, began to be distributed as everything from THC to LSD and often was added to marijuana cigarettes. It commonly is referred to as "angel dust."

Ketamine, a widely used anesthetic, increasingly has been found on the streets and often is ingested by large numbers of people at so-called raves.

Psilocin and psilocybin

These indole alkaloids are found worldwide in a variety of mushrooms and have been used by indigenous peoples of Central America for centuries in religious rites. Ingesting only a few mushrooms may produce hallucinogenic affect, but, generally, large numbers of mushrooms are required. Analysis of street samples of "psilocybin" found that less than one third of the samples actually contained the alkaloid.

Mescaline

Mescaline is a phenylethylamine-derived alkaloid that is found worldwide in a variety of cacti, the best known being the North American peyote cactus. Similar to the mushroom-derived hallucinogens, mescaline in the form of peyote cactus buttons has been used in rituals by many Native Americans for centuries. To achieve the desired effect, 5-10 buttons are chewed and ingested.

Salvinorin A

Salvinorin A is a naturally occurring hallucinogen that is found in a variety of plants but is named from Salvia divinorum, or diviners sage, a member of the mint family. Salvinorin A is unique, in that unlike other known hallucinogenic substances that interact with serotonin (5-HT2 receptors) metabolism, this substance has been identified as the first known naturally occurring kappa-opioid receptor agonist. This substance has been used by the Mazatec Indians in Mexico for ceremonial purposes.

Atropine and scopolamine

Atropine and scopolamine are found in a variety of plants, and overdoses can induce hallucinations as well as a variety of more serious effects. Both are found in Datura stamonium (Jimson weed), Atropa belladonna (Deadly nightshade), and Mandragora officinarum (Mandrake), and scopolamine alone in Hyoscyamus niger (Henbane).

Designer drugs

Designer drugs were originally described as such as they were derived from chemically altered legitimate parent compounds. These drugs were initially derived to circumvent prosecution by the Drug Enforcement Agency. However, changes to federal drug laws in 1986 made all such chemically altered compounds illegal. Most of these substances are chemically derived from methamphetamine, but increasing numbers of opioid-derived substances as well as new classes of agents are appearing in this category. The best known of the hallucinogenic amphetamine derivatives is MDMA, commonly known as "ecstasy."

The following is a list of common designer drugs with hallucinogenic properties and the substances they are derived from:

• Amphetamine derivatives
• • MDMA (ecstasy)
  • MDA¹
  • Methylenedioxyethylamphetamine (MDEA)
  • R,S-1-(1',3'-benxodioxol-5'-yl)-2-butanamine (BDB)
  • R,S-N-methylbenzodioxolylbutanamine (MBDB)
• Piperazine derivatives
• • Benzylpiperazines - Benzylpiperazine (BZP), 1-(3,4-methylenedioxybenzyl)piperazine (MDBP)
  • Phenylpiperazines - m-Chlorophenylpiperazine (mCPP), trifluoromethylphenylpiperazine (TFMPP), p-methoxyphenylpiperazine (MeOPP)
• Pyrrolidinophenone derivatives
• • R,S-alpha-pyrrolidinopropiophenone (PPP)
  • R,S-4'-methoxy-alpha-pyrrolidinopropiophenone (MOPPP)
  • R,S-3',4'-methylenedioxy-alpha-pyrrolidinopropiophenone (MDPPP)
  • R,S-4'-methyl-alpha-pyrrolidinopropiophenone (MPPP)
  • R,S-4'-methyl-alpha-pyrrolidinohexanophenone (MPHP)

Many of the newer designer drugs are also described as belonging to the hallucinogenic tryptamines, of which the naturally occurring agents psilocin, psilocybin, and dimethyltryptamine (DMT) belong. Two of the newest agents in the group are "foxy" (5-MeO-DIPT) and alpha-methyltryptamine (AMT). Other agents in this group include bufotenine, alpha-ethyltryptamine, diethyltryptamine (DET), and 5-MeO-DMT.

Pathophysiology

The major effects are centered in the CNS, although many of these substances produce additional systemic effects similar to those of the compounds from which they originate.²

Indole amine derivatives appear to create hallucinogenic effects by acting at the 5-HT2 serotonin receptors. Most indole derivatives also produce sympathomimetic effects. Piperidine derivatives appear to block the reuptake of serotonin, dopamine, and norepinephrine and may block postsynaptic acetylcholine binding. Phenylethylamine derivatives enhance presynaptic release and block reuptake of serotonin and norepinephrine. The cannabinoids' mechanisms of action may involve alteration of the balance of catecholamine and serotonin actions.

Frequency

United States

The National Institute on Drug Abuse data from 1994 indicate a slight decline in hallucinogen abuse from 1976-1992 but then increased use in 1993 and 1994. In 1994, 2.7% of adolescents aged 12-17 years and 5.1% of adults aged 18-25 years reported using hallucinogens. The Monitoring the Future Study reports an annual rate of LSD use in 8.4% of high school seniors in 1995. Drug Abuse Warning Network (DAWN) reports an increase in LSD-related ED visits in the latest 1994 data. Lifetime hallucinogen use was reported in 8.7% of total respondents to the 1994 National Household Survey on Drug Abuse.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• Although most patients who present to the ED with hallucinogen intoxication have a history of recent ingestion, not all are diagnosed easily.³
• Consider possible hallucinogen ingestion in patients with acute psychotic behavior and attempt to trace the onset and causes of the behavior.
• A history of previous hallucinogen abuse may indicate acute ingestion, flashback behavior, or psychotic break caused by the abuse.
• Make an effort to screen patients for other potential exposures or ingestions as well as infectious, traumatic, or other underlying etiologies of the behavior.
• Question family, friends, and prehospital care personnel closely for clues to possible etiology of the behavior.
• Lysergic acid diethylamide
• • Patients presenting for ED care are generally those for whom the hallucinogenic experiences have become uncomfortable (ie, "bad trips") or those who have become injured or appear at risk for self-injury because of their behavior. Initial evaluation may reveal a patient who is agitated and psychotic.
  • The patient may be confused or disoriented, display distorted perceptions and impaired judgment, and have impaired concentration and intellectual functions. Physical examination may reveal mydriasis, tachycardia, and tachypnea without any other significant physical findings. Examine the patient thoroughly for traumatic injuries and the possibility of other etiologies, such as CNS infections or other acute intoxication. Laboratory evaluation may include urine drug assays, urinalysis, and blood glucose. Perform additional testing if etiology of the behavior is in doubt.
• Phencyclidine and ketamine
• • Individuals who ingest these substances often have been found in bizarre situations or have placed themselves in danger. The dissociative properties of these drugs allow the abusers to believe they are outside of their body, and the anesthetic properties prevent normal pain feedback mechanisms that usually limit physical activity.
  • Individuals with significant intoxication can sustain tremendous and even life-threatening injuries without perceived pain. They often fluctuate from combative and anxious to sedated and somnolent. Patients generally have mixed nystagmus, comprising horizontal, vertical, and rotatory. Rotatory nystagmus strongly suggests PCP intoxication.
  • Most patients have mild-to-moderate hypertension and approximately one third have tachycardia. Confusion, altered perceptions, visual hallucinations, and significant violent or self-destructive behavior may occur. The period of psychotic behavior may be prolonged, with episodes of severe depression and schizophrenia.
• Psilocin and psilocybin
• • The most common effects are perceptual distortions or hallucinations. Hallucinations are generally visual but other types may occur. Some patients experience euphoria and tachycardia, and most patients have some mydriasis. Hyperreflexia, anxiety, and drowsiness may occur.
  • Some species of toxic mushrooms may cause adverse GI reactions, including cramping, nausea and vomiting, and diarrhea. Always consider the possibility of toxic mushroom ingestion in patients presenting with a history of mushroom use.
• Mescaline
• • Initial responses include agitation, diaphoresis, and abdominal cramping with nausea and vomiting. Initially, mildly elevated blood pressure with reflex bradycardia and mildly elevated body temperature may occur. Larger ingestions can produce hypotension and respiratory depression. Often the individual ritualistically collects and re-ingests the vomited material to maximize the hallucinogenic effect. These adverse effects generally persist for only 1-2 hours.
  • Feelings of euphoria and associated hallucinations generally begin 2-4 hours postingestion. The sympathomimetic effects may persist throughout the intoxication. Hallucinations are mostly visual, but all forms may occur. A sense of expansion of self and tremendous power has been described, with associated intense visual images in bright colors and geometric patterns. Adverse perceptions of self, anxiety, and depression can occur. The intoxication generally lasts 6-8 hours and usually is followed by somnolence.
  • Patients presenting after mescaline ingestion often complain of the sympathomimetic effects and GI distress associated with the ingestion. Although physical injury can occur because of the dysphoria and sense of power, this is less common than with PCP.
• Designer drugs
• • The amphetamine-derived designer drugs all have sympathomimetic effects that account for the adverse effects (eg, hypertension, tachycardia, hyperthermia).⁴ Hyperthermia may be the most serious adverse effect, and it may be compounded by the use as "club drugs" or at "raves" where use is associated with prolonged dancing and dehydration. The prolonged dancing or other physical activity may contribute to the severe hyperthermia that has been described, and this as well as the dehydration may contribute to associated rhabdomyolysis⁵ and renal failure. Hypertensive crisis has also been described.
  • Effects last from a few hours to as long as 24 hours for drugs like AMT.
  • Seizures may occur.

Physical

• Patient presentations may vary from appearing anxious and agitated to somnolent or sedated.
• Mydriasis is often present, particularly with LSD use.
• Tachycardia, tachypnea, and mild-to-moderate elevation of blood pressure often are noted.
• Temperature generally is normal, but a patient experiencing episodes of extreme exertion, combative behavior, or infection may present with hyperthermia.
• The neurologic examination should be nonfocal, with varying degrees of cognitive distortions or deficits.
• Traumatic injuries may be present and may be caused by the altered perceptions of reality or combative or destructive behavior.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Ergot alkaloid toxicity

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Laboratory evaluation of suspected hallucinogen poisonings usually is not helpful except for correction of metabolic abnormalities (eg, hypoglycemia).
• Drug screens of patients in the ED rarely affect treatment protocols.
• Urine drug screens generally detect only some of the hallucinogens, specifically PCP, cocaine, and cannabinoids.
• Particularly with LSD, the doses ingested to produce effects may be so small as to be essentially undetectable, even with careful assays.
• In patients with other etiologies of acute mental status changes (eg, CNS infection), a thorough evaluation is indicated, including blood chemistries, CBC, blood cultures, and arterial blood gases.
• Because a wide variety of medications can induce illusions and hallucinations, a comprehensive drug screen may be indicated to fully evaluate the patient if diagnosis is unclear.

Imaging Studies

• Imaging studies are indicated if the physician suspects other causes of altered mental status such as CNS infection or trauma. These studies include CT scanning or MRI of the head. Altered mental status with associated hypertensive crisis or hyperthermia should also prompt CNS imaging because these conditions may be associated with intracerebral pathology.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Prehospital Care

• Focus prehospital care on preventing patients from harming themselves or others and transporting them to an appropriate facility for further evaluation. Calm, reassuring, and nonthreatening behavior can be useful in "talking down" patients to allow care and interventions to proceed.
• Appropriate use of physical and chemical restraints may be required. Benzodiazepines are probably the safest sedatives and can be effective for calming and restraining most patients. However, these agents are best administered intravenously, necessitating intravenous access before administration.
• Avoid use of antipsychotics, particularly haloperidol or droperidol, in patients who may have ingested PCP or other agents with significant adrenergic stimulant effects. Cardiac dysrhythmias and seizures could result from the combination of these agents.
• If use of physical restraint is necessary, the team approach, using at least 5 persons, should be effective in quickly subduing and restraining the patient and minimizing risks of additional injury to patient or rescuers.

Emergency Department Care

• Lysergic acid diethylamide
• • Once patients have been evaluated for significant trauma and other potential etiologies, place them in quiet rooms with diminished lighting and other stimuli. Patients may require sedation with benzodiazepines, but, generally, supportive reassurance that the hallucinations are not real or dangerous is adequate care. The toxic psychosis generally resolves in 2-4 hours.
  • If patients do not respond to supportive care and benzodiazepines, or they demonstrate a frank psychotic break, haloperidol (2-5 mg IM q1-2h) may be necessary to control the toxic psychosis.
  • Chronic and intermittent psychotic states resulting from LSD use are well described. Patients may unmask underlying psychotic behavior or develop new psychoses or personality disorders. Posthallucinogen perceptual disorder (ie, flashbacks) occurs in most patients who have taken LSD more than 10 times. These episodes are generally perceptual alterations or pseudohallucinations produced by sudden changes of lighting. Occasionally, more bizarre and frightening images reoccur. Treatment of these episodes is supportive; they may be managed as panic attacks with benzodiazepines.
  • Intoxication usually lasts 8-12 hours, but psychotic behavior may be present for days. Patients generally can be observed until the acute intoxication has cleared and mental status has returned to normal. Patients without residual effects or psychosis can be discharged safely with suggested follow-up in a few days. Admit any patient with prolonged toxic effects for observation until the toxic symptoms resolve or the patient has had psychiatric evaluation for persistent psychotic behavior.
• Phencyclidine and ketamine
• • General supportive management is important, as is adjusting the environment to decrease stimulation and agitation. After screening patients for potential injury or other causes of behavior, they should be secluded, if possible. Use physical restraints for extremely combative patients and sedate them with benzodiazepines. Large amounts of benzodiazepines may be needed to sedate the patient, and supportive airway management may be indicated.
  • Manage frankly psychotic behavior with combinations of benzodiazepines and haloperidol. Use phenothiazines with caution because the potential for seizures and cardiovascular compromise exists in patients experiencing significant sympathomimetic effects. Be aware that the dissociative anesthetic properties of phencyclidine and ketamine may allow patients to appear far stronger than they are and to be insensitive to painful feedback.
• Psilocin and psilocybin
• • For most patients, care consists of placement in a subdued and supportive environment. Frank psychoses rarely occur. Aggressive and destructive behaviors are also uncommon.
  • Anxiety and agitation can be managed with benzodiazepines, and antiemetics may help GI complaints. Intoxication can last several hours and may wax and wane with a larger ingestion.
• Mescaline
• • Anxiety and intense agitation may occur carefully monitor the patient for potential hemodynamic compromise and respiratory depression.
  • As with the other hallucinogens, a subdued and supportive environment is important. Patients with respiratory depression may require ventilatory assistance; intubation is indicated in cases of significant intoxication because of the potential for aspiration secondary to CNS depression. Initiate intravenous crystalloid fluid boluses to treat hypotension. Benzodiazepines are indicated for the agitated patient.
• Designer drugs
• • Care of patients who have ingested any of these substances is primarily supportive and focused on decreasing adverse stimuli. Benzodiazepines are used to reduce agitation and induce sedation. Intravenous sodium nitroprusside may be required to manage hypertensive emergencies. Avoid beta-blockers because unopposed alpha-adrenergic properties may lead to hypertensive crises. Management of seizures includes administration of benzodiazepines and phenytoin (Dilantin).
  • If significant hyperthermia is present, initiate cooling measures and evaluate the patient for rhabdomyolysis. Perform early hydration and urine alkalinization if evidence of rhabdomyolysis is present.
  • Management of hypertensive crisis may require the use of sodium nitroprusside or nitroglycerin infusions to rapidly control blood pressure.

Consultations

• Management of simple hallucinogen intoxications does not require routine consultation with behavioral health specialists. However, consultation with behavioral health specialists and possible inpatient care is indicated for patients who have complicated ingestion responses with acute psychosis or destructive behaviors. Refer patients with a history of substance abuse for behavioral health evaluation.
• Consult with a toxicologist or regional poison control center for patients requiring admission for management of severe intoxications.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Sedatives

Decrease agitation or combative behavior when patients are at risk of harming themselves or others.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Patients with only minor agitation and adverse sympathomimetic effects can be safely treated in the ED with observation until symptoms have resolved.
• Patients with hyperthermia, uncontrolled hypertension, seizures, or any evidence of cardiovascular instability should be admitted to a monitored patient care area. Consider consultation with a toxicologist or regional poison control center.
• Perform GI decontamination if co-ingestions are suspected. This probably is accomplished most effectively by activated charcoal administration.
• Obtain a psychiatric evaluation for patients with signs of persistent or severe psychotic behavior. Patients should be completely detoxified. Transfer patients for inpatient psychiatric care if psychiatric symptoms persist.

Further Outpatient Care

• Patients with minimal or resolving symptoms can be discharged from the hospital safely. Advise these patients to avoid similar exposures and refer them to a behavioral health specialist for substance abuse evaluation. Discharge with medications is not indicated.

In/Out Patient Meds

• Titration of benzodiazepines may be indicated to control agitation; administer phenothiazines only when indicated by severe psychotic reaction. Do not administer phenothiazines to patients with signs of sympathomimetic overstimulation.
• No outpatient medications should be required.

Transfer

• Transfer patients with significant psychotic manifestations unresponsive to therapy if appropriate behavioral health specialists are not available for evaluation. Exercise caution when transferring patients who demonstrate signs of continued intoxication.

Patient Education

• For excellent patient education resources, visit eMedicine's Substance Abuse Center. Also, see eMedicine's patient education articles Club Drugs, Drug Dependence and Abuse, and Substance Abuse.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Delay in the diagnosis and treatment of hyperthermia is a pitfall. These patients may present with agitation and delirium, and obtaining a complete set of vital signs (especially an accurate temperature) can be difficult.
• Inadequate control of destructive behavior should be avoided. Agitated and destructive patients on hallucinogens require appropriate sedation to prevent injury to themselves and others.
• Failure to discuss long-term detoxification programs with the patient is a pitfall. Physicians should discuss drug avoidance programs with all patients who present with drug intoxication.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the assistance of Lada Kokan, MD, with the literature review and referencing for this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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Article Last Updated: Dec 10, 2007