SALVIA DIVINORUM: EXPOSURES REPORTED TO A STATEWIDE POISON
CONTROL SYSTEM OVER 10 YEARS
Rais Vohra, MD,* Andrew Seefeld, MD,* F. Lee Cantrell, PHARM D,† and Richard F. Clark, MD‡
*Olive View-UCLA Medical Center, Los Angeles, California, †California Poison Control System, San Diego Division, San Diego,
California, and ‡University of California, San Diego Medical Center, San Diego, California
Reprint Address: Rais Vohra, MD, Department of Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive,
North Annex, Sylmar, CA 91342
e Abstract—Background: Salvia divinorum, a hallucino-
genic herb, has in recent years become popular among teen-
agers and young adults. Salvia is presently marketed as a
“legal” alternative to other drugs of abuse, but little is known
about the clinical toxicity of this substance. Objectives: The
purpose of this study is to describe the clinical and demo-
graphic features of this emerging substance of recreational
center. Methods: We performed retrospective review of expo-
sures to the herbal hallucinogen Salvia divinorum as reported
to the California Poison Control System (CPCS) over the last
10 years. Demographic and clinical data were collected and
compiled from the computerized records of the CPCS for the
search terms “salvia” and “sage.” Results: There were 37 expo-
sures to S. divinorum and 96 exposures to non-hallucinogenic
Salvia species. Eighteen (49%) of the exposures were to S.
divinorum alone. Intentional Salvia exposures resulted in a
variety of neurologic, cardiovascular, and gastrointestinal ef-
fects. Notably, the use of concomitant substances of abuse was
associated with a high rate of complications and psychomotor
disturbances. Conclusions: Intentional use of S. divinorum,
whether alone or in combination with alcoholic beverages and
other drugs, causes neurologic, cardiovascular, and gastroin-
testinal effects. This poison-center-based review helps to char-
acterize the clinical toxicity of S. divinorum, but more clinical
and pharmacologic research is warranted for this rapidly
emerging substance of abuse.© 2009 Elsevier Inc.
e Keywords—Salvia divinorum; hallucinogen; poison con-
Salvia divinorum is a perennial species of sage with
hallucinogenic properties originally found in Northern
Mexico (Figure 1). Also known as “Diviner’s Sage,”
“Mystic Sage,” and “Magic Mint,” S. divinorum was
originally used by the Mazatec population for shaman-
istic purposes, and continues to be used in the religious
rites of some indigenous Mexican cultures (1). Since the
mid-1990s, S. divinorum has become more readily avail-
able for consumers. Various preparations are being sold
openly at smoke (“head”) shops as well as through mul-
tiple Internet retailers, where it is sold as an herbal
extract to be smoked for recreational purposes (Figure 2).
S. divinorum use/abuse is becoming increasingly popular
among both adolescents and adults (2,3). S. divinorum
intoxication videos have become a popular type of sub-
mission on widely accessed open Internet sites such as
At present, the clinical effects of S. divinorum are not
well defined. A literature search in the PubMed database
in December 2008 revealed no clinical case reports or
case series on the acute toxic effects of S. divinorum.
Despite this paucity of published data, many states in the
United States, as well as international governing bodies,
have proposed listing this plant as a scheduled or illegal
substance (6,7). This retrospective study describes the
clinical and demographic details of inquiries made to a
RECEIVED: 29 January 2009; FINAL SUBMISSION RECEIVED: 21 April 2009;
ACCEPTED: 30 May 2009
The Journal of Emergency Medicine, Vol. xx, No. x, pp. xxx, 2009
Copyright © 2009 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/09 $–see front matter
ARTICLE IN PRESS
statewide poison control network regarding exposures to
S. divinorum and non-hallucinogenic Salvia species over
a 10-year period.
We performed a retrospective study of all Salvia species
exposure cases reported to the California Poison Control
System (CPCS) from January 1998 to May 2008. Infor-
mation collected from the search results included: patient
age and gender; the dose, formulation, and route of
exposure to Salvia divinorum; other medications or sub-
stances coingested; symptoms reported; laboratory re-
sults; duration of effects; and length of stay for those
patients treated in a health care facility. The data were
collected and tabulated using a standardized spreadsheet
template. Verbatim entries were made for qualitative or
descriptive data, and when a data parameter was not
reported, the entry was flagged as “NR.” Patients whose
outcome or clinical course was unavailable or unreported
at the time of the review were noted as “lost to follow-
up.” Descriptive data included items such as unique
physical examination findings as well as the content and
nature of hallucinations or thought disturbances. These
were noted in an attempt to further define a specific toxic
syndrome from Salvia exposure. The study was reviewed
and approved by our institution’s Investigational Review
A total of 133 cases were identified in the CPCS data-
base. The average age of patients was 11 years (range
1–71 years), and 77 (58%) were male. The distribution of
exposures by age (including both S. divinorum and non-
divinorum exposures) were as follows: 86 exposures in
children aged ? 10 years old, 23 exposures in teenagers
15–20 years old, and 22 exposures in adults over 21
years old. (There were no exposures in patients aged
11–14 years, and ages were not noted in two case
One hundred cases were managed at home; 33 cases
were evaluated in a health care facility, and 5 patients
were admitted to the hospital.
The cases fell into two broad and demographically
distinct categories: exposures due to Salvia divinorum
(which is the only Salvia species known to be hallucino-
genic), and exposures to non-divinorum Salvia species.
Figure 1. Picture of Salvia divinorum, a perennial sage spe-
cies indigenous to Northern Mexico. Source: http://www.
Figure 2. Picture of the herbal extract of Salvia divinorum.
Note the concentration label “40?” with no other units of
measurement provided. This is typical of available speci-
mens of Salvia divinorum. Source: http://www.salvia.uk.
2 R. Vohra et al.
ARTICLE IN PRESS
Exposures to S. divinorum
There were 37 exposures to S. divinorum. All of these
were in the context of recreational use of S. divinorum
and were classified as “intentional” exposures (Table 1
lists demographic and clinical details and outcomes of
these cases). There were no deaths. Sixteen of these 37
(43%) exposures were reported to have concomitant ex-
posures to other psychoactive agents, and 18/37 (49%)
exposures were only to S. divinorum (for the three cases,
the presence of other ingested or inhaled drugs was
unknown or not reported).
As indicated in Table 1, vital sign abnormalities were
reported for some but not all of the cases of intentional S.
divinorum cases. In cases where S. divinorum was the
sole agent of exposure, vital sign anomalies were docu-
mented in 2 patients: systolic hypertension and tachycar-
dia in one case, and only tachycardia in another (in the
latter case, a 24-year-old patient denied concomitant
intoxication but had used LSD, phencyclidine, mari-
juana, and amphetamine 2 days before smoking Salvia).
Table 2 lists the clinical symptoms and their fre-
quency in cases of isolated S. divinorum exposures. The
most common symptoms recognized after isolated S.
divinorum use were confusion or disorientation, halluci-
nations, giddiness or dizziness, flushed sensation, and
tachycardia. Symptoms related to mental or neurologic
effects were prevalent in a majority of patients with
intentional Salvia exposures. Of the patients with inten-
tional exposures to only S. divinorum, 13 (72%) had evi-
dence of psychotomimetic or neuromotor disturbances.
For 18 cases of intentional Salvia exposure, con-
comitant ingestions included the following: ethanol (5
cases); marijuana (5 cases); mushrooms (1 case); jim-
son weed (2 cases); MDMA or methamphetamines (2
cases); GHB (1 case); rootone (1 case); damina leaves and
2,5-dimethoxy-4-iodophenethylamine (1 case). Routes of
exposure included oral (n ? 8), inhaled (n ? 24), or
unknown/unreported (n ? 5). In the majority (n ? 20) of
S. divinorum cases, the formulation used by the patient
was unknown or unreported; when described, the formu-
lations were: leaves/flowers (n ? 13), S. divinorum ex-
tract (n ? 3), or tablet form (n ? 1).
Interventions made for patients possibly exposed to S.
divinorum are listed by case in Table 1. These included:
benzodiazepines for agitation (5 cases), intubation (2
cases), pacemaker placement for 3rd-degree heart block
(1 case, in which the history of recurrent syncope was
suggestive of primary conduction system disease), cal-
cium channel blocker for hypertension (1 case), activated
charcoal (1 case), and oral challenge/dilution with fluids
Cases Attributed to Salvia Types Other
than S. divinorum
The majority of exposures to the non-divinorum types of
Salvia plants were exploratory ingestions in children. In
adults, there was no indication that the non-divinorum
sage plants were being used recreationally. Our study
revealed that 96/133 cases involved exposures to non-
divinorum species of Salvia. In this group, the average
age of patients was 7 years (range 1–71 years). Routes of
exposure were oral (90 cases), skin contact (2 cases),
accidental inhalation of fumes from a burning sage plant
(1 case), or unknown (2 cases). The majority (total 86,
65%) of these cases were ingestions by children aged 10
years or younger and involving species other than S. divi-
norum. These pediatric ingestions of ornamental or garden
plants were categorized as unintentional (Table 3). The
remaining patients were adults whose cases were re-
ported to the poison control center after accidently tast-
ing non-divinorum Salvia species, or those who (in 2
cases) used Salvia miltorrhiza as a Chinese medicinal
Salvia divinorum is an increasingly popular recreational
divinorum for hallucinogenic or dissociative purposes can
be achieved via the oral, sublingual, or, most commonly,
inhalational route using leaves or dried extracts of the
plant (8). According to self-reports by those who have used
it, psychological effects occur within seconds to minutes
and typically last for up to 1 h (9). Hallucinations and
alterations or enhancements in sense perception are typ-
ically experienced. The active component in S. divino-
rum is thought to be salvinorin A, a diterpene with
effects on the kappa opioid receptors found in the brain
and spinal cord (10,11). Recent basic-science investiga-
tions have revealed that salvinorin A has a variety of
neurologic effects, including psychotomimesis, analge-
sia, sedation, diuresis, and inhibition of gut motility
(8,12). A recent survey estimates that 4% of college
students have tried this substance for recreational intox-
ication in the last year (2).
Previous descriptions of S. divinorum’s psychological
effects have been largely anecdotal, and many are first-
hand accounts after recreational experimentation (4,5,12).
Our study represents the first clinical case series of this
emerging recreational drug.
In this study, we reviewed 37 cases in which S.
divinorum exposure was intentional, defined as a case in
which the patient was using the herbal Salvia plant or
extract to achieve a recreational “high.” Roughly half of
Salvia divinorum Exposures3
ARTICLE IN PRESS
Table 1. Exposures to Salvia divinorum Reported to CPCS, 1998–2008
Years SexRouteCoingestants Vital SignsSymptomsComments
Temp 36°C, pulse 75 beats/min,
BP 153/80 mm Hg (24 h post-
Afebrile, other vital signs N/R
Excessive laughing, confusion
6 17M Oral None Persistent anxiety, time
Dizzy, “spacey sensation”
Ingested S. divinorum 1 week prior
7 18M SmokedNone N/R Left against medical advice and lost to
Monitored in ED
Left against medical advice and lost to
Left against medical advice and lost to
Confusion, psychosis, flushed skin
1017MSmoked NoneN/R“Not acting normal” s/p exposure
3 days prior
“Feels like he has had a stroke”
N/R Lost to follow-up, patient refused
GI bleeding unrelated to S. divinorum
Lower GI bleed (unrelated)
Anxiety, palpitationsLeft against medical advice and lost to
Used LSD, phencyclidine and
marijuana, and amphetamines 2
days before use of S. divinorum
Confusion noted three days after S.
1624M SmokedNone “Tachycardic” (pulse not
1722M SmokedNoneN/R “Mind is blown,” confusion
18 24M Smoked NoneN/RNausea, vomiting, diaphoresis ?4
Seizures, agitation, confusion
Temp 39°C, pulse 119 beats/
min, BP 155/100 mm Hg
“HTN” noted (BP not
Pulse 100 beats/min, BP 122/70
Lost to follow-up
2121MSmokedUnknownAgitation, HTNLost to follow-up
2219MSmokedEthanol Anxiety RBBB on ECG, monitored for 2–3 h in
ED, then home
Monitored in ED 23 18M SmokedMarijuana Confusion, lethargic, responds to
Agitation, hallucinations2419 MSmokedMushroomsAfebrile, pulse 70 beats/min, BP
148/86 mm Hg, Oxygen
saturation 98% room air
“Tachycardia” noted (pulse not
Monitored in ED
2517MSmokedMarijuanaCombativeMonitored in ED
2618MSmoked EthanolRapid eye movement (REM)
activity while awake
Monitored in ED
R. Vohra et al.
ARTICLE IN PRESS
Table 1. (Continued)
Years Sex RouteCoingestants Vital SignsSymptomsComments
27 17M OralPossible jimsonweed,
Temp 40.0°C, pulse 107 beats/
min, BP 200/150 mm Hg
Serotonin syndrome vs. anticholinergic
delirium vs. steroid-induced
psychosis (wrestler), patient
extubated on hospital day 2
Monitored in ED 2819M UnknownGamma hydroxy
Afebrile, other vital signs stableVomiting, agitation, confusion,
mydriasis, dry skin, flushed
2917M Oral Afebrile, pulse 110 beats/min,
Monitored in ED, patient stated Salvia
baked in brownies
30 18M UnknownN/RAgitationLeft against medical advice and lost to
Symptoms due to preexisting cardiac
3115MUnknown Ethanol, protein
Blood pressure 100s systolic,
pulse 70–80 beats/min
Pulse 94 beats/min BP 164/110
Afebrile, pulse 111 beats/min,
BP 128/71 mm Hg,
respirations 18 breaths/min
Syncope, 3rd-degree heart block
N/V, wk, dizzy
Agitation, mydriasis, HTN,
Admitted to hospital for observation
35 26MOralDamina leaves,
Admitted to hospital, intubated for 2
days and extubated without
36 UnknownF Smoked Fasciculations of neck Left against medical advice and lost to
37 20M SmokedNoneN/RAbdominal pain, hypoglycemia
(blood glucose 60 mg/dL)
BP ? blood pressure; ED ? emergency department; N/R ? not reported or recorded in the poison center database; GI ? gastrointestinal; HTN ? hypertension; RBBB ? right bundle
branch block; ECG ? electrocardiogram; MDMA ? methylene-deoxy-methamphetamine “Ecstasy”; wnl ? within normal limits.
Salvia divinorum Exposures
ARTICLE IN PRESS
these cases also involved exposure to other psychoactive
agents, confounding the assessment of S. divinorum’s
particular contribution to toxicity. In cases where only S.
divinorum was inhaled or ingested, neurologic symptoms
and signs of intoxication were noted and compiled. Ac-
cording to this analysis, S. divinorum intoxication is
characterized by a constellation of symptoms and signs:
anxiety, bizarre and vivid hallucinations, giddiness,
space-time disorientation, nystagmus, palpitations, hy-
pertension, tachycardia, nausea, and vomiting. As with
many recreational substances, not all patients experience
all of the symptoms listed, and more clinical information
is necessary to fully depict the range and severity of signs
and symptoms of this emerging recreationally used sub-
stance. Clinicians caring for patients intoxicated by S.
divinorum are encouraged to pay close attention to pos-
sible psychiatric, neurologic, gastrointestinal, and cardio-
From this study, it seems that the concomitant use of
multiple psychoactive agents is more likely to result in
more serious adverse effects (e.g., seizures, intubation)
than the use of S. divinorum alone. For example, vital
sign abnormalities were noted in 2/18 cases in which S.
divinorum was the sole agent of intentional intoxication;
in contrast, abnormal vital signs were reported in 6/16
cases in which additional psychoactive substances were
also involved. Furthermore, in those cases with more
significant adverse effects, other psychoactive substances
besides S. divinorum were reported in at least one, and
possibly three, of the four cases. Two of these cases
experienced seizures. Despite a small sample size, these
data suggest that polysubstance abuse is a risk factor for
more severe adverse clinical outcomes in the setting of
intentional S. divinorum use.
A dose-response relationship was not possible to es-
tablish from this case series. There was an overall pau-
city of data about the doses and formulations used by
patients in this case series. In the vast majority of cases,
information about quantity consumed was either unre-
ported, unavailable, or unreliable. For instance, in many
cases, there was a lack of caller certainty about the
amount or strength utilized, even when the exposures
were intentionally undertaken. Indeed, much of the am-
biguity about doses consumed is a consequence of herbal
manufacturing practices; S. divinorum extracts are usu-
ally marketed as concentrations such as “5?,” “10?,” or
“50?,” without listing milligram equivalents (Figure 2).
Each manufacturer determines the strength rating based
on subjective criteria such as the age and water weight
for a particular batch. This marketing practice, com-
pounded by the paucity of physiologic data on this plant,
currently challenges attempts to establish a clinically
useful dose-response relationship for this substance. A
robust estimation of dose-response for this plant product
will have to wait until doses can be more precisely deter-
mined of Salvia consumed in recreational settings. Analyt-
ical laboratory methods such as liquid chromatography-
mass spectroscopy have been employed recently to detect
Salvinorin in both commercial samples and biological
fluids, but these techniques have not gained wide accep-
tance in common clinical practice (8,13,14).
Using our search criteria, we were surprised to learn
that the majority of calls about “Salvia” species referred
to plant species not known to have hallucinogenic or
psychoactive effects. Poison center specialists and clin-
ical toxicologists may be asked to provide advice on
both hallucinogenic and non-hallucinogenic varieties of
Salvia plants, and this study highlights the need to dis-
tinguish the exact species of Salvia to help make appro-
priate triage and therapeutic decisions. Consistent with
prior research on household plant exposures, our study
confirmed that pediatric, exploratory, or low-dose expo-
sures to non-hallucinogenic Salvia varieties have a be-
nign clinical course, as demonstrated by the asymptom-
atic outcomes of children ? 6 years old who ingested
Table 2. Signs/Symptoms Associated with Isolated Use of
Altered mental state (confusion, disorientation)
Table 3. Species of Non-hallucinogenic Salvia or Sage
Plants Implicated in Pediatric Ingestions of
Salvia columbriae (chia)
Abronia fragrans (Red Lantana)
6 R. Vohra et al.
ARTICLE IN PRESS
leaves, flowers, or other parts of non-hallucinogenic
Salvia plants (15).
Limitations of this study include the small sample size
and retrospective design. These factors limit the com-
pleteness of clinical information available for review.
A number of patients were ultimately lost to adequate
follow-up by poison control center personnel, so any
delayed signs and symptoms may have been missed.
Incomplete documentation or reporting regarding the
circumstances surrounding the exposures makes it diffi-
cult to draw many concrete conclusions such as dose-
response relationship. Many laypersons and clinicians
choose not to report asymptomatic or mildly symptom-
atic exposures of toxins to regional poison centers, so the
available reports may be skewed to reflect a more ill
population of patients. Even ill patients with poisonings
are sometimes not reported to the poison control center,
so our data were likely subject to a general under-
reporting of Salvia exposure cases. Our small sample
size and inability to review hospital records in detail also
limit us from making firm conclusions about the poten-
tial interactions (synergism/antagonism) between S. di-
vinorum and other psychoactive substances. Notably,
because there are no laboratory tests or biological mark-
ers commonly available for the detection of Salvinorin
A, its related metabolites, or specific physiologic effects
of this substance, the exposure to S. divinorum was
confirmed only by history or, more rarely, a specimen of
the plant or labeled extract available for identification by
health care providers. Finally, self-reporting bias limits
the accuracy of the clinical findings, as patients may have
been mistaken or confused about the agent(s) involved in
their exposure at the time of the poison center inquiry.
Salvia divinorum seems to be rising in popularity among
adolescents and young adults. This poison-center-based
case review adds to the expanding knowledge of S.
divinorum’s clinical effects. In patients who intentionally
used S. divinorum alone, psychiatric effects were most
evident, while neurologic, cardiovascular, and gastroin-
testinal effects were loosely associated with the expo-
sure. Clinicians should also note that patients who have
intentional exposures to this agent frequently present
with concomitant exposures to other psychoactive sub-
stances, and the use of multiple agents seems to carry a
higher risk of severe adverse effects. Because most clin-
ical laboratories are not equipped to detect Salvinorin A
or related metabolites, the diagnosis of S. divinorum
intoxication must, at present, rely on historical details.
Additional basic and clinical research will elucidate the
pharmacokinetics, full spectrum of clinical effects, and
any unique treatments required for this emerging sub-
stance of abuse. We encourage emergency physicians
who care for patients exposed to Salvia plant species to
enlist the assistance of clinical toxicologists and poison
center personnel via regional poison control centers.
1. Valdés LJ 3rd, Díaz JL, Paul AG. Ethnopharmacology of ska
María Pastora (Salvia divinorum, Epling and Játiva-M.). J Ethno-
2. Lange JE, Reed MB, Croff JM, Clapp JD. College student use of
Salvia divinorum. Drug Alcohol Depend 2008;94:263–6.
3. Hoover V, Marlowe DB, Patapis NS, Festinger DS, Forman RF.
Internet access to Salvia divinorum: implications for policy, pre-
vention, and treatment. J Subst Abuse Treat 2008;35:22–7.
4. YouTube: Broadcast YourselfTM. Available at: http://www.youtube.
com. Accessed September 20, 2008.
5. The Salvia divinorum Research and Information Center website.
Available at: http://www.Sagewisdom.org. Accessed September
6. Griffin OH, Miller BL, Khey DN. Legally high? Legal consider-
ations of Salvia divinorum. J Psychoactive Drugs 2008;40:183–91.
7. Allday E. Legal, intense hallucinogen raises alarms. San Francisco
Chronicle. Page A-1, June 27, 2007.
8. Grundmann O, Phipps SM, Zadezensky I, Butterweck V. Salvia
divinorum and salvinorin A: an update on pharmacology and
analytical methodology. Planta Med 2007;73:1039–46.
9. Dalgarno P. Subjective effects of Salvia divinorum. J Psychoactive
10. Roth BL, Baner K, Westkaemper R, et al. Salvinorin A: a potent
naturally occurring nonnitrogenous kappa opioid selective agonist.
Proc Natl Acad Sci U S A 2002;99:11934–9.
11. Valdés LJ 3rd. Salvia divinorum and the unique diterpene hallu-
cinogen, Salvinorin (divinorin) A. J Psychoactive Drugs 1994;26:
12. Bücheler R, Gleiter CH, Schwoerer P, Gaertner I. Use of nonpro-
hibited hallucinogenic plants: increasing relevance for public
health? A case report and literature review on the consumption of
Salvia divinorum (Diviner’s Sage). Pharmacopsychiatry 2005;38:
13. McDonough PC, Holler JM, Vorce SP, Bosy TZ, Magluilo J Jr,
Past MR. The detection and quantitative analysis of the psychoac-
tive component of Salvia divinorum, salvinorin A, in human bio-
logical fluids using liquid chromatography-mass spectrometry. J
Anal Toxicol 2008;32:417–21.
14. Wolowich WR, Perkins AM, Cienki JJ. Analysis of the psychoac-
tive terpenoid salvinorin A content in five Salvia divinorum herbal
products. Pharmacotherapy 2006;26:1268–72.
15. Froberg B, Ibrahim D, Furbee RB. Plant poisoning. Emerg Med
Clin North Am 2007;25:375–433; abstract ix.
Salvia divinorum Exposures7
ARTICLE IN PRESS
1. Why is this topic important?
The rapid rise in popularity and widespread availabil-
ity of Salvia divinorum as a recreational substance of
abuse represents a potentially significant emerging toxin.
Emergency clinicians and poison center personnel may
be asked to provide care for patients under the influence
of this hallucinogenic plant, about which there are very
few clinical and pharmacologic data currently available.
2. What does this study attempt to show?
This study describes clinical and demographic details
of exposures to Salvia divinorum and describes the symp-
toms likely to be encountered by emergency physicians
in cases of isolated Salvia divinorum exposure. In addi-
tion, non-hallucinogenic species of Salvia (sage) plants
are provided for reference, as these may be confused or
mistaken for the recreationally used Salvia divinorum
variety of sage.
3. What are the key findings?
In patients who intentionally used Salvia divinorum
alone, neurologic, cardiovascular, and gastrointestinal ef-
fects were evident. The concomitant use of multiple
agents or drugs of abuse is more likely to result in more
serious adverse effects (e.g., seizures, intubation) than the
use of Salvia divinorum alone.
4. How is patient care impacted?
Physicians caring for young adults or teenagers who
manifest unexplained mental status changes or cardiovas-
cular and neurologic symptoms should consider the di-
agnosis of exposure to Salvia divinorum. Patients who
present with Salvia divinorum intoxication require ag-
gressive monitoring and supportive care acutely, espe-
cially if exposed to multiple toxic agents.
8 R. Vohra et al.
ARTICLE IN PRESS