Prolonged hallucinations and dissociative self mutilation following use of Salvia divinorum in a bipolar adolescent girl

Article (PDF Available)inJournal of Substance Use 15(2):113-117 · April 2010with 111 Reads
DOI: 10.3109/14659890903060167
Abstract
The case of a bipolar 17-year-old girl who developed prolonged vivid hallucinations and a dissociative state involving self-destructive behaviour following the use of Salvia divinorum is presented. The herb has mostly short-term (10–15 min) hallucinogenic properties. Salvatorin A, the main active compound, is a highly selective agonist of the kappa-opioid receptor. The plant is available at tobacco or other specialized stores in many countries such as France, UK, Canada, and USA, where it is legal. The clinical case reported in this article suggests that the recreational use of Salvia divinorum may result in serious psychiatric consequences in vulnerable individuals.
Journal of Substance Use, April 2010; 15(2): 113–117
ISSN 1465-9891 print/ISSN 1475-9942 online © 2010 Informa UK Ltd.
DOI: 10.3109/14659890903060167
TJSU1465-98911475-9942Journal of Substance Use, Vol. 1, No. 1, Aug 2009: pp. 0–0Journal of Substance Use
ORIGINAL ARTICLE
Prolonged hallucinations and dissociative self
mutilation following use of Salvia divinorum
in a bipolar adolescent girl
Prolonged hallucinations following use of Salvai divinorumJ. J. Breton et al.
J. J. BRETON1, C. HUYNH1, S. RAYMOND1, R. LABELLE1, N. BONNET2,
D. COHEN3, & J. M. GUILÉ1
1Clinique des Troubles de l’humeur, Hôpital Rivière-des-Prairies, Département de Psychiatrie,
Université de Montréal, Montréal, Québec, Canada, 2Équipe d’addictologie ECIMUD, Paris,
France, and 3Groupe hospitalier Pitié-Salpétrière, Paris, France
Abstract
The case of a bipolar 17-year-old girl who developed prolonged vivid hallucinations and a dissociative
state involving self-destructive behaviour following the use of Salvia divinorum is presented. The herb
has mostly short-term (10–15 min) hallucinogenic properties. Salvatorin A, the main active
compound, is a highly selective agonist of the kappa-opioid receptor. The plant is available at
tobacco or other specialized stores in many countries such as France, UK, Canada, and USA, where
it is legal. The clinical case reported in this article suggests that the recreational use of Salvia divinorum
may result in serious psychiatric consequences in vulnerable individuals.
Keywords: Adolescents, Salvia divinorum, prolonged hallucinations, dissociative state, bipolarity.
Past history
Marylin was first evaluated in a Child Psychiatry Outpatient department (OPD) at the age
of 9 years for phobias, and disruptive and anxious behaviour triggered by separation from
her mother. Her father was diagnosed as bipolar and her mother was chronically
depressed. Further investigations revealed that her mother was also bipolar with cycles of
depression and mania. Marylin had two brothers older than herself. She was born at 30
weeks gestation and hospitalized several times for asthma. She had one episode of febrile
convulsions. A diagnosis of generalized anxiety disorder was made, and individual psycho-
therapy and parental guidance were recommended. The child missed several appoint-
ments, as her mother was not very supportive of the therapeutic intervention. Both mother
and child discontinued the treatment after 18 months.
Correspondence: J. J. Breton, 7070, Boulevard Perras, Montréal, H1E 1A4, Canada. Tel: (514) 323-7260. Fax: (514) 322-4163.
E-mail: jj.breton.hrdp@ssss.gouv.qc.ca
J Subst Use Downloaded from informahealthcare.com by University of Montreal
For personal use only.
114 J. J. Breton et al.
At 14 years of age Marylin was admitted to an adolescent in-patient unit as a result of
her emotional outbursts, increased energy, reduced sleep, irritability, and sadness. A diagnosis
of bipolar disorder type 1, with mixed episodes, was made. Lithium was initiated and her
mood status improved. However, partly as a consequence of the parents’ psychiatric prob-
lems, family relationships remained chaotic and conflictual. At that time, the adolescent
started using cannabis and became over weight. She was emotionally unstable, impulsive,
performed poorly at school, and presented with chronic sleep problems (mostly initial
insomnia). She had difficulty accepting her diagnosis of bipolar disorder and, conse-
quently, took her medication irregularly. She had to be hospitalized three times in the same
year for mixed episodes with visual hallucinations, self-mutilation, and oppositional
behaviour. She was diagnosed with borderline personality disorder, later confirmed with
the Diagnostic Interview for Borderlines—Revised (Zanarini, Gunderson, Frankenburg, &
Chauncey, 1989), in addition to the diagnosis of Bipolar disorder. Clonidine and quetiapine
were added to decrease aggressive behaviours and improve sleep. She was finally referred
to a residential centre for 18 months, but had to be hospitalized twice for suicidal crises
and self-mutilation.
Current episode
At the time of the Salvia divinorum consumption, the patient was 17 years old and living in
a block of flats supervised by an educator, who was resident at the site. Marylin was under-
going a period of symptomatic remission and expected to make good progress. She did not
take cannabis and had not self-mutilated for the past 9 months. She was enrolled in a
university teaching hospital Mood Disorders OPD. Her daily pharmacological treatment
was lithium 900 mg, loxapine 15 mg, clonidine 0.1 mg, fluoxetine 10 mg, and lipitor 10
mg (for elevated cholesterol). On a Sunday night in July, she smoked dried leaves of Salvia
divinorum with two other male adolescents. The dried leaves were bought legally in a store.
The legality and ease of access led the adolescents to believe that the plant was not harmful.
The three adolescents smoked the ‘joint’ of Salvia seated on a bench in a park. The two
boys encountered immediate changes in perception with feelings of derealization (being in
a spatial vessel for one and moving very rapidly for the other), which lasted for 10–15 min.
Marylin was bewildered because she felt no effect of smoking Salvia divinorum. How-
ever, 3 h later, while going to bed, she started to experience feelings of derealization with
frightening visual, auditory, olfactory, and somatic hallucinations. Everything was unreal,
with the floor moving like the surface of water and voices coming out of furniture. She saw
dead people, heard screams and moaning, felt burning smells and the sensation of a puff
on her neck. In the past, the visual hallucinations she experienced occurred only during her
mixed episodes. She became very frightened and called both her mother at home and her
educator at the site. The educator went up to her flat and was able to progressively calm
her down. The hallucinations continued the next day, and worsened over the afternoon
and the evening. She went to bed with her eyes still open (unable to sleep) and had what
she later described as a 45-min ‘blackout’. Upon arousal she saw blood on the sheets,
discovered several cuts on her left forearm and abdomen, and realized with anguish that
she had been self-mutilating during this episode. She had absolutely no recollection of her
behaviour. She panicked and called her educator and the emergency services of two hospitals
to get help. Her educator came up and was again able to calm her down. The emergency
calls were cancelled. The frightening hallucinations decreased slowly and she was able to
sleep. The next morning, she got in touch with our Mood Disorders Clinic and had an
J Subst Use Downloaded from informahealthcare.com by University of Montreal
For personal use only.
Prolonged hallucinations following use of Salvia divinorum 115
appointment with the child psychiatrist (JJB) and the nurse (SR) the following day. At the
mental examination, she was very anxious, but not psychotic. She reported suicidal urges
when near a metro station. Loxapine was increased, and a follow-up meeting with Marylin
and her educator was planned the following day. The hallucinations and the suicidal urges
decreased progressively over the following 4 days. She recovered completely after 1 week
from her episode and returned to her previous adequate level of functioning.
Salvia divinorum
Description. Salvia divinorum is a plant in the sage genus belonging to the mint family. The
Sage genus encompasses 700 species. The herb was originally cultivated in the state of
Oaxaca, Mexico by Mazatec Indians, and used for spiritual and religious purposes as a
substitute for psilocybes, when these mushrooms were not available. The herb has mostly
hallucinogenic properties. In traditional societies, the plant is often a reincarnation of Mary,
who appears and speaks to the user. Other names include ‘Mary herb’, ‘Magic Mint’ and
‘Diviner’s Sage’. The plant can be chewed, drunk (as a juice) or smoked (Hostettmann,
2002). Smoking is the preferred method of use (Dalgarno, 2007). It is known as a very
short-acting drug with psychedelic effects starting immediately after inhalation and lasting
for 5–15 min and not exceeding 2 h. In addition to hallucinations, the drug generates eupho-
ria, identity disturbance, derealization and dissociative phenomena (Dalgarno, 2007;
Gonzales, Riba, Bouso, Gomez-Jarabo, & Barbanoj, 2006; Nortier, 2007).
The plant is available on many web sites and is also available through tobacco or other
specialized stores in countries where it is legal. The drug is presented as a safe, legal, and
undetectable product by usual routine tests, characteristics that make it very appealing for
use by both adults and adolescents. Indeed, web sites devoted to drugs are proliferating
with a large number of commercial sites ignoring the risks and harms related to the use of
psychedelic drugs (Montagne, 2008). A 2005 survey in France revealed that hallucinogens
were used over lifetime by 5.2% of boys and 2.1% of girls 17 years [Observatoire français
des drogues et toxicomanies (OFDT), 2007] and in Quebec, 9% of 12–17-year-old adoles-
cents in secondary schools reported having used hallucinogenic drugs in 2006 (Dubé &
Fournier, 2006). The drug is legal in many countries like France, UK, Canada, and USA,
although not in all states, but prohibited in Spain, Australia, Italy, Sweden, and Denmark.
A recent survey among 1526 college students in the United States revealed that 4.4% of
the sample reported using Salvia over the previous year. Being male, white, member of a
fraternity/sorority group, a heavy alcohol- and drug-user were associated with increased
probability of Salvia use. Alcohol and drug use represented the highest risk factor for tak-
ing Salvia (OR of 11) (Lange, Reed, Ketchie Croff, & Clapp, 2008).
Mechanisms of action. Salvia divinorum is a hallucinogen with specific properties different
from indolealkylamines and phenylalkylamines, the two major classes of hallucinogens
(Nortier, 2007; Stahl, 2008). Indolealkylamines encompass psilocybin and psilocin, the
active compounds of psilocype mushrooms, dimethyltryptamine (DMT) coming from
virola’s bark, ibogaine from Tabernanthe iboga, as well as the classic synthetic hallucinogen
LSD. They act mainly as agonists at 5-HT2A receptor sites with additional effects on other
neurotransmitter systems. The second class is represented by phenylalkylamines encom-
passing mescalin, the active compound of cactus peyote and synthetic drugs, such as the
well known MDMA or ecstasy. They have complex interactions at norepinephrine and
dopamine receptor sites (OFDT data base; Stahl, 2008).
J Subst Use Downloaded from informahealthcare.com by University of Montreal
For personal use only.
116 J. J. Breton et al.
Salvatorin A is the main active compound of Salvia divinorum. Salvatorin A does not
have binding affinity for 5-HT2A receptor compared with many hallucinogens. This
compound is a highly selective agonist of the kappa-opioid receptor (Babu, McCurdy &
Boyer, 2008; see Table I). A gender effect difference in elimination was observed in the
only study using intravenous administration on two male and two female rhesus monkeys
with males having a shorter elimination half-life than females. The sedative effect lasted
about 15 min (Grundmann, Phipps, Zadezensky, & Butterweck, 2007).
Discussion
The case of Marylin is very unusual because of the delay in the psychedelic effects and the
week-long duration of the vivid hallucinatory phenomena. Moreover, this adolescent
presented a dissociative state with self-injury behaviour the day after taking the substance.
The suicidal urges reported during her first visit at our Mood Disorders Clinic appear to be
secondary to the psychological distress. The two other male adolescents had a very short
hallucinatory experience, but the gender effect observed in a non-human primate study
cannot obviously account for such a substantial difference in reactions.
We did not find in the literature any other case describing effects lasting for several days
following the use of Salvia divinorum. The bipolarity of this patient with previous episodes
of visual hallucinations, self-mutilation, and suicidal crises made her more vulnerable. In
addition, the psychotropic medication taken by Marylin, with molecules having affinity for
alpha adrenergic, dopamine, and 5-HT receptors, might have contributed to the intense
and prolonged reaction in this bipolar girl, although the molecular mechanisms involved in
neurotransmitter systems are quite difficult to elucidate. Hallucinogens act at serotonine
and dopamine systems on reward circuits consisting of the ventral tegmental area, the
nucleus acumbens, and the amygdala (Stahl, 2008). A neurochemical adaptation of the
dopamine system and its receptors related to the chronic use of the psychotropic medication,
especially loxapine, might have contributed to the delayed and prolonged hallucinatory
phenomena. Use of psychotropic medication as such by adolescents with mental disorders
could then be a major risk factor for serious complications following use of hallucinogens.
T
a
bl
e
I
.
M
a
i
n c
h
aracter
i
st
i
cs o
f
h
a
ll
uc
i
nogen
i
c compoun
d
s use
d
f
or recreat
i
ona
l
purposes
Active compounds Mechanism
Mushroom Psylocybe (Psilocybe cubensis,
hoogshagenii, mexicana, muliercula,
zapotecorum)
Psilocybin, Psilocin
Agonist R 5HT-2
Interaction with 5HT network
Mushroom Panaeolus
Mushroom Gynopilus Boletus manicus
Morning glory (Ipomea) Amide of d-lysergic acid Interaction with 5HT network
Ololuiqui (Rivea corymbosa) Agonist R 5HT-2
Virola (Virola calophylla) Indolealkylamins Inhibition of mono-amine oxydase
Agonist R 5HT1 and R-5HT2
Iboga (Tabernanthe iboga) Indolealkylamins Agonist of g and k-opioid R
Ibogaine Antagonist R NMDA
Cactus peyote Mescalin Agonist dopamine R,
(Iophophora Williamsi) Agonist noradrenaline
Cactus San Pedro
Scarlet sage (Saslvia divinorum) Salvinorin A Agonist of k-opioid R
Based on OFDT data (Observatoire français des drogues et toxicomanies).
J Subst Use Downloaded from informahealthcare.com by University of Montreal
For personal use only.
Prolonged hallucinations following use of Salvia divinorum 117
Overall, it appears clear that the recreational use of Salvia divinorum can result in serious
psychiatric problems in vulnerable individuals. In addition to prolonged hallucinatory
phenomena, a dissociative state involving self-destructive behaviour (self-mutilation in this
case) following use of the drug can have harmful consequences. Discussion about the legal
status of the drug in many countries should take into consideration descriptions and
comments, such as the one presented in this clinical case-study.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of the paper.
References
Babu, K. T., McCurdy, C..R., & Boyer, E..W. (2008). Opioid receptors and legal highs: Salvia divinorum and
Kratom. Clinical Toxicology, 46, 146–152.
Dalgarno, P. (2007). Subjective effects of Salvia divinorum. Journal of Psychoactive Drugs, 39, 143–149.
Dubé, G., & Fournier, C. (2006). Enquête québécoise sur le tabac, l’alcool, la drogue et le jeu chez les élèves du
secondaire, 2006. Institut de la statistique du Québec, Publications du Québec.
Gonzales, D., Riba, J., Bouso, J..C., Gomez-Jarabo, & Barbanoj, M. J. (2006). Pattern of use of Salvia divinorum
among recreational users. Drug and Alcohol Dependence, 85, 157–162.
Grundmann, O., Phipps, S. M., Zadezensky, I., & Butterweck, V. (2007). Salvia divinorum and salvitorin A: An
update on pharmacology and analytical methodology. Planta Med, 73, 1039–1046.
Hostettmann, K. (2002). Les plantes qui deviennnent des drogues, Éditions Favre.
Lange, J. E., Reed, M. B., Ketchie Croff, J. M., & Clapp, J. D. (2008). College students’ use of Salvia divinorum.
Drug and Alcohol Dependence, 94, 263–266.
Montagne, M. (2008). Drugs on the Internet. 1: Introduction and web sites on psychedelic drugs. Substance Use
and Misuse, 43: 17–25.
Nortier, E. (2007). Drogues anciennes, drogues nouvelles, pratiques actuelles (2ième partie), Psychiatric Science
and Human Neuroscience, 5, 71–88.
Observatoire français des drogues et toxicomanies (2007). Hallucinogènes: une consommation limitée mais plus
présente chez les adolescents et les jeunes adultes. Synthèse OFDT, March 2007. Available at: http://www.ofdt.fr/
ofdtdev/live/produits/hallucin/conso.html
Stahl, S. (2008). Stahl’s essential psychopharmacology. Neuroscientific basis and practical applications, 3rd edn.
Cambridge: Cambridge University Press.
Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R., & Chauncey, D. L. (1989). The Revised Diagnostic
Interview for Borderlines. Journal of Personal Disease, 3, 10–18.
J Subst Use Downloaded from informahealthcare.com by University of Montreal
For personal use only.
  • ... La possibilité d'une unité de lieu, que serait le service hospitalier permettrait d'atténuer cet écueil de prise en charge. L'avantage d'une telle interface entre service de soins pédo-psychiatrique et consultation jeune consommateurs se retrouve dans une plus grande facilité d'articulation, entre professionnels, des soins nécessitant des espaces distincts qu'il s'agisse de soins ambulatoires (la prise en charge psychiatrique, la psychothérapie ou la thérapie familiale), ou des liens avec les unités d'hospitalisations nécessaire dans les moments aigus ou en cas de passage à l'acte grave [17,18] Ce type de dispositif permet donc un travail trans-disciplinaire qui assure une fonction de contenance rassurante pour les adolescents tout en évitant certains processus de clivage inhérent à la multiplication de lieux de soins et aux difficultés de communication qui en découle. ...
    Article
    Full-text available
    Since the end of the 1990s, there is a growing use of psycho-active drugs and the rejuvenation of the concerned population in all Western countries, including France. This has led governments to implement specific public health policies to target youth addictive behaviours. Among those, young drug users’ clinics have been created by medico-social institutions and in the community. Those clinics must provide a better understanding and management of the young population and their relatives regarding drug-related problems to improve their access to an evaluation by health professionals and to adopt healthier behaviours. Here, we aimed at describing such a clinics recently opened in a University hospital. The case of a 13-year-old adolescent with severe comorbid addictive behaviours will be detailed in order to highlight the interactions with others healthcare facilities within the same setting. She presented a borderline disorder with serious self-injuries and dangerous behaviour. Despite appropriate cares, the initial management was unsuccessful without an efficient drug addiction support within the young drugs user's clinic.
  • ... According to the respondents', and especially the psychiatrists', (Table 3 ) clinical experience , the use of NPS should be considered both an important and overlooked medical risk factor, which may be especially associated with the occurrence of 329 nps: results from an italian survey aggression/psychomotor agitation. Furthermore, most interviewees (71.2%) expressed concern for the already well-known (Baggott et al., 2004; Bonta, 2004; Prisinzano, 2005; Fletcher & Honey, 2006; Schanzer et al., 2006; Rounsaville, 2007; Lange et al., 2008; Bajaj et al., 2010; Breton et al., 2010; Wood et al., 2010; Corazza et al., 2011a; Lusthof et al., 2011; Schifano et al., 2011) potential risk of occurrence of acute psychotic episodes in association with the intake of a range of NPS. In confirming previous observations (Corazza et al., 2011b ), most respondents were concerned of the lack of guidelines in terms of treatment and management of NPS misuse. ...
    Novel psychoactive substances (NPS; a.k.a. 'legal highs' or 'smart drugs') are advertised online as 'safe' and 'legal' natural/synthetic analogues of controlled illicit drugs. However, only little research has been carried out in identifying the health professionals' knowledge and expertise relating to the intake of these compounds. Data presented here refer to the Italian component of the European Union-wide, European Commission-funded, ReDNet project survey. An ad-hoc questionnaire was administered to professionals from the departments of Addiction, Psychiatry, Paediatrics and Emergency Room Services in Italy. The interviewees' sample included 243 professionals, mostly from the departments of Addiction (35%) and Psychiatry (28.4%). Overall, interviewees self-reported a poor technical knowledge relating to NPS; some 27% of respondents confirmed of not being aware if their patients presented with a previous history of NPS misuse. Novel psychoactive substances prevalence of misuse was not considered to be an unusual phenomenon in Italy, and most health professionals appeared to have concerns relating to associated medical and psychopathological risks, especially in terms of aggression/psychomotor agitation. Overall, most respondents reported the need to have better access to NPS-related reliable sources of information. Copyright © 2013 John Wiley & Sons, Ltd.
  • ... Salvinorin A has pharmacological activity consistent with other KOP agonists including aversion, inhibition of GI transit and depressant effects; sweating, tachycardia, and nausea have also been reported, among other symptoms (González et al., 2006;Vohra et al., 2011). Although extended psychotic-type reactions are uncommon they are not unknown, with several reported in published case studies (Singh, 2007;Przekop and Lee, 2009;Breton et al., 2010). Dose-response relationships have not been established as laboratories are seldom equipped to detect Salvinorin A and historical accounts are often unreliable due to the distribution of Salvia in concentrations (5×, 10×, 50×) subjectively determined by manufacturers without listed milligramme equivilants (Vohra et al., 2011). ...
    Article
    Full-text available
    Background: Salvia divinorum is a potent, naturally occurring hallucinogen gaining popularity as a recreational drug in North America. To date, detailed epidemiologic information about the use of this substance among adolescents living outside the United States has been limited. This study provides information on the prevalence and correlates of Salvia divinorum use among adolesecents in Canada using a nationally representative sample. Methods: Data were obtained from a representative sample of 42,179 Canadian adolescents aged 12-17 years living across all 10 provinces who completed the Youth Smoking Survey in 2008-09. Results: Overall, 3.8% of adolescents reported using Salvia in the past year and 6.2% had used the substance in their lifetime. A conservative estimate suggests 23.2% of youth were repeat users. Salvia use was highest among youth in British Columbia and Quebec. Comparatively, the prevalence of 12-month Salvia use was higher than 12-month cocaine and amphetamine use but lower than 12-month ecstasy, cannabis, and other hallucinogen use. Correlates of Salvia use included older age, male gender, high available spending money, binge drinking, illicit drug use and smoking in fully adjusted models. Findings suggest low self-esteem may be an important correlate specific to the use of this substance among youth. Conclusions: Salvia divinorum use is prevalent among Canadian adolescents. Salvia may be a significant public health issue in Canada given it is readily available, under limited regulation, and little is known about the abuse liability of the substance, interactions with other substances, and potential complications from use.
  • ... Although reported effects of SD appear brief and range from laughter to depersonalization (González et al. 2006), a few reports raise the question of possibly persisting neuropsychiatric effects (i.e. paranoia, psychosis) (Breton et al. 2010; Paulzen and Grunder 2008; Przekop and Lee 2009). One case report of paranoia and cognitive impairment sometimes attributed to SD appears to have been caused by marijuana, illustrating the difficulties of defining psychoactive effects without controlled trials (Singh 2007). ...
    Article
    Full-text available
    Salvinorin A (SA) is a highly selective kappa opioid receptor agonist and the putative psychoactive compound in Salvia divinorum (SD), an increasingly abused hallucinogenic plant. The objectives of this study were to characterize the physiological and subjective effects of SA versus placebo and measure drug and metabolite levels. Sublingual SA doses up to 4 mg were administered in dimethyl sulfoxide/polyethylene glycol 400 solution to eight SD-experienced subjects using a placebo-controlled ascending-dose design. No dose of SA produced significantly greater physiological or subjective effects than placebo. Furthermore, effects did not resemble reported "typical" effects of smoked SD. SA was detectable in plasma and urine, but was, in most cases, below the reliable limit of quantification (0.5 ng/mL). Our results suggest that the sublingual bioavailability of SA is low. Higher doses, alternate formulations, or alternate routes of administration will be necessary to study the effects of SA in humans.
  • Article
    Full-text available
    Background. The recent emergence of new recreational drugs, combined with the ability of the Internet to disseminate information quickly, have raised a number of concerns in the fields of drug policy, substance use research, and public health. Methods. A semi-structured questionnaire was advertised on The Study Room's website from November to December 2010 to explore the awareness, the use and the perception of risks of "legal highs" among student population in the UK. Results. One-third (31.40%) of the 446 participants reported use of these kinds of drugs. Respondents were more likely to have taken were: mephedrone (41.4%), Salvia divinorum (20%), "Spice drugs" (10.7%), methylone (1.4%), naphyrone (NRG) (2.1%) and benzylpiperazine (BZP) (2.1%), while 15.7% did not know what compounds they had ever consumed. The large majority (78.9%) considered these as legal substances, while 74.2% did not consider these safer than illicit drugs. Half (50.8%) of the respondents were aware of the presence of illegal agents in the products they had consumed. Conclusions. The study contributes to an initial assessment of the use and the risks awareness of novel psychoactive compounds among students in the UK. Further research is required, especially in terms of personality and lifestyle attitudes to better profile these new forms of abuse also in non-recreational settings.
  • Article
    Full-text available
    CONTEXT: Media and scientific reports have indicated an increase in recreational use of Salvia divinorum. Epidemiological data are lacking on the trends, prevalence, and correlates of S. divinorum use in large representative samples, as well as the extent of substance use and mental health problems among S. divinorum users. OBJECTIVE: To examine the national trend in prevalence of S. divinorum use and to identify sociodemographic, behavioral, mental health, and substance-use profiles of recent (past-year) and former users of S. divinorum. DESIGN: Analyses of public-use data files from the 2006-2008 United States National Surveys on Drug Use and Health (N = 166,453). SETTING: Noninstitutionalized individuals aged 12 years or older were interviewed in their places of residence. MAIN MEASURES: Substance use, S. divinorum, self-reported substance use disorders, criminality, depression, and mental health treatment were assessed by standardized survey questions administered by the audio computer-assisted self-interviewing method. RESULTS: Among survey respondents, lifetime prevalence of S. divinorum use had increased from 0.7% in 2006 to 1.3% in 2008 (an 83% increase). S. divinorum use was associated with ages 18-25 years, male gender, white or multiple race, residence of large metropolitan areas, arrests for criminal activities, and depression. S. divinorum use was particularly common among recent drug users, including users of lysergic acid diethylamide (53.7%), ecstasy (30.1%), heroin (24.2%), phencyclidine (22.4%), and cocaine (17.5%). Adjusted multinomial logistic analyses indicated polydrug use as the strongest determinant for recent and former S. divinorum use. An estimated 43.0% of past-year S. divinorum users and 28.9% of former S. divinorum users had an illicit or nonmedical drug-use disorder compared with 2.5% of nonusers. Adjusted logistic regression analyses showed that recent and former S. divinorum users had greater odds of having past-year depression and a substance-use disorder (alcohol or drugs) than past-year alcohol or drug users who did not use S. divinorum. CONCLUSION: S. divinorum use is prevalent among recent or active drug users who have used other hallucinogens or stimulants. The high prevalence of substance use disorders among recent S. divinorum users emphasizes the need to study health risks of drug interactions.
  • Article
    Salvia divinorum is a member of the Lamiaceae family and contains the psychotropic diterpene and kappa-opioid receptor agonist salvinorin-A. Originally a shamanic inebriant used by the Mexican Mazatec Indians, the plant and its preparations are becoming increasingly popular among non-traditional users. Demographic data and information on pattern of use and subjective effects were obtained by means of self-report questionnaires from a sample of 32 recreational users of salvia and other psychedelics. Involvement with salvia appeared to be a recent phenomenon. Smoking the extract was the preferred form of administration. Subjective effects were described as intense but short-lived, appearing in less than 1 min and lasting 15 min or less. They included psychedelic-like changes in visual perception, mood and somatic sensations, and importantly, a highly modified perception of external reality and the self, leading to a decreased ability to interact with oneself or with one's surroundings. Although some aspects of the subjective effects reported were similar to high doses of classical psychedelics with serotonin-2A receptor agonist activity, the intense derealization and impairment reported appear to be a characteristic of salvia. The observed simultaneous high scores on the LSD and PCAG subscales of the Addiction Research Center Inventory (ARCI) have been previously reported for other kappa-opioid agonists, and support kappa receptor activation as the probable pharmacologic mechanism underlying the modified state of awareness induced by salvia.
  • Article
    The Diagnostic Interview for Borderlines (DIB) was revised to sharpen its ability to discriminate between clinically diagnosed borderline patients and patients with other types of Axis II clinical diagnoses. The discriminant power of both the revised DIB (DIB-R) and the DIB itself was then tested in a sample of 237 inpatients and outpatients given an Axis II diagnosis by their therapists. The DIB-R was administered blind to clinical diagnosis, while a DIB score was independently derived from DIB-R and other data using a predetermined scoring algorithm. At a cutoff of 8, the DIB-R had a sensitivity of .82, a specificity of .80, a positive predictive power of .74, and a negative predictive power of .87. Overall, these conditional probabilities compare favorably to those obtained for the DIB at its standard cutoff of 7: sensitivity = .97, specificity = .27, positive predictive power = .47, and negative predictive power = .93. They also compare favorably with those obtained in studies that used semistructured or self-report instruments based on DSM-III or DSM-III-R criteria for BPD.
  • Article
    When humans departed from their simian cousins, endowed with a large frontal brain capable of planning and self-reference in the arid savannah, they walked away from the shaded calm of the fruit trees on two feet to encounter a troubling world of new dangers and uncertainties. From that point forward, humans have created gods, myths, language and war and sought out magical plants to relieve suffering and anguish, escape the imprisoning world, and find the courage to confront it. For millennia, drugs have been a part of sacred, magical and medicinal knowledge. All medical psychopharmacology is based on the same foundation underpinning that “primitive” psychopharmacology, and the technological and scientific revolution of the nineteenth century, which made it possible to isolate active ingredients and synthesize new molecules, set the stage for the emergence of varied routes of administration, expanded by the circulation of people, goods and information on a planetary scale. Today, this mass consumption and trafficking, and the profits they generate, are resulting in major public health challenges in modern societies, as well as serious sociopolitical and economic problems. From an evolutionary perspective, pure psychoactive drugs and the direct means of administering them are recent phenomena and pathogenic in that they short-circuit adaptive processes by acting directly on the circuits of the primitive brain, which controls emotions and basic survival behaviour. This development and the use of cocktails of psychoactive drugs suggest an evolution toward the true chemical regulation of existence. After having previously discussed tranquilizers and psychostimulants (part one), this second part will describe the vast world of psychodysleptic drugs. Acting more on psychological processes expressed in “digital” mode, they disrupt self-awareness, perceptual categories, and analogic memories. Sometimes truly psychotogenic, they increasingly result in psychiatric complications, particularly troublesome in certain patients who are probably genetically predisposed.
  • Article
    Full-text available
    Salvia divinorum L. (Lamiaceae) has been used for centuries by the Mazatecan culture and has gained popularity as a recreational drug in recent years. Its potent hallucinogenic effects seen in case reports has triggered research and led to the discovery of the first highly selective non-nitrogenous κ opioid receptor agonist salvinorin A. This review critically evaluates the reported pharmacological and toxicological properties of S. divinorum and one of its major compounds salvinorin A, its pharmacokinetic profile, and the analytical methods developed so far for its detection and quantification. Recent research puts a strong emphasis on salvinorin A, which has been shown to be a selective opioid antagonist and is believed to have further beneficial properties, rather than the leaf extract of S. divinorum. Currently animal studies show a rapid onset of action and short distribution and elimination half-lives as well as a lack of evidence of short- or long-term toxicity. Salvinorin A seems to be the most promising approach to new treatment options for a variety of CNS illnesses. However, many further investigations are necessary to fully understand and elucidate the various medicinal properties of the plant itself and to provide the legislative authorities with enough information to cast judgement on S. divinorum. Abbreviations CNS: central nervous system FST: forced swimming test i. t.: intrathecal KOR: kappa opioid receptor LSD: lysergic acid diethylamide norBNI: norbinaltorphimine p. o.: per os s. c.: subcutaneous ssp.: subspecies
  • Article
    Salvia divinorum is a hallucinogenic plant native to Mexico, where the Mazatec Indians use it in divinatory rituals as a facilitator for contacting the spirits of the dead. A number of traditions surrounding the ritualistic use of Salvia are still observed. Generally the leaves are chewed for the visionary effects. Salvia has recently been embraced by Western drug cultures, where the traditional methods of ingestion are generally eschewed for the more immediately effective technique of smoking the dried leaves. This article discusses the history and indigenous cultural uses of Salvia before outlining its rediscovery in the 1960s and its subsequent introduction to the Western drug scenes (particularly Britain) since the mid 1990s. Qualitative data from 10 Salvia users were collected by means of email interviews. The participants were asked to provide as in-depth responses as possible. No time or space limit on answers was imposed. Their responses to each question are presented verbatim. The effects of Salvia appear to vary between users and seem sensitive to situational factors. Users who understand something of the ritualistic setting for traditional use would appear to have a fuller experience than those who do not.
  • Article
    Salvia divinorum (salvia) is a plant that appears to be enjoying increased popularity as a legal hallucinogen in many U.S. jurisdictions. While the popular press has claimed that its use has become widespread, there have been no epidemiological studies published documenting this within the U.S. A sample of college students was randomly drawn from a large public university in the southwestern U.S. and invited to participate in an online survey that included salvia use among a set of other drug use items. From the sample of 1516 college student respondents, a pattern of use emerged that indicates that salvia is indeed becoming a significant member of the list of drugs used, with 4.4% of students reporting using salvia at least once within the past 12 months. Subpopulations that are typically most at risk for drug use within college students (Whites, males, fraternity members, heavy episodic drinkers) also were most likely to use salvia. The results indicate that more research is needed to determine the generalizability of these findings, and identify whether there are any negative consequences experienced either by the user or the community associated with this drug.
  • Article
    The Internet has greatly expanded access to information about all types of drugs. Web sites devoted to psychedelic drugs are proliferating. These sites vary considerably in terms of the quality and objectivity of information, financial support (non-profit vs. commercial), ideological stance, and the identification of creators and maintainers. Representative sites are reviewed and assessed on criteria of credibility and quality.
  • Article
    Salvia divinorum and Mitragyna speciosa ("Kratom"), two unscheduled dietary supplements whose active agents are opioid receptor agonists, have discrete psychoactive effects that have contributed to their increasing popularity. Salvia divinorum contains the highly selective kappa- opioid receptor agonist salvinorin A; this compound produces visual hallucinations and synesthesia. Mitragynine, the major alkaloid identified from Kratom, has been reported as a partial opioid agonist producing similar effects to morphine. An interesting minor alkaloid of Kratom, 7-hydroxymitragynine, has been reported to be more potent than morphine. Both Kratom alkaloids are reported to activate supraspinal mu- and delta- opioid receptors, explaining their use by chronic narcotics users to ameliorate opioid withdrawal symptoms. Despite their widespread Internet availability, use of Salvia divinorum and Kratom represents an emerging trend that escapes traditional methods of toxicologic monitoring. The purpose of this article is to familiarize toxicologists and poison control specialists with these emerging psychoactive dietary supplements.