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
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