Peyote and mescaline exposures: A 12-year review of a statewide poison center database

Abstract

Peyote, a cactus containing the hallucinogen mescaline, has been used by Native Americans for thousands of years. Illicit use is also known to occur, but reports in the medical literature consist only of isolated case reports.
We sought to identify characteristics of patients with reported exposure to peyote or mescaline.
We performed a retrospective review of the California Poison Control System database for the years 1997-2008 for all cases of single-substance human exposure using the search terms "peyote" and "mescaline."
There were a total of 31 single-substance exposures to peyote or mescaline. Thirty (97%) exposures were intentional; 30 (97%) exposures were through the oral route, whereas one patient (3%) insufflated mescaline powder. Five patients (16%) were managed at home, whereas the remainder patients were managed in a healthcare facility. Commonly reported effects included hallucinations, tachycardia, agitation, and mydriasis. Vomiting was reported in only one case.
Although uncommonly encountered, use of peyote and mescaline was associated with clinically significant effects requiring treatment in a substantial number of patients. Clinical effects were usually mild or moderate, and life-threatening toxicity was not reported in this case series.

Full text

Clinical Toxicology (2010) Early Online, 1–4
Copyright © Informa UK, Ltd.
ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.3109/15563650903586745
LCLT
ARTICLE
Peyote and mescaline exposures: a 12-year review of a statewide
poison center database
Peyote and mescaline exposures
SHAUN D. CARSTAIRS1,2 and F. LEE CANTRELL3
1Department of Emergency Medicine, Division of Medical Toxicology, University of California San Diego, San Diego, CA, USA
2Department of Emergency Medicine, Naval Medical Center, San Diego, CA, USA
3California Poison Control System – San Diego Division, San Diego, CA, USA
Background. Peyote, a cactus containing the hallucinogen mescaline, has been used by Native Americans for thousands of years. Illicit use
is also known to occur, but reports in the medical literature consist only of isolated case reports. Objectives. We sought to identify
characteristics of patients with reported exposure to peyote or mescaline. Methods. We performed a retrospective review of the
California Poison Control System database for the years 1997–2008 for all cases of single-substance human exposure using the search
terms “peyote” and “mescaline.” Results. There were a total of 31 single-substance exposures to peyote or mescaline. Thirty (97%)
exposures were intentional; 30 (97%) exposures were through the oral route, whereas one patient (3%) insufflated mescaline powder. Five
patients (16%) were managed at home, whereas the remainder patients were managed in a healthcare facility. Commonly reported effects
included hallucinations, tachycardia, agitation, and mydriasis. Vomiting was reported in only one case. Conclusions. Although
uncommonly encountered, use of peyote and mescaline was associated with clinically significant effects requiring treatment in a substantial
number of patients. Clinical effects were usually mild or moderate, and life-threatening toxicity was not reported in this case series.
Keywords Toxic plants; Hallucinations; Acute poisoning; Poison control centers
Introduction
Peyote (Lophophora williamsii) is a cactus containing the
hallucinogen mescaline [2-(3,4,5-trimethoxyphenyl)etha-
namine] and is found primarily in the southwestern United
States and northern Mexico. The dried tops of the cactus, also
known as “buttons,” have been used for centuries by Native
Americans in religious ceremonies and for the treatment of
various physical ailments.1 Use of peyote is currently illegal
in the United States, although an exception has been granted
for religious use through the Native American Church.
Although illicit use has been well described in nonscientific
sources,2 there are currently no published case series of illicit
exposure to peyote in the medical literature. We sought to
characterize the clinical symptoms of patients who contacted
a poison control center with reported exposures to peyote and
mescaline.
Methods
The University of California-San Diego Institutional Review
Board approved this retrospective observational case series.
A retrospective chart review of the California Poison Control
System (CPCS) electronic database (Visual Dotlab, Madera,
CA, USA) for cases between the years 1997 and 2008 was
performed (standardized data collection in California using
this system began in 1997). Search codes included the terms
“peyote” and “mescaline”; to ensure all cases were identified,
the database was searched both by substance coding and
within free text of the cases. Cases were assessed by the
principal investigator only after the removal of all patient
identifiers. Inclusion criteria included patients of any age
with reported single-substance exposures to peyote or mesca-
line and follow-up to a known outcome. Exclusion criteria
included history of any coingestants and inability to follow
the patient to a known outcome.
Descriptive data collected included date of exposure, age,
gender, dosage form, symptoms, duration of clinical effects,
site of exposure, whether exposure was intentional or unin-
tentional, management site, treatment administered, length of
symptoms, and clinical outcome. Tachycardia was defined as
a heart rate >100 beats per minute (bpm) or the presence of
the term “tachycardia” in the free text of the case. Hyperten-
sion was defined as a systolic blood pressure >140 mmHg or
diastolic blood pressure >90 mmHg or the presence of the
Received 28 October 2009; accepted 23 December 2009.
Data from this study were originally presented in poster form at
the 2009 North American Congress of Clinical Toxicology, San
Antonio, TX, September 2009.
Address correspondence to Shaun D. Carstairs, Department of
Emergency Medicine, Division of Medical Toxicology, University
of California San Diego, 200 W. Arbor Drive, MC 8925, San Diego,
CA 92103, USA. E-mail: shaunc@yahoo.com
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2S.D. Carstairs and F.L. Cantrell
term “hypertension” in the free text of the case. Outcomes
were coded as “no effect,” “minor effect,” “moderate effect,”
“major effect,” or “death” according to the criteria set forth
by the American Association of Poison Control Centers.3
Coded outcomes were verified by the principal investigator to
assure that selected outcomes followed the American Associ-
ation of Poison Control Centers criteria. All data abstracted
were transcribed into a standardized Microsoft Excel 2008
for Mac (Microsoft, Redmond, WA, USA) spreadsheet.
Results
A total of 31 cases of peyote and mescaline exposure meeting
inclusion criteria were reported to the CPCS between 1997
and 2008 (Table 1). Twenty-six patients (84%) were male.
Patient ages ranged from 14 to 59 years with a mean of
23 years and median of 21 years; 26 (84%) were 25 years or
less. Thirty (97%) exposures were intentional. One patient
(patient no. 13) was a 21-year-old female who reportedly
ingested an unknown number of peyote buttons that had been
surreptitiously placed in her food. She was presented to an
emergency department (ED) with a heart rate of 150 bpm and
was given activated charcoal; she was discharged several
hours later.
Thirty (97%) exposures were through the oral route: 23
(74%) ingested plant material; 6 (19%) boiled peyote buttons
and drank the resulting tea; and 1 (3%) ingested a tablet con-
taining mescaline. One patient (3%) insufflated mescaline
powder (patient no. 18): in that case, an 18-year-old female
was presented to an ED 6 h after exposure; she complained
of hallucinations and was noted to have tachycardia and
Table 1. Characteristics of patients exposed to peyote and mescaline
Patient
no.
Age
(years)/
gender Dosage form Tachycardia Agitation Hallucinations Mydriasis Vomiting
Other
symptoms
Treatment
site Treatment
125 MTea −+−−−HTN,
paranoia
ICU INT, IVF, BZD
2 20 M Plant + + −−− ICU BZD, DRO
3 17 M Plant + −+−− ICU BZD
4 15 M Plant + + + + −Psychosis Ward IVF, BZD
5 17 F Plant + + + + −Psychosis Ward IVF, BZD
6 22 M Plant + + −−−Seizure Ward AC
716 MTea + + −−−HTN Ward
8 22 M Plant + −++−Nausea ED IVF, BZD
9 15 M Plant −− +−− ED IVF, BZD
10 21 M Tea −− − −−AMS ED IVF, AC
11 24 M Plant + + + + −ED IVF
12 19 M Tea + −++−ED AC
13 21 F Plant + −− −− ED AC
14 17 M Plant + −++−ED
15 44 M Plant −− +−− ED
16 16 M Plant + −+−− ED
17 14 M Plant −− +−− ED
18 18 F Mescaline
insufflation
+−+−− ED
19 30 M Plant −− +−− ED
20 23 M Plant −+−−− ED
21 23 M Mescaline
tablet
++ + +−HTN ED
22 22 M Plant + + + + −Nausea ED
23 41 M Plant −+−−−Paranoia ED
24 59 F Plant + −− −− ED
25 17 M Plant −− − +−ED
26 17 M Tea −− − −−AMS ED
27 16 M Tea −− +−− Home
28 26 F Plant −− +−− Home
29 25 M Plant −− − −+ Home
30 23 M Plant −− +−− Home
31 25 M Plant −− − −− Home
M, male; F, female; AMS, altered mental status; HTN, hypertension; INT, intubation; IVF, intravenous fluids; BZD, benzodiazepine; AC, activate
d
charcoal; DRO, droperidol; (+), present; (–), not present or not reported.
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Peyote and mescaline exposures 3
nystagmus. She was treated supportively and was eventually
discharged home from the ED.
The most frequently reported effect was the presence of
hallucinations, which occurred in 18 patients (58%). Tachy-
cardia was also commonly reported, occurring in 16 patients
(52%). Of those 16 patients, 12 had a documented heart rate
demonstrating tachycardia, ranging from 101 to 190 bpm
(mean 127 bpm, median 120 bpm). One patient (patient no.
6) was reported as having experienced a seizure at home after
ingestion of peyote; evaluation in the ED (including com-
puted tomography of the head) was normal and he was admit-
ted to the hospital overnight.
Five patients (16%) were managed at home; one of these
patients was referred to an ED but declined to be evaluated.
The remaining patients (n = 26) were evaluated in the ED
with hospitalization occurring in seven patients [ICU (n = 3)
or inpatient ward (n = 4)]. Therapies administered included
benzodiazepines (n = 7), intravenous fluids (n = 7), activated
charcoal (n = 4), and droperidol (n = 1). One patient (patient
no. 1) underwent endotracheal intubation after being found
drooling and unconscious several hours after boiling peyote
buttons and drinking the tea; he was extubated the following
morning and was subsequently discharged.
Outcomes were as follows: no effect, n = 1 (3.2%); minor,
n = 9 (29.0%); moderate, n = 20 (64.5%); major, n = 1
(3.2%). No deaths occurred. Symptoms lasted <24 h in all
patients with the exception of one case (patient no. 7): a 16-
year-old male boiled an unknown number of peyote buttons
and drank the resulting tea; he presented with tachycardia,
hypertension, and agitation and was hospitalized for 3 days
before his symptoms resolved.
Discussion
Native Americans have used peyote for centuries, not only
for its hallucinogenic effects but also for its purported
medicinal effects. Lumholtz in 1903 described its use in the
treatment of snakebites, burns, wounds, and rheumatism.4 It
has also been used for the treatment of toothache, fever, scor-
pion stings, arrow wounds, and for “strength in walking.”1,5
Although it is classified as a Schedule I substance by the U.S.
Drug Enforcement Administration and is therefore illegal for
general use, a specific exemption has been granted for its use
by members of the Native American Church for “bona fide
traditional ceremonial purposes”6 and has been used with
apparent safety for many years within this group.7 Serious
effects from peyote ingestion have been described only rarely
and include Mallory–Weiss lacerations from severe vomiting8
and botulism from ingestion of improperly stored peyote
buttons.9
Mescaline, the primary active component in peyote (and
which is also found in the San Pedro cactus, Echinopsis pach-
anoi, and the Peruvian Torch cactus, Echinopsis peruviana),
is a phenethylamine derivative and, as such, would be expected
to cause symptoms consistent with a sympathomimetic
toxidrome. In this case series, symptoms of sympathetic
excess including tachycardia, agitation, and mydriasis were
seen in a substantial number of patients. Hallucinations were
also noted in a majority of patients. The methoxy side chains
are likely responsible for mescaline’s hallucinogenic effects
and are found in similar compounds that are known halluci-
nogens, including 2,5-dimethoxy-4-methylphenylisopropy-
lamine (also known as STP or DOM), a “designer” street
drug.10 The addition of other methoxy groups has been
shown to increase the hallucinogenic properties of mescaline
analogs.11
Exposures to peyote reported to poison control centers are
uncommon compared to those of other drugs of abuse such as
marijuana, amphetamines, and cocaine. In 2007, a total of
116 peyote/mescaline exposures were reported to U.S. poison
control centers out of more than 2.8 million total reported
exposures, accounting for 0.004% of all exposures.3 Of those,
31 (27%) were intentional exposures. A total of 32 patients
(28%) were treated in a healthcare facility; no major effects
and no deaths were reported. Additionally, among youths
aged 12–17, lifetime prevalence of peyote and mescaline use
has been reported to be significantly less (0.4 and 0.3%,
respectively) than that of other hallucinogens including
ecstasy (3.2%), LSD (3.1%), or psilocybin-containing
mushrooms (2.1%).12
In this case series, the vast majority of exposures
occurred in adolescents and young adults, which is in
accord with other common drugs of abuse. Life-threatening
symptoms did not occur and most cases of peyote exposure
were associated with mild or moderate clinical effects, with
tachycardia and CNS effects most frequently seen. The
duration of symptoms in almost all cases was <24 h. Most
patients treated in a healthcare facility typically did not
require anything more than sedation and supportive
measures.
One of the most interesting findings in our study was the
lack of reported vomiting in patients ingesting peyote. Vom-
iting has frequently been associated with peyote ingestion.2
The reason for this is not entirely clear but is likely because
of the very bitter taste of the plant5 rather than the active sub-
stance, mescaline. Indeed, a volunteer study in which sub-
jects were administered synthetic mescaline did not describe
vomiting in any participants.13 Several methods have been
described for reducing emesis by mixing the plant material
with fruit juices or gelatin or by pulverizing the buttons and
placing the powder into gelatin capsules.1 Whether any of
these methods were employed by our study subjects is
unclear.
Our study has several limitations. This was a retrospective
study, which limits the amount of data that we were able to
retrieve from each case. Some symptoms (such as vomiting)
may have been present but were not reported to CPCS, and
our frequency of clinical effects may not represent actual fre-
quency of effects. Our study likely did not capture all cases of
peyote exposures evaluated in a healthcare facility, given that
reporting of such cases by healthcare practitioners to CPCS is
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4S.D. Carstairs and F.L. Cantrell
voluntary. Additionally, confirmation of exposure in all cases
was not possible because assays for measurement of plasma
mescaline levels are not widely available. We also could not
exclude the possibility of coingestants that may have contrib-
uted to the patients’ symptoms.
Conclusions
Although uncommonly reported, peyote and mescaline use
was associated with clinically significant effects and hospital
evaluation in a substantial number of patients reported to a
poison control center. Most exposures occurred in adoles-
cent and young adult males. Vomiting, which has been
anecdotally described in peyote intoxication, was not
encountered in the majority of patients in this series, and its
absence should therefore not be used to rule out peyote
intoxication. Most peyote intoxications appear to be mild in
nature and are unlikely to produce life-threatening
symptoms.
Declaration of interest
The views expressed in this article are those of the authors
and do not reflect the official policy or position of the
Department of the Navy, Department of Defense, or the
United States Government.
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