Laboratory Studies

Testing directed at confirming exposure to a hallucinogenic substance is rarely useful. Treatment is symptom guided and results of confirmatory testing are not rapidly available.

The urine drug screen (UDS) may be misleading when used to diagnose the cause of presenting clinical features. The UDS is limited and often does not contain a screen for common hallucinogens. In addition, false-positive and false-negative results are common with the typical UDS immunoassay (eg, diphenhydramine, dextromethorphan, and venlafaxine have been reported to cause a false-positive phencyclidine screen).^{[32, 33]}Finally, even a true-positive UDS result does not always identify the cause of a patient's current presentation; for example, the UDS could be positive for phencyclidine because the patient took it 3 days ago.

Laboratory tests such as basic metabolic profiles, blood gases, hormonal concentrations (thyroid-stimulating hormone, cortisol), and creatine kinase can be used to identify complications from hallucinogens and exclude alternative causes of altered mental status (eg, acid-base disturbances, metabolic and endocrine pathology, electrolyte abnormalities, rhabdomyolysis, renal failure, or stroke).

When exposure confirmation is necessary (ie, forensic cases, research purposes) expanded drug testing can be performed using specialized immunoassays, liquid chromatography and mass spectrometry, or a variety of other methods which are available through specialized reference laboratories.

Imaging Studies

Imaging is rarely useful in evaluating the effects of hallucinogen exposure. However, advanced imaging, including computed tomography or magnetic resonance imaging of the brain, can be useful in identifying complications and clinical disorders often associated with recreational hallucinogen use, including trauma, infection, hyperthermia, and hypertensive crisis.

Treatment & Management

Hill SL, Thomas SH. Clinical toxicology of newer recreational drugs. Clin Toxicol (Phila). October 2011. 49:705-719. [QxMD MEDLINE Link].
Al-Mugahed L. Khat chewing in Yemen: turning over a new leaf. Bull World Health Organ. 2008 Oct. 86(10):741-2. [QxMD MEDLINE Link]. [Full Text].
White, William. The DXM Experience. Erowid.org. Available at https://www.erowid.org/chemicals/dxm/faq/dxm_experience.shtml. Accessed: January 16, 2021.
EcstasyData.org. Available at http://www.ecstasydata.org. Accessed: January 16, 2021.
Hastings, D. "New drug N-bomb hits the street, terrifying parents, troubling cops.". New York Daily News. May 7, 2013. Available at http://www.nydailynews.com/news/national/new-synthetic-hallucinogen-n-bomb-killing-users-cops-article-1.1336327.
Rutherford RS, Polkis JL and Polkis A. "A case of 25I-NBOMe (25-I) intoxication: a new potent 5-HT2A agonist designer drug.". Clinical Toxicology. March 2013. 51(3):174-77.
Sangalli BC, Chiang W. Toxicology of nutmeg abuse. J Toxicol Clin Toxicol. 2000. 38 (6):671-8. [QxMD MEDLINE Link].
Lundberg GD, Gupta RC, Montgomery SH. Phencyclidine: patterns seen in street drug analysis. Clin Toxicol. 1976. 9 (4):503-11. [QxMD MEDLINE Link].
Shulgin AT, MacLean DE. Illicit synthesis of phencyclidine (PCP) and several of its analogs. Clin Toxicology. 9(4):553-560. [QxMD MEDLINE Link].
Jennings PA, Cameron P, Bernard S. Ketamine as an analgesic in the pre-hospital setting: a systematic review. Acta Anaesthesiol Scand. 2011 Jul. 55 (6):638-43. [QxMD MEDLINE Link].
Burnett AM, Salzman JG, Griffith KR, Kroeger B, Frascone RJ. The emergency department experience with prehospital ketamine: a case series of 13 patients. Prehosp Emerg Care. 2012 Oct-Dec. 16 (4):553-9. [QxMD MEDLINE Link].
Andrade C. Ketamine for Depression, 2: Diagnostic and Contextual Indications. J Clin Psychiatry. 2017 May. 78 (5):e555-e558. [QxMD MEDLINE Link]. [Full Text].
Matveychuk D, Thomas RK, Swainson J, Khullar A, MacKay MA, Baker GB, et al. Ketamine as an antidepressant: overview of its mechanisms of action and potential predictive biomarkers. Ther Adv Psychopharmacol. 2020. 10:2045125320916657. [QxMD MEDLINE Link]. [Full Text].
FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor’s office or clinic. U.S. Food & Drug Administration. Available at https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified. March 05, 2019; Accessed: January 29, 2021.
Parks KA, Kennedy CL. Club drugs: reasons for and consequences of use. J Psychoactive Drugs. 2004 Sep. 36 (3):295-302. [QxMD MEDLINE Link].
Tylš F, Páleníček T, Horáček J. Psilocybin--summary of knowledge and new perspectives. Eur Neuropsychopharmacol. 2014 Mar. 24 (3):342-56. [QxMD MEDLINE Link].
Ross S. Therapeutic use of classic psychedelics to treat cancer-related psychiatric distress. Int Rev Psychiatry. 2018 Aug 13. 1-14. [QxMD MEDLINE Link].
Yan F, Roth BL. Salvinorin A: a novel and highly selective kappa-opioid receptor agonist. Life Sci. 2004 Oct 15. 75(22):2615-9. [QxMD MEDLINE Link].
Bücheler R, Gleiter CH, Schwoerer P, Gaertner I. Use of nonprohibited hallucinogenic plants: increasing relevance for public health? A case report and literature review on the consumption of Salvia divinorum (Diviner's Sage). Pharmacopsychiatry. 2005 Jan. 38(1):1-5. [QxMD MEDLINE Link].
Drug Enforcement Administration Office of Diversion Control Drug & Chemical Evaluation Section. Salvia Divinorum and Salvinorin A. www.deadiversion.usdoj.gov. Available at http://www.deadiversion.usdoj.gov/drug_chem_info/salvia_d.pdf. March 2020; Accessed: January 16, 2021.
Capela JP, Carmo H, Remião F, Bastos ML, Meisel A, Carvalho F. Molecular and cellular mechanisms of ecstasy-induced neurotoxicity: an overview. Mol Neurobiol. 2009 Jun. 39(3):210-71. [QxMD MEDLINE Link]. [Full Text].
Every-Palmer S. Synthetic cannabinoid JWH-018 and psychosis: an explorative study. Drug Alcohol Depend. 2011 Sep 1. 117(2-3):152-7. [QxMD MEDLINE Link]. [Full Text].
Hill SL, Thomas SH. Clinical toxicology of newer recreational drugs. Clin Toxicol (Phila). 2011 Oct. 49(8):705-19. [QxMD MEDLINE Link].
Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2020. [Full Text].
Riederer AM, Campleman SL, Carlson RG, Boyer EW, Manini AF, Wax PM, et al. Acute Poisonings from Synthetic Cannabinoids - 50 U.S. Toxicology Investigators Consortium Registry Sites, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Jul 15. 65 (27):692-5. [QxMD MEDLINE Link]. [Full Text].
Centers for Disease Control and Prevention. Outbreak of Life-threatening Coagulopathy Associated with Synthetic Cannabinoids Use. CDC. Available at https://emergency.cdc.gov/han/han00410.asp. May 25, 2018; Accessed: January 16, 2021.
Brooks M. Severe Bleeding Tied to Synthetic Cannabinoids, CDC Warns. Medscape Medical News. Available at https://www.medscape.com/viewarticle/897268. May 25, 2018; Accessed: January 16, 2021.
Australian Institute of Health and Welfare. 2013 National Drug Strategy Household Survey report. Australian Institute of Health and Welfare. Available at http://www.aihw.gov.au/publication-detail/?id=60129549469. 25 Nov 2014; Accessed: January 16, 2021.
European Monitoring Centre for Drugs and Drug Addiction. European Drug Report 2020: Trends and Developments. Luxembourg: Publications Office of the European Union; 2020. [Full Text].
Substance Abuse & Mental Health Services Administration. The 2019 NSDUH Detailed Tables. United States Department of Health and Human Services. Available at https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables. 2020; Accessed: January 16, 2021.
Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 30. 65 (50-51):1445-1452. [QxMD MEDLINE Link]. [Full Text].
Sena SF, Kazimi S, Wu AH. False-positive phencyclidine immunoassay results caused by venlafaxine and O-desmethylvenlafaxine. Clin Chem. 2002. 48(4):676-7. [QxMD MEDLINE Link].
Rengarajan A, Mullins ME. How often do false-positive phencyclidine urine screens occur with use of common medications?. Clin Toxicol (Phila). 2013 Jul. 51(6):493-6. [QxMD MEDLINE Link].
O’Halloran RL, Lewman LV. Restraint Asphyxiation in Excited Delirium. American Journal of Forensic Medicine and Pathology. 1993. 14(4):289-295. [QxMD MEDLINE Link].
Stratton SJ, Rogers C, Brickett K, Gruzinski. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med. 2001. 19(3):187-191. [QxMD MEDLINE Link].
Ho JD, Smith SW, Nystrom PC, Dawes DM, Orozco BS, Cole JB, et al. Successful management of excited delirium syndrome with pre-hospital ketamine: two case examples. Prehosp Emerg Care. 2013. 16(4):274-9. [QxMD MEDLINE Link].
Burnett AM, Salzman JG, Griffith KR, Kroeger BK, Frascone RJ. The emergency department experience with pre-hospital ketamine: a case series of 13 patients. Prehosp Emerg Care. 2012. 16(4):553-9. [QxMD MEDLINE Link].
Mayberg TS, Lam AM, Matta BF, et al. Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in patients undergoing craniotomy. Anesth Analg. 1995. 81:84-9. [QxMD MEDLINE Link].
Bar-Joseph G, Guilburd Y, Tamir A, et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009. 4:40-6. [QxMD MEDLINE Link].
Bourgoin A, Albanese J, Wereszczynski N, et al. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003. 31:711-7. [QxMD MEDLINE Link].
Himmelseher S, Durieux ME. Revising a dogma: ketamine for patients with neurological injury?. Anesth Analg. 2005 Aug. 101(2):524-34, table of contents. [QxMD MEDLINE Link].
Ballow SL, Kaups KL, Anderson S, Chang M. A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients. J Trauma Acute Care Surg. 2012 Dec. 73(6):1401-5. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Joseph L D'Orazio, MD, FAAEM, FACMT Director, Division of Medical Toxicology, Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University; Consulting Staff in Medical Toxicology, Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia

Joseph L D'Orazio, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Bassett, DO, FAAEM Fellow in Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center; Clinical Assistant Professor of Emergency Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Robert Bassett, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

William J Boroughf, DO Fellow in Medical Toxicology, Attending Physician, Department of Emergency Medicine, Einstein Medical Center

William J Boroughf, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.