LSD

Lysergic acid diethylamide (LSD), or acid, is the most potent psychoactive drug. Doses of 1 to 1.5 µg/kg produce psychedelic effects. The typical dose taken for an acid “trip” is approximately 25 to 100 µg. LSD is sold in tablets (microdots), liquid, powder, gelatin squares (window panes), and “blotter” acid. Sheets of blotting paper are sprayed with LSD, dried, and perforated into small squares. Graphics are incorporated onto the blotting paper in designs that include cartoon characters (e.g., Felix the Cat) and geometric designs (Fig. 156-1). Each sheet is composed of hundreds of squares that are placed sublingually or eaten whole. Massive ingestions are rare.

In addition to synthetic LSD, several plants contain alkaloids similar in structure and action to LSD. These plants include Hawaiian baby woodrose (Argyreia nervosa), Hawaiian woodrose (Merremia tuberosa), morning glory (Ipomoea violacea), and oliliuqui (Rivea corymbosa). Intoxication may result after ingestion of the seeds or an extract.²

Tryptamines

Substances in the tryptamines category are both naturally occurring and synthesized. For centuries, Native Central and South Americans have used tryptamine-containing beverages, ayahuasca, in their religious ceremonies. This plant-derived drink, which contains dimethyltryptamine (DMT) and 5-methoxy-dimethyltryptamine (5-MeO-DMT), has gained popularity in Europe and North America. Designer tryptamines can be synthesized and possess the psychotropic effects of the naturally found compounds.

Psilocybin and psilocin are naturally occurring tryptamines found in some species of Psilocybe (Fig. 156-2), Panaeolus, and Conocybe mushrooms.³ Psilocybin remains active even when the mushrooms are dried or cooked. Street psilocybin sold as pills or capsules is usually substituted with phencyclidine (PCP) or LSD. Misidentification of other poisonous species is a danger of consuming mushrooms.

Naturally occurring tryptamines are found not only in plants and fungi but also in the parotid glands of the Bufo toad species. The venom of the Sonoran Desert or Colorado River toad (Bufo alvarius) contains the hallucinogenic substance 5-MeO-DMT, found in the drink ayahuasca. Smoking of the dried venom results in psychoactive effects similar to those of 5-MeO-DMT.⁴

In addition to the tryptamines that occur in nature, designer tryptamines have been synthesized and are orally active.⁵ Included in this group are α-methyltryptamine, diisopropyltryptamine, and diisopropyl-5-methoxytryptamine, which is also known on the streets as “foxy” or “foxy methoxy”.⁶ The effects of these synthetic derivatives are similar to those of naturally occurring tryptamines.

Designer Amphetamines and Cathinones (Bath Salts)

New designer amphetamines appear in drug communities each year. This class of chemicals usually has a structural base of a phenylalkylamine with addition or substitution of side chains or rings. Agents include 3,4-methylenedioxymethamphetamine (MDMA, ecstasy, XTC, or Adam), 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxyethamphetamine (Eve), paramethoxyamphetamine (PMA or death), 4-methyl-2,5-dimethoxyamphetamine (serenity, tranquility, and peace [STP]), 2,5-dimethoxy-4-iodoamphetamine (DOI), 2,5-dimethoxy-4-bromoamphetamine (DOB), and others.⁹

MDMA is the best known of these agents. It was first synthesized in 1914 as an appetite suppressant. Recreational and psychotherapeutic use began in the late 1970s and has remained ubiquitous. MDMA and MDA have been called love drugs because of claims from users that sexual pleasure and feelings are heightened, but the sympathomimetic effects of these drugs may produce erectile dysfunction. MDMA can produce euphoria and increase emotional awareness, and it has been reported to improve interpersonal communications. The psychedelic and stimulant effects of MDMA are preferred to MDA by most users. Overt hallucinations of the type experienced with LSD are rare; however, sensory enhancement and distortion and illusions can occur. Because of these effects, these drugs are called entactogens (i.e., enabling the user to “touch within”). MDMA was classified as a Schedule I drug by the Drug Enforcement Agency (DEA) in 1985.

Entactogens are predominantly used in three main settings: (1) as “psychotherapeutic adjuncts,” (2) recreationally in small groups or by couples, and (3) at dance clubs or “rave” parties. Herbal ecstasy, known as ma huang or ephedra, is sometimes substituted for MDMA at these gatherings when MDMA is scarce. Although this herb contains ephedrine, its effects are not as psychedelic as those of MDMA. Ecstasy tablets may also contain other chemicals, such as amphetamine, methamphetamine, caffeine, and ketamine. MDMA is widely available and is sold in clubs, on the street, and at raves (usually 30-150 mg/pill), with a typical dose of 1 or 2 mg/kg.¹⁰ The continuous muscle activity required during these parties in combination with the psychostimulants may produce rhabdomyolysis and hyperthermia. Nine deaths in Canada associated with paramethoxyamphetamine (PMA) were originally reported in 1974, but clusters of multiple deaths in association with PMA exposure have occurred in Europe and Australia.^11,12 Signs and symptoms of adrenergic excess occur before death, but whether PMA is more toxic in equipotent dosages than other amphetamines is not known.

Designer cathinones may be advertised and distributed as “bath salts” or “plant food” in packaging that suggests the actual intent of the product even though it might be labeled “not for human consumption.” These synthetic cathinones sold unregulated over the Internet initially contained mephedrone, but their content rapidly changed to include methylone, ethylone, butylone, pyrovalerone, methylenedioxypyrovalerone (MDPV), methcathinone, ethcathinone, and numerous others. These products may be ingested, inhaled, or injected and result in severe agitation, sympathomimetic effects, or even death.¹³ Detection of these cathinones is more difficult as their structures are dissimilar enough to classic amphetamines and methamphetamines that routine urine drug testing is not able to detect them.

Mescaline

Mescaline is usually consumed in the form of peyote buttons, which are derived from the small blue-green cacti Lophophora williamsii and Lophophora diffusa (Fig. 156-3). The cacti grow in the deserts of the southwestern United States and Mexico. Peyote buttons are the round fleshy tops, which are removed and dried. Mescaline is the active hallucinogenic alkaloid found in the buttons of the cactus.

Peyote has been used in religious ceremonies for 8000 years. Mescaline is also contained in the San Pedro cactus (Trichocereus pachanoi) of South America and is used ritualistically by Andean Native Americans.¹ These cacti contain many other alkaloids, some of which are also psychoactive. The use of peyote is legal for members of the Native American Church in some states. Adverse reactions (e.g., panic) to peyote are rare in this structured religious use. Mescaline has an onset of action of 45 to 60 minutes with a duration of 4 to 8 hours. The central nervous system (CNS) and physiologic effects of mescaline use are similar to those of LSD, but more vivid hallucinations can occur. Nausea and vomiting are pronounced and almost always precede the hallucinogenic effects.

Piperazines

N-Substituted piperazine compounds such as 1-benzylpiperazine (BZP or A2), 1-(trifluoromethylphenyl)piperazine (TFMPP or Molly), and 1-(chlorophenyl)piperazine (CPP) have emerged as drugs of abuse and have been sold as safe, legal alternatives to MDMA; they are referred to as Legal E or Legal X on Internet websites.14,15 Although BZP was originally synthesized as a potential anthelmintic agent, there are currently no therapeutic applications for BZP or its congeners. Both in vitro and animal studies demonstrated that these piperazine compounds stimulate release of serotonin and other monoamines but are less potent in comparison to MDMA.¹⁵ In 2002, both BZP and TFMPP were classified as Schedule I drugs because of their potential for abuse and hazard to the public. There are no deaths directly attributed to these piperazines, but fatalities occur in association with their use.¹⁴

Nutmeg

Nutmeg is a spice derived from the seed of the nutmeg tree, Myristica fragrans. Use of nutmeg as a natural and legal psychotropic agent was popularized in the 1960s. Despite lack of any in vivo human studies, myristicin and elemicin have been suggested as the agents responsible for intoxication because their chemical structures resemble that of mescaline. Reports of intoxication are uncommon.16,17 Ingestion of 5 to 30 g (1-4 tablespoons) of the spice is said to induce euphoria and hallucinations but is more likely to cause gastroenteritis.