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Three Part Question

In [adolescent and adult ED patients] presenting with [Salvia divinorum intoxication], what are the [clinical features associated with acute intoxication]?

Clinical Scenario

An 18-year-old male is brought to your Emergency Department by his mother with a chief complaint of \"acting odd\". The patient has been intermittently unresponsive to verbal stimuli, laughing uncontrollably, and appears to hallucinating. In his front pocket, you find a crude pipe and a foil package labeled \"Saliva 10x\" (sic). You begin to wonder what clinical suprises this patient may have in store for you.

Search Strategy

Medline 1946–February week 1 2013 using OVID interface: (Salvia divinorum.mp). LIMIT to humans and English language.

The Cochrane Library Issue 1 of 12 2013: ‘Salvia divinorum’ in title abstract keywords.

Search Outcome

66 papers were identified. Of these, 3 studies were relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Johnson et al, 2011, USA	4 Volunteer participants (2 men, 2 women) 23–35 years of age, screened to be previously psychologically and physically healthy. Effect of ascending weight-based doses of Salvinorin A, administered by inhalation, over the course of 20 sessions	Double-blind and placebo controlled trial	Time course of acute drug effects	Mean peak effect at 2 minutes post-inhalation, Mean end of effect at 20 minutes.	Very small sample size. Sampled only health adults who had previously used other hallucinogens. Uncertainty of generalizability of doses of drug given in this study to common doses of commercially available drug.
			Effect on blood pressure and heart rate	No statistically significant effect at any dose
			Psychobehavioral effects observed	No psychomotor agitation observed, patients were generally behaviorally inactive. Brief epsiodes of verbal unresponsiveness at high doses. High subjective scores of \\\'positive\\\' and \\\'drug liking\\\' responses
Addy, 2012, USA	30 pre-screened adult volunteers from ages 25-65 who self reported physical and psychological health and self reported hallucinogen use.	Case series	Physiological measures before and after drug	Mild decreases in diastolic blood pressure (4 mm Hg) and pulse (5 bpm). No other statistically significant alterations.	Small sample size. Volunteers healthy and had used hallucinogens before. Vitals signs not taken during period of intoxication. Absolute dosing (rather than weight based) used. Uncertain dosing generalizability. Participants were allowed to self-administer the drug, likely leading to idiosyncratic dose delivery.
			Behavioral effects during session	Statistically significant behaviors included: increased movement while sitting, laughing, increased physical contact, paranoia, and increase talking.
			Self reported psychological effects	The drug increased ratings on all six clusters in the Hallucinogen Rating Scale: affect, cognition, intensity, perception, somaesthesia, and volition.
			Self reported after-effects at 8 week followup	Few negative effects lasting greater than 24h noted: headache, fatigue, difficulty concentrating, and mood lability. At 8 weeks, 87% stated they would like to use the drug again.
Vohra et al, 2011, USA	133 cases of exposure to Salvia spp. 37 of these cases were exposures to the hallucinogenic Salivia divinorum. All of these were intentional and recreational exposures. These patients range in age from 15 years to 44 years. 37 of these cases were exposures to the hallucinogenic S. divinorum	Retrospective case review	Deaths	None	Retrospective study with a small sample size. Many entries were missing objective clinical information, such as vital signs. Many patients left against medical advice, and were lost to follow up.
			Case referred to a health facility	33/37 cases
			Concomitant intoxication with other drugs	19/37 cases
			Clinical symptoms in isolated S. divinorum exposure	Symptoms noted include nausea, anxiety, confusion, hallucinations, laughter, tachycardia

Comment(s)

None of these studies directly evaluate S. divinorum intoxication in the emergency department setting. The studies above that do observe the acute toxidrome all feature small sample sizes, with data that may or may not be readily generalisable to the emergency department setting. More studies will be required to judge the breadth of S. divinorum intoxication. However, the studies that exist to this point suggest that the duration of intoxication is quite short.

Clinical Bottom Line

The most common features of intoxication are tachycardia, hallucinations and acute alteration in mental status.

References

1. Johnson MW, MacLean KA, Reissig CJ et al. Human psychopharmacology and dose-effects of salvinorin A, a kappa opioid agonist hallucinogen present in the plant Salvia divinorum. Drug Alcohol Dependence 2011;115; pp 150-155.
2. Addy, PH. Acute and post-acute behavioral and psychological effects of Salvinorin A in humans. Psychopharmacol 2012;220:195–204.
3. Vohra R, Seefeld A, Cantrell FL, et al. Salvia divinorum: exposures reported to a statewide poison control system over 10 years. J Emerg Med 2011;40:643–50.