Subjective effects of Salvia divinorum: LSD- or marijuana-like?

A Focused Review on Cognitive Improvement by the Genus Salvia L. (Sage)-From Ethnopharmacology to Clinical Evidence

Ethnopharmacology has been an important starting point in medical and pharmaceutical sciences for discovering drug candidates from natural sources. In this regard, the genus Salvia L., commonly known as sage, is one of the best-known medicinal and aromatic plants of the Lamiaceae family; it has been recorded as being used for memory enhancement in European folk medicine. Despite the various uses of sage in folk medicines, the records that have pointed out sage's memory-enhancing properties have paved the way for the aforementioned effect to be proven on scientific grounds. There are many preclinical studies and excellent reviews referring to the favorable effect of different species of sage against the cognitive dysfunction that is related to Alzheimer's disease (AD). Hence, the current review discusses clinical studies that provide evidence for the effect of Salvia species on cognitive dysfunction. Clinical studies have shown that some Salvia species, i.e., hydroalcoholic extracts and essential oils of S. officinalis L. and S. lavandulaefolia leaves in particular, have been the most prominently effective species in patients with mild to moderate AD, and these species have shown positive effects on the memory of young and healthy people. However, the numbers of subjects in the studies were small, and standardized extracts were not used for the most part. Our review points out to the need for longer-term clinical studies with higher numbers of subjects being administered standardized sage preparations.

The Altered States Database: Psychometric data from a systematic literature review

In this paper, we present the development of the Altered States Database (ASDB), an open-science project based on a systematic literature review. The ASDB contains psychometric questionnaire data on subjective experiences of altered states of consciousness (ASC) induced by pharmacological and non-pharmacological methods. The systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Scientific journal articles were identified through PubMed and Web of Science. We included studies that examined ASC using the following validated questionnaires: Altered States of Consciousness Rating Scale (APZ, 5D-ASC, 11-ASC), Phenomenology of Consciousness Inventory (PCI), Hallucinogen Rating Scale (HRS), or Mystical Experience Questionnaire (MEQ30). The systematic review resulted in the inclusion of a total of 165 journal articles, whereof questionnaire data was extracted and is now available on the Open Science Framework (OSF) website (https://osf.io/8mbru) and on the ASDB website (http://alteredstatesdb.org), where questionnaire data can be easily retrieved and visualized. This data allows the calculation of comparable psychometric values of ASC experiences and of dose-response relationships of substances inducing ASC.

Measurement(s)	Psychometric questionnaire data
Technology Type(s)	Systematic literature review (PRISMA)
Sample Characteristic - Organism	Human

Pharmacokinetics and Pharmacodynamics of Salvinorin A and Salvia divinorum: Clinical and Forensic Aspects

Salvia divinorum Epling and Játiva is a perennial mint from the Lamiaceae family, endemic to Mexico, predominantly from the state of Oaxaca. Due to its psychoactive properties, S. divinorum had been used for centuries by Mazatecans for divinatory, religious, and medicinal purposes. In recent years, its use for recreational purposes, especially among adolescents and young adults, has progressively increased. The main bioactive compound underlying the hallucinogenic effects, salvinorin A, is a non-nitrogenous diterpenoid with high affinity and selectivity for the κ-opioid receptor. The aim of this work is to comprehensively review and discuss the toxicokinetics and toxicodynamics of S. divinorum and salvinorin A, highlighting their psychological, physiological, and toxic effects. Potential therapeutic applications and forensic aspects are also covered in this review. The leaves of S. divinorum can be chewed, drunk as an infusion, smoked, or vaporised. Absorption of salvinorin A occurs through the oral mucosa or the respiratory tract, being rapidly broken down in the gastrointestinal system to its major inactive metabolite, salvinorin B, when swallowed. Salvinorin A is rapidly distributed, with accumulation in the brain, and quickly eliminated. Its pharmacokinetic parameters parallel well with the short-lived psychoactive and physiological effects. No reports on toxicity or serious adverse outcomes were found. A variety of therapeutic applications have been proposed for S. divinorum which includes the treatment of chronic pain, gastrointestinal and mood disorders, neurological diseases, and treatment of drug dependence. Notwithstanding, there is still limited knowledge regarding the pharmacology and toxicology features of S. divinorum and salvinorin A, and this is needed due to its widespread use. Additionally, the clinical acceptance of salvinorin A has been hampered, especially due to the psychotropic side effects and misuse, turning the scientific community to the development of analogues with better pharmacological profiles.

Abuse and Effects of Salvia divinorum in a Sample of Patients Hospitalized for Substance Dependence

The study goal is to document the prevalence of salvia use among patients admitted for detoxification of other illicit drug use and to determine its effect. This cross-sectional study included 47 heavy drug users who were admitted for detoxification of other illicit drug abuse at a psychiatric hospital in Lebanon. The prevalence of salvia use was 66%. The salvia effect started and dissipated rapidly (15 min). No significant difference was found between salvia and non-salvia users in terms of affect, cognition and somaesthesia subscales of the Hallucinogen Rating Scale. Ratings of intensity and volition subscales were higher in non-salvia users than salvia users, while perception score was higher in users. Salvia use was correlated with perceptual alteration and hallucinogenic effects.

In further defense of nonclinical abuse liability testing of biologics

Risk assessment is not a choice. Drug Abuse Liability (DAL) is mandated under international and national drug control statutes for all drugs targeting the CNS. Once administered to humans many biologics may have long-lived or permanent physiological effects that make DAL testing arduous. We respond to premises of a recently published position on DAL testing of biologics by de Zafra et al. (2018). We propose that, at a minimum, Sponsors submitting a Biologics Licensure Application (BLA) must think "outside the box" and include differential study designs for the same three core small NME assays detailed in the current DAL guidelines (self-administration, drug discrimination, and dependence liability). Abuse liability testing for drug scheduling decisions for marketing approval are not excluded or limited from risk assessment analysis simply because the entity is a biologic. In fact, more robust study designs may be necessary to address alterations in the reinforcing and discriminative stimulus effects of common drugs of abuse, as well as the dependence liability of the biologic, itself.

When good times go bad: managing 'legal high' complications in the emergency department

Patients can use numerous drugs that exist outside of existing regulatory statutes in order to get "legal highs." Legal psychoactive substances represent a challenge to the emergency medicine physician due to the sheer number of available agents, their multiple toxidromes and presentations, their escaping traditional methods of analysis, and the reluctance of patients to divulge their use of these agents. This paper endeavors to cover a wide variety of "legal highs," or uncontrolled psychoactive substances that may have abuse potential and may result in serious toxicity. These agents include not only some novel psychoactive substances aka "designer drugs," but also a wide variety of over-the-counter medications, herbal supplements, and even a household culinary spice. The care of patients in the emergency department who have used "legal high" substances is challenging. Patients may misunderstand the substance they have been exposed to, there are rarely any readily available laboratory confirmatory tests for these substances, and the exact substances being abused may change on a near-daily basis. This review will attempt to group legal agents into expected toxidromes and discuss associated common clinical manifestations and management. A focus on aggressive symptom-based supportive care as well as management of end-organ dysfunction is the mainstay of treatment for these patients in the emergency department.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

Looking for the Self: Phenomenology, Neurophysiology and Philosophical Significance of Drug-induced Ego Dissolution

There is converging evidence that high doses of hallucinogenic drugs can produce significant alterations of self-experience, described as the dissolution of the sense of self and the loss of boundaries between self and world. This article discusses the relevance of this phenomenon, known as “drug-induced ego dissolution (DIED)”, for cognitive neuroscience, psychology and philosophy of mind. Data from self-report questionnaires suggest that three neuropharmacological classes of drugs can induce ego dissolution: classical psychedelics, dissociative anesthetics and agonists of the kappa opioid receptor (KOR). While these substances act on different neurotransmitter receptors, they all produce strong subjective effects that can be compared to the symptoms of acute psychosis, including ego dissolution. It has been suggested that neuroimaging of DIED can indirectly shed light on the neural correlates of the self. While this line of inquiry is promising, its results must be interpreted with caution. First, neural correlates of ego dissolution might reveal the necessary neurophysiological conditions for the maintenance of the sense of self, but it is more doubtful that this method can reveal its minimally sufficient conditions. Second, it is necessary to define the relevant notion of self at play in the phenomenon of DIED. This article suggests that DIED consists in the disruption of subpersonal processes underlying the “minimal” or “embodied” self, i.e., the basic experience of being a self rooted in multimodal integration of self-related stimuli. This hypothesis is consistent with Bayesian models of phenomenal selfhood, according to which the subjective structure of conscious experience ultimately results from the optimization of predictions in perception and action. Finally, it is argued that DIED is also of particular interest for philosophy of mind. On the one hand, it challenges theories according to which consciousness always involves self-awareness. On the other hand, it suggests that ordinary conscious experience might involve a minimal kind of self-awareness rooted in multisensory processing, which is what appears to fade away during DIED.

Evolutionary Considerations on the Emerging Subculture of the E-psychonauts and the Novel Psychoactive Substances: A Comeback to the Shamanism?

BACKGROUND

Evolutionary research on drug abuse has hitherto been restricted to proximate studies, considering aetiology, mechanism, and ontogeny. However, in order to explain the recent emergency of a new behavioral pattern (e.g. 'the e-psychonaut style') of novel psychoactive substances' (NPS) intake, a complementary evolutionary model may be needed.

OBJECTIVE

A range of evolutionary interpretations on the 'psychonaut style' and the recent emergency of NPS were here considered.

METHOD

The PubMed database was searched in order to elicit evolutionary theory-based documents commenting on NPS/NPS users/e-psychonauts.

RESULTS

The traditional 'shamanic style' use of entheogens/plant-derived compounds may present with a range of similarities with the 'e-psychonauts' use of mostly of hallucinogen/psychedelic NPS. These users consider themselves as 'new/technological' shamans.

CONCLUSION

Indeed, a range of evolutionary mechanisms, such as: optimal foraging, costly signaling, and reproduction at the expense of health may all cooperate to explain the recent spread and diffusion of the NPS market, and this may represent a reason of concern.

The Association of Salvia divinorum and Psychotic Disorders: A Review of the Literature and Case Series

The association of substance abuse and psychotic disorders is of interest to clinicians, academics, and lawmakers. Commonly abused substances, such as cannabis, cocaine, amphetamines, and alcohol, have all been associated with substance-induced psychosis. Hallucinogens can induce desired psychedelic effects and undesirable psychomimetic reactions. These are usually transient and resolve once the duration of action is over. Sometimes, these effects persist, causing distress and requiring intervention. This article focuses on the hallucinogenic substance Salvia divinorum, the use of which has been observed, particularly among youth worldwide. We present background information based on a review of the literature and on our own clinical encounters, as highlighted by two original case reports. We hypothesize that consumption of Salvia divinorum could be associated with the development of psychotic disorders. We propose that clinicians routinely inquire about the use of Salvia in patients with substance use disorders or psychotic illnesses. More research is required to assess any relationship between Salvia divinorum and psychosis. Additionally, we advocate increased public and medical awareness of this substance and other emerging drugs of abuse.

From divination to madness: features of acute intoxication with Salvia use

Salvia divinorum is a psychoactive botanical plant that is increasingly used for the 'legal' highs that it can produce. It is readily available for purchase on the Internet, and most abusers are unaware of the toxicity and abuse potential associated with its use. As the use of novel compounds among abusers is not uncommon, physicians need to increase their awareness and recognition of these new substances. Herein, we report a case of an acute presentation of Salvia intoxication.

The subjective experience of acute, experimentally-induced Salvia divinorum inebriation

This study examined the overall psychological effects of inebriation facilitated by the naturally-occurring plant hallucinogen Salvia divinorum using a double-blind, randomized, placebo-controlled trial. Thirty healthy individuals self-administered Salvia divinorum via combustion and inhalation in a quiet, comfortable research setting. Experimental sessions, post-session interviews, and 8-week follow-up meetings were audio recorded and transcribed to provide the primary qualitative material analyzed here. Additionally, post-session responses to the Hallucinogen Rating Scale provided a quantitative groundwork for mixed-methods discussion. Qualitative data underwent thematic content analysis, being coded independently by three researchers before being collaboratively integrated to provide the final results. Three main themes and 10 subthemes of acute intoxication emerged, encompassing the qualities of the experience, perceptual alterations, and cognitive-affective shifts. The experience was described as having rapid onset and being intense and unique. Participants reported marked changes in auditory, visual, and interoceptive sensory input; losing normal awareness of themselves and their surroundings; and an assortment of delusional phenomena. Additionally, the abuse potential of Salvia divinorum was examined post hoc. These findings are discussed in light of previous research, and provide an initial framework for greater understanding of the subjective effects of Salvia divinorum, an emerging drug of abuse.

Recent advances in the neuropsychopharmacology of serotonergic hallucinogens

Serotonergic hallucinogens, such as (+)-lysergic acid diethylamide, psilocybin, and mescaline, are somewhat enigmatic substances. Although these drugs are derived from multiple chemical families, they all produce remarkably similar effects in animals and humans, and they show cross-tolerance. This article reviews the evidence demonstrating the serotonin 5-HT2A receptor is the primary site of hallucinogen action. The 5-HT2A receptor is responsible for mediating the effects of hallucinogens in human subjects, as well as in animal behavioral paradigms such as drug discrimination, head twitch response, prepulse inhibition of startle, exploratory behavior, and interval timing. Many recent clinical trials have yielded important new findings regarding the psychopharmacology of these substances. Furthermore, the use of modern imaging and electrophysiological techniques is beginning to help unravel how hallucinogens work in the brain. Evidence is also emerging that hallucinogens may possess therapeutic efficacy.

Salvia divinorum: from Mazatec medicinal and hallucinogenic plant to emerging recreational drug

Salvia divinorum is a sage endemic to a small region of Mexico and has been traditionally used by the Mazatec Indians for divination and spiritual healing. Recently, it has gained increased popularity as a recreational drug, used by adolescents and young adults as an alternative to marijuana and LSD. Salvinorin A, the major active ingredient of the plant, is considered to be the most potent known hallucinogen of natural origin. This review surveys the current state of knowledge on the neurochemical, pharmacokinetic, and pharmacological properties of salvinorin A, the trends and motivation behind S. divinorum use, and the health problems among users of the plant's products. S. divinorum induces intense, but short-lived, psychedelic-like changes in mood and perception, with concomitant hallucinations and disorientation. Many websites have misinterpreted the limited existing research-based information on the side effects of salvia as evidence for its safety. However, data accumulated over the last few years indicate that potential health risks are associated with the use of S. divinorum, especially by teenagers, users of other substances of abuse, and individuals with underlying psychotic disturbances. Taken together, the data presented in this review point to the need for further basic and clinical studies to create a basis for the development of well-addressed prevention and treatment strategies.

Dose-related effects of salvinorin A in humans: dissociative, hallucinogenic, and memory effects

RATIONALE

Salvinorin A is a kappa opioid agonist and the principal psychoactive constituent of the plant Salvia divinorum, which has increased in popularity as a recreational drug over the past decade. Few human studies have examined salvinorin A.

OBJECTIVE

This double-blind, placebo-controlled study evaluated the dose-related effects of inhaled salvinorin A in individuals with histories of hallucinogen use.

METHODS

Eight healthy hallucinogen-using adults inhaled up to 16 doses of salvinorin A (0.375-21 μg/kg) in ascending order. Physiological, behavioral, and subjective effects were assessed every 2 min for 60 min after administration. Qualitative subjective effects were assessed retrospectively via questionnaires at the end of sessions. Persisting effects were assessed 1 month later.

RESULTS

Orderly dose-related effects peaked at 2 min and then rapidly dissipated, replicating previous findings. Subjective effects were intense, with maximal drug strength ratings or unresponsiveness frequently observed at high doses. Questionnaires assessing qualitative effects (Hallucinogen Rating Scale, Pharmacological Class Questionnaire) suggested some overlap with serotonergically mediated classic hallucinogens. Salvinorin A also produced dose-related dissociative effects and impairments in recall/recognition memory. At 1-month follow-up, there was no evidence of persisting adverse effects. Participants reported that salvinorin A effects were qualitatively different from other drugs.

CONCLUSIONS

Salvinorin A produces a unique profile of subjective and cognitive effects, including strong dissociative effects and memory impairment, which only partially overlap with classic hallucinogen effects. Along with nonhuman studies of salvinorin A, these results are important for understanding the neurobiology of the kappa opioid system and may ultimately have important therapeutic applications.

Epidemiology of adolescent Salvia divinorum use in Canada

BACKGROUND

Salvia divinorum is a potent, naturally occurring hallucinogen gaining popularity as a recreational drug in North America. To date, detailed epidemiologic information about the use of this substance among adolescents living outside the United States has been limited. This study provides information on the prevalence and correlates of Salvia divinorum use among adolesecents in Canada using a nationally representative sample.

METHODS

Data were obtained from a representative sample of 42,179 Canadian adolescents aged 12-17 years living across all 10 provinces who completed the Youth Smoking Survey in 2008-09.

RESULTS

Overall, 3.8% of adolescents reported using Salvia in the past year and 6.2% had used the substance in their lifetime. A conservative estimate suggests 23.2% of youth were repeat users. Salvia use was highest among youth in British Columbia and Quebec. Comparatively, the prevalence of 12-month Salvia use was higher than 12-month cocaine and amphetamine use but lower than 12-month ecstasy, cannabis, and other hallucinogen use. Correlates of Salvia use included older age, male gender, high available spending money, binge drinking, illicit drug use and smoking in fully adjusted models. Findings suggest low self-esteem may be an important correlate specific to the use of this substance among youth.

CONCLUSIONS

Salvia divinorum use is prevalent among Canadian adolescents. Salvia may be a significant public health issue in Canada given it is readily available, under limited regulation, and little is known about the abuse liability of the substance, interactions with other substances, and potential complications from use.

Correlates of Salvia divinorum use in a national sample: findings from the 2009 National Survey on Drug Use and Health

Salvia, a hallucinogenic plant legally available in most of the United States, has become a widely discussed drug in the media. The extant research on Salvia use relies on non-probability samples and studies of college students. There is a clear need for research that identifies the correlates of Salvia use using data from a large sample that is nationally representative. The current study fills this important gap in the literature by using data from the 2009 National Survey on Drug Use and Health. This survey includes data from nearly 70,000 respondents ages 12 and older living in all 50 U.S. states and the District of Columbia. Due to survey design, separate analyses are conducted among adolescents and adults. Findings indicate that 1.66% of adolescents (respondents ages 12 to 17) and 5.08% of adults (respondents ages 18-34) report the use of Salvia at some point in their lifetime. Correlates of use among adolescents include age, gender, income, peer and parent attitudes toward substance use, and other forms of drug use. Correlates of use among adults include age, gender, race, religiosity, marital status, criminal involvement, and other forms of substance use. Implications of the findings and limitations of the current study are discussed.

Salvia divinorum use and phenomenology: results from an online survey

Salvia divinorum is a hallucinogenic plant with ethnopharmacological and recreational uses. It differs from classic serotonergic hallucinogens such as LSD and psilocin in both phenomenology and potent agonist activity of the active component salvinorin A at κ-opioid receptors. Awareness of S. divinorum has grown recently, with both an increase in its public representation and concern over its potential harmful effects. This discussion is particularly relevant as S. divinorum is legal to use in many countries and regions and easily available through online retailers. Drawing upon previous investigations of S. divinorum and other hallucinogens, this study surveyed 154 recent users and questioned them on their use behaviours, consequences of use and other attitudinal measures. Although reporting an extensive substance use history, and considering the limitations of online surveys, there was little evidence of dysfunctional S. divinorum use, and few reports of troubling adverse consequences of use. Furthermore, there was no evidence that users exhibited increased schizotypy. Respondents reported that S. divinorum produced mixed hallucinogenic and dissociative effects, which lends support to assertions that it phenomenologically differs from other hallucinogens with primary serotonergic activity. The functions of use changed with greater experiences with the drug, and although many respondents reported use of S. divinorum as an alternative to illegal drugs it, was apparent that legal proscription would be unlikely to dissuade them from use. These results are discussed with reference to psychopharmacologically informed public health responses to substance use.

Recent national trends in Salvia divinorum use and substance-use disorders among recent and former Salvia divinorum users compared with nonusers

Context

Media and scientific reports have indicated an increase in recreational use of Salvia divinorum. Epidemiological data are lacking on the trends, prevalence, and correlates of S. divinorum use in large representative samples, as well as the extent of substance use and mental health problems among S. divinorum users.

Objective

To examine the national trend in prevalence of S. divinorum use and to identify sociodemographic, behavioral, mental health, and substance-use profiles of recent (past-year) and former users of S. divinorum.

Design

Analyses of public-use data files from the 2006–2008 United States National Surveys on Drug Use and Health (N = 166,453).

Setting

Noninstitutionalized individuals aged 12 years or older were interviewed in their places of residence.

Main measures

Substance use, S. divinorum, self-reported substance use disorders, criminality, depression, and mental health treatment were assessed by standardized survey questions administered by the audio computer-assisted self-interviewing method.

Results

Among survey respondents, lifetime prevalence of S. divinorum use had increased from 0.7% in 2006 to 1.3% in 2008 (an 83% increase). S. divinorum use was associated with ages 18–25 years, male gender, white or multiple race, residence of large metropolitan areas, arrests for criminal activities, and depression. S. divinorum use was particularly common among recent drug users, including users of lysergic acid diethylamide (53.7%), ecstasy (30.1%), heroin (24.2%), phencyclidine (22.4%), and cocaine (17.5%). Adjusted multinomial logistic analyses indicated polydrug use as the strongest determinant for recent and former S. divinorum use. An estimated 43.0% of past-year S. divinorum users and 28.9% of former S. divinorum users had an illicit or nonmedical drug-use disorder compared with 2.5% of nonusers. Adjusted logistic regression analyses showed that recent and former S. divinorum users had greater odds of having past-year depression and a substance-use disorder (alcohol or drugs) than past-year alcohol or drug users who did not use S. divinorum.

Conclusion

S. divinorum use is prevalent among recent or active drug users who have used other hallucinogens or stimulants. The high prevalence of substance use disorders among recent S. divinorum users emphasizes the need to study health risks of drug interactions.