Toxicology Today

Society has divided plants into those that are acceptable for recreational use and those that are not. For example, tobacco is a dangerous and addictive substance containing nicotine, as almost everyone will agree, but it is legal to smoke and chew. Cannabis, on the other hand, is illegal.

In between are many substances that may be chewed, brewed and smoked and that can produce a variety of physiological and psychological changes in the user. Many substances are anticholinergics when consumed as tea, for example.

One example is Jimson weed, also known as loco weed, devil’s trumpet, angel’s trumpet and by other names. It contains, among other things, belladonna alkaloids which produce strong anticholinergic properties. These alkaloids include atropine and scopolamine. They are competitive antagonists with acetylcholine and bind to peripheral and central muscarinic receptors. The peripheral receptors are on exocrine glands which affect sweating, salivation, and smooth and cardiac muscle. Poisoning causes paralysis of organs innervated by the parasympathetic nervous system. Jimson weed can produce hallucinations, hyperthermia, tachycardia, photophobia and other typical anticholinergic effects.⁵

Use of Jimson weed seems to occur in cycles. Plants can be bought from numerous sources online. With the growth of social media, information about “highs” can explode and result in a surge of overdose cases popping up in various places all over the world.

Brugmansia is another genus of flowering plants sometimes called angel’s trumpet. Its properties are similar to Jimson weed’s.

A study published in 2002 reported an increase of intoxications in persons using alkaloid-containing plants for their hallucinogenic effects. The study found that adolescents were the principal users of these plants. The authors found a syndrome of toxic psychosis with hallucinations, disturbances of orientation, psychomotor agitation, aggression and anxiety resulting from use.⁶

For EMS providers, patients experiencing hallucinations are among the most dangerous, since they can become severely paranoid. These patients are also a threat to themselves as well, and they can get into situations that lead to excited delirium.

In 2009, the American College of Emergency Physicians issued a white paper recognizing excited delirium as a syndrome.⁷

Excited delirium is a condition characterized by a number of ingredients: males with a mean age of 36, who become hyperaggressive, combative, and exhibit bizarre behavior, insensitivity to pain, hyperthermia and tachycardia. There is typically a struggle with law enforcement involving physical combat, use of pepper spray or Taser, followed by a period of quiet, and then sudden death. The majority of cases involve ingestion of cocaine, but methamphetamine, PCP and LSD have also been implicated.

The syndrome is characterized by pain tolerance, tachypnea, sweating, agitation, tactile hyperthermia, noncompliance with police, lack of tiring and unusual strength.

EMS providers often arrive to find the patient subdued, handcuffed and possibly hog-tied, and lying on his chest. Prone positioning of the restrained patient can be lethal, so it is most important to place the patient in a position where he can breathe—which means, at a minimum, turning him onto his side.

It is beyond the scope of this article to explore all the aspects of excited delirium. But it is important to understand that it can be a part of the outcome of ingestion of recreational drugs.

Drug Cocktails

The ingenuity of drug users can never be underestimated. They will seek and discover new and more stimulating ways to abuse substances on a daily basis.

But some things remain relatively static. Drug users mix drugs. One of the most famous cases involving a mixture of drugs involved the death of John Belushi, who allegedly self-administered a combination of heroin and cocaine, commonly known as a “speed ball.” There are various versions of that cocktail, but they all involve a depressant plus stimulants. The idea is to produce a “mellow high.”

Currently, ethanol (ETOH) is one of the most commonly used depressants, and crack cocaine or methamphetamines, or other versions of them, are commonly used with it to produce that “mellow” high.