Morning Report

Morning Report: Salvia Psychosis

Presented by Dr. S Harding.

Salvia Divinorum and Salvia Psychosis

(AKA Diviner’s Sage, Ska Maria Pastora, Seer’s Sage)

  • Native to cloud forests in Oaxaca, Mexico
  • Squared, hollow stems often with white flowers with violet calyces
  • Historically used by Mazatec Shamans in religious ceremonies/divination
  • “Salvinorin A”
    • Member of the diterpenoid class – includes various aromatics, coloring agents, menthol, camphor, cannabinoids
    • Potent k-opioid and D2 receptor agonist
    • Similar effects reported to serotonergic agonists like mescaline and LSD

Ingestion

  • Traditional/historical – tea can be made with crushed leaves
  • Can also be chewed and swallowed (slower absorption, longer effect)
  • Smoking is the more common modern use – requires a lower dose for effect
  • 50mg to 172mg is the typical dose
  • Various concentrations are available

Effects

– Peak effect in 1 minute; Lasts approximately 1-5 min, followed by the “afterglow”

– Return to baseline in 15-20 minutes

– Effects:

  • Uncontrollable Laughter
  • Past memories
  • Sensing motion or pulling by unseen forces
  • Merging with objects
  • “Overlapping realities”
  • Vivid hallucinations otherwise
  • Synesthesia and glossolalia
  • Per DEA: “perceptions of bright lights, vivid colors and shapes, as well as body movements and body or object distortions. Other effects include dysphoria, uncontrolled laughter, a sense of loss of body, overlapping realities, and hallucinations . . . adverse physical effects may include incoordination, dizziness, and slurred speech.”

Double blinded, randomized, crossover, counterbalanced study – 10 subjects, varying doses of salvia – “wide range of transient effects.” Intermittent use pattern explained by lack of euphoric effects and presence of perceptual altering effects.

Psychosis

– Several case reports

– Am J Psychiatry – 21 yo male no pmh, no psychiatric hx

  • Smoked salvia – became suspicious, attempted to jump out of a moving car
  • Echolalia, paranoia, flight of ideas, psychomotor agitation
  • Transferred to psychiatric unit – continued to be agitated for 2d
  • Attempted to barricade himself in his room
  • Controlled with Risperdal
  • After tapering and withdrawal of Risperdal, psychosis returned acutely
  • Suspicion is that pt was genetically predisposed to schizophrenia and the dopaminergic effect of salvinorin A precipitated the psychosis

– Other case reports mention:

  • paranoia, déjà vu experiences, and a blunted affect with thought blocking and slow speech that lasted for three days
  • bizarre feelings of depersonalization
  • 23 yo male – psychosis, paranoia, disorganized thinking , hypervigilance, mood lability

Uses

  • several similar k-opioid agonists have shown promise as anti-addictive medication (esp for cocaine), antidepressant properties (afterglow)
  • Salvinorin A is too short acting – improved pharmacokinetics in synthetics

Citations

1. Persistent psychosis associated with salvia divinorum use. Przekop P, Lee T. Am J Psychiatry. 2009 Jul;166(7):832. doi: 10.1176/appi.ajp.2009.08121759.

2. Salvia divinorum. Meyer EG, Writer BW. Psychosomatics. 2012 May-Jun;53(3):277-9. doi: 10.1016/j.psym.2011.07.003. Epub 2012 Jan 29.

3. From divination to madness: features of acute intoxication with Salvia use. Winslow M, Mahendran R. Singapore Med J. 2014 Apr;55(4):e52-3.

4. Dose-related behavioral, subjective, endocrine, and psychophysiological effects of the κ opioid agonist Salvinorin A in humans. Ranganathan M, Schnakenberg A, Skosnik PD, Cohen BM, Pittman B, Sewell RA, D’Souza DC. Biol Psychiatry. 2012 Nov 15;72(10):871-9. doi: 10.1016/j.biopsych.2012.06.012. Epub 2012 Jul 18.

5. Salvinorin A analogs and other kappa-opioid receptor compounds as treatments for cocaine abuse. Kivell BM, Ewald AW, Prisinzano TE. Adv Pharmacol. 2014;69:481-511. doi: 10.1016/B978-0-12-420118-7.00012-3.

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