Drug misuse, intoxication and withdrawal: Hallucinogens: Pathology review

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Case study0:00–1:12

In the middle of the night, two people are brought to the clinic. First comes 18 year old Kyle and his mother, who's noticed that lately, Kyle seems to have an increased appetite, and won’t stop laughing or giggling.
Kyle adds that he feels like time has stopped and that’s making him a bit anxious. Upon physical examination, Kyle’s eyes are extremely red, he has a heart rate of 105 beats per minute, and a blood pressure of 130 over 90 millimeters of mercury.
Next comes 25 year old Matt and his girlfriend Allison, who is very concerned for him. She says that in the past few months, Matt has been very aggressive and violent, and has been frequently getting into fights with strangers for no good reason.
Matt interrupts Allyson and tells you that the reason he gets into fights is because some voices in his head tell him so.
Upon physical examination, you notice that Matt keeps tapping his feet, and his eyes keep moving from side to side and up and down.
In addition, he has a heart rate of 110 beats per minute, and a blood pressure or 135 over 95 millimeters of mercury.Based on the initial presentation, both Kyle and Matt seem to have some form of hallucinogen intoxication.

Hallucinogen1:12–2:03

Hallucinogens are a class of psychoactive drugs that cause hallucinations, which are distortions of a person’s sensory perception, mood, and thought, as well as enhancement of feelings and introspection.
The way they do this isn’t clearly understood, but it involves the interaction of numerous neurotransmitters, including serotonin, dopamine, and glutamate.
Now, some high yield hallucinogens include lysergic acid diethylamide or LSD, cannabis or marijuana, MDMA or ecstasy, and phencyclidine or PCP.
And in addition to causing hallucinations, they can all cause their own set of unique symptoms that you need to be able to recognize for your exams.
In addition to these, they can all cause their own set of unique symptoms that you need to be able to recognize for your exams.Okay, let’s begin with lysergic acid diethylamide, better known as LSD.

LSD2:03–3:55

This drug is available as pills, capsules, and liquid, and is illegal in most countries. Now, LSD intoxication has a wide variety of effects, including hallucinations that are mainly visual and auditory, so individuals may see or hear things that aren’t real, like vivid colors, distorted objects, or imaginary noises.
At the same time, individuals may experience euphoria, which is a state of extreme happiness, self-confidence, and expansiveness.
But it’s not all literal rainbows and happiness. Another classic sign of LSD intoxication is depersonalization, which is when an individual feels like they’re an outside observer of their own thoughts, feelings, or body.
So for instance, a person may feel like they’re floating and watching over themselves without being able to control their own behavior or movements.
And this might be combined with anxiety, panic attacks, as well as paranoia, where the individual is accusatory or generally distrustful and suspicious of other people.
Now, LSD may also have some long-term consequences, meaning that they don’t occur during intoxication, but may persist for months or even years.
So, some individuals may develop flashbacks, which are episodes where they can experience some of these effects even after the LSD has worn off.
Finally, LSD also seems to be a precipitating factor for the development of psychosis, a severe mental disorder characterized by perceptual distortion associated with hallucinations, delusions, and disorganized thought and speech.
The good news is that LSD use typically doesn’t cause dependence, meaning that the body doesn’t adapt to the drug over time, so the person isn’t likely to suffer from withdrawal if the drug is stopped.

Cannabis (marijuana)3:55–6:21

And that’s a high yield fact!Next we have cannabis, better known as marijuana. Cannabis is available as smokable herbs, teas, or edibles, as well as pills, creams, and transdermal patches.
The use of cannabis as a recreational drug is still illegal in many countries nowadays, while its use for medical purposes has been legalized in lots of countries.
Now, the main psychoactive compound of cannabis is called cannabinoid. Cannabinoid acts on brain areas involved in sensory and time perception, thought, and emotions.
As a result, marijuana intoxication is typically associated with hallucinations, slowed perception of time, and impaired judgement, along with euphoria and uncontrollable laughter.
Very often, individuals also experience increased appetite, and heightened senses, particularly that of taste. Sometimes though, usually with higher doses, individuals may experience adverse effects like anxiety, paranoia, panic attacks, and social withdrawal, meaning they may isolate and become antisocial.
Cannabis intoxication also has some physical effects. A telltale sign that someone’s consumed cannabis is conjunctival injection or red eyes.
That’s because cannabis can cause dilation of the capillaries in the conjunctiva of the eyes. Often, individuals may also experience cottonmouth, or dry mouth, as cannabis causes a decrease in saliva secretion.
Cannabis can also impair motor coordination, balance, and reaction time. Finally, some individuals may develop tachycardia and hypertension.
For your exams, you should also know that some countries have approved the use of cannabis or synthetic cannabinoids like dronabinol for medical purposes.
They are mainly used as antiemetics to reduce nausea and vomiting for individuals undergoing chemotherapy, or as appetite stimulants, for individuals with cancer or AIDS.
Finally, marijuana may also help relieve chronic pain.Over time, cannabis use may result in dependence. As a result, individuals that stop using it may experience withdrawal symptoms, including mood changes like irritability, depression, or anxiety, as well as insomnia and restlessness, meaning that they’re unable to relax and rest.
Finally, withdrawal of cannabis can result in a decreased appetite. A way more dangerous hallucinogen is MDMA, more commonly called ecstasy or molly.

MDMA (ecstasy)6:21–10:08

It's available mostly in the form of pills or capsules. MDMA stands for 3,4-methylenedioxymethamphetamine, and it is a sympathomimetic amphetamine, which means it increases the effect of serotonin and catecholamines, in particular norepinephrine and dopamine.
For that reason, in addition to its hallucinogenic effects like enhanced senses, and distorted time perception, bear in mind that MDMA also acts as a stimulant, and can cause euphoria and a feeling of having lots of energy.
This is often associated with hyperactivity, as well as disinhibition, or disregard for social rules that leads to inappropriate, impulsive, or even aggressive behavior.
On top of these, two very suggestive signs of MDMA misuse are appetite suppression and bruxism, or involuntary teeth grinding.Now, what you should definitely remember for your exams is that MDMA can have several life-threatening effects like tachycardia and severe hypertension, which may lead to the development of dysrhythmias or myocardial infarction, as well as intracranial hemorrhage.
Another very dangerous effect of MDMA is hyperthermia or severe overheating, which is characterized by a core temperature that’s greater than 38.5°C or 101.3°F.
Now, hyperthermia combined with hyperactivity can cause excessive sweating and dehydration. To try and prevent this, some MDMA users may drink excessive amounts of water.
As a result, they may develop severe hyponatremia, or low blood sodium, which can lead to severe complications like cerebral edema or brain swelling, coma, and death.
And that’s a high yield fact! Less frequently, hyperthermia can lead to disseminated intravascular coagulation, rhabdomyolysis or skeletal muscle breakdown, organ failure, and death.Finally, a very high yield adverse effect of MDMA intoxication is serotonin syndrome.
Keep in mind that this is more likely to occur with high MDMA doses or when combined with other serotonergic drugs, such as some antidepressants.
Now, to help you remember the symptoms of serotonin syndrome, think of the clinical triad of the 3 As, which are autonomic effects, abnormal neuromuscular activity, and altered mental status.
Autonomic effects can include diaphoresis or excessive sweating, hyperthermia, tachycardia, or diarrhea. Abnormal neuromuscular activity may manifest as myoclonus or muscle twitching, hyperreflexia or excessive reflexes, hypertonia or increased muscle tone, tremor or involuntary shaking, and even seizures.
Finally, altered mental status may present with agitation, confusion, hallucinations, or even coma.Over time, MDMA misuse can cause dependence, so individuals can experience intense withdrawal symptoms.
Psychological withdrawal symptoms are mainly due to the lack of stimulation and may include depression, fatigue or lack of energy, and difficulty concentrating.
In addition, some individuals may feel anxiety, irritability, and insomnia. On the other hand, physical symptoms of MDMA withdrawal may include poor appetite, which can lead to unwanted weight loss and malnutrition.
These symptoms can persist to the point where a person may relapse and return to using the MDMA just to feel normal and energized once again, further reinforcing the dependence.The last high yield hallucinogen is phencyclidine, or PCP for short.

Phencyclidine (PCP)10:08–12:17

A fun fact is that PCP was actually developed as an anesthetic agent, but was discontinued because of its side effects. Nowadays, it is illegally available as pills, capsules, powder, or liquid form.
Users may take PCP for its mind-altering effects, which include distorted perception of reality, such as auditory and visual hallucinations; this can also have a dissociative effect, which is a feeling of disconnection or detachment from one’s self and the surrounding environment.
Finally, PCP may also lead to psychosis and delirium, characterized by delusions, disorientation, disorganized thinking, and incoherent speech.For your exams, keep in mind that PCP also has some clearly noticeable effects.
One of them is psychomotor agitation, where the individual performs movements that have no purpose, such as tapping their feet or wandering around the room.
A hallmark sign of PCP intoxication is nystagmus, which is a fast and involuntary movement of the eyes that may be horizontal or side to side, as well as vertical or up and down.
Now, what’s even more important for your test is that PCP intoxication can cause aggressiveness, impulsivity, and violent behavior.
And of course, PCP has the ability to produce anesthesia or numbness, and analgesia or inability to feel pain. So if you combine these effects, the result is that most deaths associated with PCP are due to trauma.
And finally, PCP intoxication can have adverse effects like hypertension and tachycardia. And at high doses, PCP may also cause seizures, coma, and death.Over time, PCP misuse may result in dependence.
Withdrawal symptoms most often include elevated body temperature, rhabdomyolysis, and even seizures. Finally, some individuals may also experience agitation, hallucinations, and muscle twitching.All right, as a quick recap… Hallucinogens are a class of psychoactive drugs that cause distortions of sensory perception, mood, and thought, as well as enhanced feelings and introspection.

Review12:17–15:13

Some high yield hallucinogens include lysergic acid diethylamide or LSD, cannabis or marijuana, MDMA or ecstasy, and phencyclidine or PCP.
LSD intoxication mainly causes hallucinations, euphoria, and depersonalization. Sometimes, it can cause anxiety, panic attacks, and paranoia.
Long-term LSD use can cause flashbacks and psychosis, but typically doesn’t cause dependence. Most often, cannabis causes euphoria and uncontrollable laughter, as well as increased appetite, and heightened senses.
Additional effects include hallucinations, slowed time perception, and impaired judgment. Some adverse effects of cannabis include anxiety, paranoia, and panic attacks, as well as social withdrawal.
Two very common signs are conjunctival injection and dry mouth. Cannabis can also impair motor coordination, balance, and reaction time, and may cause tachycardia and hypertension.
Cannabis can be used as a recreational drug, as well as for medical purposes as an antiemetic, appetite stimulant, or to relieve chronic pain.
Over time, cannabis may cause dependence and withdrawal symptoms, such as irritability, depression, anxiety, insomnia, restlessness, and decreased appetite.
MDMA causes enhanced senses, distorted time perception, euphoria, hyperactivity, and disinhibition, as well as appetite suppression and bruxism.
Life-threatening effects of MDMA include tachycardia and severe hypertension, hyperthermia, dehydration, hyponatremia, and serotonin syndrome.
Over time, MDMA misuse can cause dependence and withdrawal symptoms like depression, fatigue, difficulty concentrating, anxiety, and poor appetite.
Finally, PCP intoxication results in a distorted perception of reality and a dissociative effect, as well as psychosis and delirium.
Individuals may also present psychomotor agitation and nystagmus. The most important effects of PCP are aggressiveness, impulsivity, and violent behavior, as well as anesthesia and analgesia; and because of this, the most common cause of death is trauma.
Other life-threatening effects of PCP intoxication include hypertension and tachycardia, as well as seizures, coma, and death.
Over time, PCP may result in dependence and withdrawal symptoms like elevated body temperature, rhabdomyolysis, seizures, agitation, hallucinations, and muscle twitching.Okay, back to our cases.

Summary15:13–16:08

First there’s 18 year old Kyle, who’s been experiencing increased appetite and uncontrollable laughter. These two findings, combined with Kyle’s slowed perception of time, should already make you think of cannabis.
The final clue here is that Kyle has conjunctival injection, together with tachycardia and hypertension. So Kyle has definitely been consuming cannabis.
Next comes 25 year old Matt, who also has tachycardia and hypertension. However, the rest of his clinical findings are quite different.
Some key facts here include Matt’s aggressive and violent behavior, together with hallucinating with voices. All this is pretty suggestive of PCP intoxication.
The final clue here is his foot taping, which points to psychomotor agitation, as well as his nystagmus, which is a hallmark finding for PCP intoxication.
Drug misuse, intoxication and withdrawal: Hallucinogens | Osmosis