Alternative "Legal" Highs: Kratom, Salvia Divinorum, Methoxetamine

General Info / Intro

Kratom	Mitragyna speciosa Korth; leafy tree indigenous to SE Asia / Thailand Alternative medicine for diarrhea, cough, opioid addiction, HTN, MSK pain, fatigue Distributed in smart-shops and on Internet; growing interest in Western countries
Salvia	Hallucinogenic herb (Diviner’s Sage, La Pastora, Yerba Maria); small region of Mexico Used for spiritual healing and divination Alternative to LSD and marijuana; distributed as above
Methoxetamine	“Legal and bladder-friendly ketamine” (MXE, Mexxy, m-ket, Special M) First detected in UK in 2010 and banned in 2012

Clinical Highlights

Kratom	Ingested or inhaled usually Active ingredients = mitragynine, 7-hydroxymitragynine Stimulant (dopamine, serotonin) / opioid-like effects (mu / kappa receptors) => used for chronic pain management and opioid withdrawal Supportive Tx
Salvia	Smoked or chewed usually Active ingredient: salvinorin A Binds kappa opioid receptor Tachycardia (CV), euphoria / AMS / hallucinations / memory impairment (Neuro), n/v (GI) Supportive Tx
Methoxetamine	Oral or intranasal usually; slower onset and longer duration than ketamine Dissociative anesthetic / NMDA antagonist / dopamine agonist Tachy / htn / agitation / hyperthermia (sympathomimetic), hallucinations / derealization / depersonalization (dissociative), truncal ataxia / dysarthria (cerebellar), mood disturbance / suicide attempt (behavioral health issues) Supportive Tx

Bottom Line

Think about the aforementioned substances in a patient with either an opioid, sympathomimetic, or hallucinogenic toxidrome.

kratom — Kratom

Salvia — Salvia Divinorum

Methoxetamine

Images from Journal of Forensic Sciences, January 2013

Further Reading

Kratom exposures reported to Texas poison centers. J Addict Dis. 2013;32(4):396-400.
Seizure and coma following Kratom (Mitragynina speciosa Korth) exposure. J Med Toxicol. 2010 Dec;6(4):424-6.
Opioid receptors and legal highs: Salvia divinorum and Kratom. Clin Toxicol (Phila). 2008 Feb;46(2):146-52.
Bath salts and other emerging toxins. Pediatr Emerg Care. 2014 Jan;30(1):47-52.
Salvia divinorum: exposures reported to a statewide poison control system over 10 years. J Emerg Med. 2011 Jun;40(6):643-50.
Methoxetamine toxicity reported to the National Poisons Information Service: clinical characteristics and patterns of enquiries (including the period of the introduction of the UK’s first Temporary Class Drug Order). Emerg Med J. 2014 Jan;31(1):45-7.
Ketamine-like effects after recreational use of methoxetamine. Ann Emerg Med. 2012 Jul;60(1):97-9.

Discussion Questions/Future Exploration

“Legal highs” come and go; which will stay / what are the most dangerous to our pts
How does the market adapt to state / federal bans

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