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

General Info / Intro

  • 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
  • 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
  • “Legal and bladder-friendly ketamine” (MXE, Mexxy, m-ket, Special M)
  • First detected in UK in 2010 and banned in 2012

Clinical Highlights

  • 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
  • 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
  • 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.



Salvia Divinorum



Images from Journal of Forensic Sciences, January 2013

Further Reading

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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