Case Series: Salvia divinorum as a Potential Addictive Hallucinogen, Joseph El-Khoury & Evelyne Baroud, 2018

Case Series: Salvia divinorum as a Potential Addictive Hallucinogen

Joseph El-Khoury, Evelyne Baroud

The American Journal on Addictions, 2018, 27, 163–165

DOI: 10.1111/ajad.12715


Background and Objective : Recreational use of Salvia divinorum (salvia), a potent, naturally occurring hallucinogen, is on the rise internationally. Despite the paucity of information about its long term health effects, salvia is readily available and generally portrayed as a safe non-addictive substance.

Methods and Results : We report on two patients who presented with an enduring and pervasive pattern of salvia use.

Discussion and Conclusions : Evaluating patients for salvia use during clinical assessment is strongly encouraged, especially among young polysubstance users.

Scientific Significance : Clinicians should be mindful of the multifaceted psychiatric effects of salvia, including the potential for a use disorder.



Salvia divinorum (salvia) is a naturally-occurring hallucinogenic plant of the Lamiaceae (Mint) family. It has been used for centuries by Mazatec shamans of Mexico for divination and spiritual healing.1 In recent years, salvia has become a popular recreational drug2 because of its potency, perceived safety, and ready availability,3 particularly among young adults at-risk for polysubstance use.4

Consumption of salvia, usually through inhalation or oral ingestion, induces powerful cognitive, affective, and perceptual changes, including derealization, depersonalization, and an “array of delusional phenomena.”2 Salvinorin A is salvia’s main psychoactive component. It is a highly selective, non-nitrogenous, potent kappa opioid receptor (KOR) agonist.1 Its rapid onset of action, short half-life and dose-dependent hallucinogenic effects only partially overlap with those of classic hallucinogens, thereby providing users with a unique and intense experience.5 The rewarding effects of salvinorin A seem to be mediated through the opioid and endocannabinoid systems in rats,6,7 therefore providing a possible mechanism for dependence.

Salvia is legally sold in several countries in “smartshops” and its use is promoted online for recreational purposes.8 Salvia is portrayed as a safe or legal substitute to other drugs with little information provided about its potential for harm.9 Salvinorin A cannot be detected by commonly available toxicology kits,10 making it more appealing to users in countries where cannabis or other hallucinogens are criminalized.

While acute effects of salvia such as psychotic experiences have been studied in laboratory and under natural conditions, chronic and heavy use leading to impairment has not yet been substantially described in the scientific literature. The recent popularity of salvia among substance users in Lebanon offers an opportunity for exploring the potential for clinical dependence. We report two cases where pervasive and
enduring pattern of salvia use appears to have been a primary contributor for loss of functionality in two young males and a reason behind them seeking psychiatric treatment.


A 16-year-old single adolescent male was brought to the Emergency department (ED) in January 2017 for symptoms of psychosis that had developed over several days, in the context of recent use of large quantities of salvia. Symptoms included paranoia, nihilistic delusions, thought insertion and thought

The patient reported a 3-year history of polysubstance use, mainly cannabis, alcohol, cocaine, and MDMA. First use of salvia was in April 2014 at age 14. He initially used salvia about once a month, whenever it was available among his peers. His use progressively increased to larger doses multiple
times a week by the end of summer of 2016. Seven months prior to presentation, he had transitioned to exclusive daily salvia use. He reported that the main motivating factor behind the switch were the “salvia-specific” effects. These included a “decreased awareness of surroundings,” feelings of euphoria
and calmness, depersonalization, and visual distortions and illusions. He reported strong cravings for salvia becoming irritable and aggressive when not using. Protracted symptoms of tremors, nausea, headaches, irritability, and anxiety made his efforts to cut down unsuccessful. One month prior to presentation he reported depressive symptoms: low mood, anhedonia, loss of appetite, insomnia, and passive death wishes. He became socially isolated and withdrawn. His use of salvia had become continuous throughout the day. He dropped out of school and engaged in gambling and driving under the influence. He consulted a psychiatrist who prescribed mirtazapine 30 mg daily. He was admitted to the psychiatric inpatient unit a week later.

On first contact, he appeared anxious and avoided eye contact. Vital signs showed tachycardia. Medical history and investigations were unremarkable. Urine toxicology was positive for tetrahydrocannabinol (THC). He was started on olanzapine 10 mg daily, increased to 15 mg a week later. Elevated liver enzymes prompted a switch to risperidone 2mg daily. Improvement was notable within days of olanzapine treatment and was sustained after switching to risperidone. While hospitalized, he presented symptoms suggestive of withdrawal: anxiety, irritability, headaches, nausea, insomnia, and cravings for salvia. He was started on diazepam 5mg twice daily. He was discharged to a residential rehabilitation center on risperidone 2mg once daily and escitalopram 10 mg once daily.