Close
About
FAQ
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
Anesthetic considerations for patients on hallucinogenic drugs
(USC Thesis Other)
Anesthetic considerations for patients on hallucinogenic drugs
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE
ANESTHETIC CONSIDERATIONS FOR PATIENTS ON HALLUCINOGENIC DRUGS
By
Hannah Kang
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2025
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE ii
Cecilia Wang, Tony Guevara, and Hannah Kang contributed the following manuscript in equal
parts.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE iii
Table of Contents
Abstract ...................................................................................................................................... vi
Chapter One .................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Research Question & Specific Aims........................................................................................... 1
Background & Significance ........................................................................................................ 2
Phencyclidine (PCP) ............................................................................................................... 4
Usage.................................................................................................................................... 5
Pharmacology ...................................................................................................................... 5
Signs and symptoms ............................................................................................................ 6
Social considerations ........................................................................................................... 7
3,4-methylenedioxy-methamphetamine (MDMA).................................................................... 8
Pharmacology ...................................................................................................................... 9
Signs and symptoms .......................................................................................................... 10
Social Considerations......................................................................................................... 12
Lysergic acid diethylamide (LSD)......................................................................................... 13
Usage.................................................................................................................................. 13
Signs and Symptoms.......................................................................................................... 14
Social Considerations......................................................................................................... 15
Chapter Two.................................................................................................................................. 16
Methodology ............................................................................................................................. 16
Chapter Three................................................................................................................................ 18
Literature Review...................................................................................................................... 18
Phencyclidine (PCP) ............................................................................................................. 18
Acute Intoxication.............................................................................................................. 18
Chronic Use ....................................................................................................................... 19
3,4-methylenedioxy-methamphetamine (MDMA).................................................................. 20
Acute Intoxication.............................................................................................................. 20
Chronic Use ....................................................................................................................... 24
Lysergic acid diethylamide (LSD)......................................................................................... 24
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE iv
Acute Intoxication.............................................................................................................. 25
Chronic Use ....................................................................................................................... 26
Results and Recommendation for Practice................................................................................ 29
Phencyclidine (PCP) ............................................................................................................. 30
3,4-methylenedioxy-methamphetamine (MDMA).................................................................. 31
Lysergic acid diethylamide (LSD)......................................................................................... 33
Chapter Five.................................................................................................................................. 36
Discussion..................................................................................................................................... 36
References..................................................................................................................................... 40
Appendix....................................................................................................................................... 48
Cognitive Aid ............................................................................................................................ 48
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE v
List of Tables
Table 1:Guide to hallucinogen duration and detection through toxicology screening 28
Table 2 : Anesthesia management of hallucinogen intoxicated patients 34
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE vi
Abstract
Hallucinogens, a class of psychoactive substances, are increasingly used as recreational
drugs, posing unique challenges in the context of anesthesia. They are among the oldest known
intoxicants used for their ability to alter perception, mood, and cognitive processes, leading to
profound changes in sensory experiences, thought patterns, and awareness. Hallucinogens can be
found in nature or produced synthetically. However, the increasing prevalence of synthetic
formulations of hallucinogenic agents, specifically phencyclidine (PCP), 3,4-methylenedioxymethamphetamine (MDMA), and lysergic acid diethylamide (LSD), raises the need to evaluate
evidence and address knowledge gaps for anesthesia providers.
PCP, MDMA, and LSD are popular yet understudied recreational drugs that can produce
adverse effects in patients undergoing general and sedation anesthesia. The literature supports
thorough patient assessment, testing, monitoring, and use of short-acting agents, as synthetic
hallucinogens can last for an extended period in the body. This paper serves as a resource for
anesthesia practitioners during the perioperative setting, providing insights into the
pharmacology, clinical implications, and social considerations associated with MDMA, LSD,
and PCP.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 1
Chapter One
Introduction
Hallucinogens, also known as psychedelics, are recognized for their perception-altering
characteristics (Carhart-Harris & Goodwin, 2017). Broadly, these substances have been used in
religious ceremonies for thousands of years (Zuflacht et al., 2020). Phencyclidine (PCP), 3,4-
methylenedioxy-methamphetamine (MDMA), and lysergic acid diethylamide (LSD) remain
some of the most popular recreational drugs used, yet they are less studied than other intoxicants
in their effects on anesthesia. Increasing use of hallucinogens has led to more clinical encounters
with acutely intoxicated individuals and chronic users presenting for anesthesia services, each
situation posing distinct challenges for anesthesia professionals. Interactions between anesthetic
drugs and hallucinogens have produced adverse events such as serotonin syndrome,
rhabdomyolysis, seizures, and even death (Zuflacht et al., 2020). As synthetic and novel
formulations of hallucinogenic agents have become increasingly available and social usage more
prevalent, it has become essential for anesthesia providers to learn about this novel group of
intoxicants. This paper will serve to investigate the effects Phencyclidine (PCP), 3,4-
methylenedioxy-methamphetamine (MDMA), and lysergic acid diethylamide (LSD) have on
patients receiving general anesthesia.
The authors have created an executive summary of evidence and produced a cognitive aid
on the clinical effects of hallucinogens as a means for anesthesia professionals to optimize
anesthetic management in this patient population.
Research Question & Specific Aims
The research question guiding this paper is: From the anesthesia provider’s perspective,
what are critical clinical considerations for hallucinogenic patients?
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 2
The specific aims of this research project are:
1. Investigate and describe the pharmacokinetics and pharmacodynamics of PCP, MDMA,
and LSD.
2. Describe the implications of recreational hallucinogen use in the setting of general
anesthesia for elective and emergent surgeries.
3. Develop an executive summary of evidence and decision tools for the care of patients
presenting with acute intoxication or chronic use of recreational hallucinogens in the
setting of elective and emergent surgery.
Background & Significance
Historically, hallucinogenic plants have been used for religious rituals to induce states of
detachment from reality and precipitate “visions” thought to provide mystical insight or enable
contact with a spirit world or “higher power” (Barbosa, 2012). The modern era of hallucinogens
traces back to the 1950s, marking a popular yet controversial movement. Medical
experimentation with hallucinogens peaked in the mid-1960s, with clinicians studying the
potential for hallucinogens in treating complex conditions such as mental illnesses and substance
abuse (Carhart-Harris & Goodwin, 2017). Clinical advancements with hallucinogens were
derailed by the Controlled Substances Act and Food Drug Administration (FDA) in the 1970s
due to public health concerns regarding adverse reactions to hallucinogens, such as psychosis
and suicidality. Subsequent regulation by the FDA restricted pharmaceutical research, essentially
shutting down an investigation into hallucinogens for decades (Hall, 2022).
Advancements in the clinical application of hallucinogen derivatives have led to a recent
increase in interest from anesthesia providers (e.g., ketamine infusion for chronic pain
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 3
management). Despite this expansion, hallucinogen use remains tightly restricted by legal
constraints. For example, the Drug Enforcement Agency (DEA) classifies LSD and MDMA
alongside heroin and cocaine as Schedule 1 drugs, defined as having a high abuse potential with
no accepted medical value (Drug Information DEA, 2022). However, many trials continue to test
the possible role of these drugs for medical use. Schedule 2 drugs, such as PCP, have some
proven medical use but also a high potential for abuse and addiction.
Recent studies show that illicit hallucinogen use, especially among males and 18–25-
year-olds, is increasing (SAMHSA, 2020). In 2021, 8% of young adults reported using
hallucinogens, marking the highest level since the first survey was conducted in 1988 (NIDA,
2022). The types of hallucinogens tracked by the NIDA included LSD, MDMA, mescaline,
peyote, psilocybin, and PCP (NIDA, 2022). Additionally, previously unknown and untracked
street drugs continue to surface, raising the possibility that usage rates might be even higher.
PCP, MDMA, and LSD pose a significant public health risk, as evidenced by their
association with increased hospitalizations (Richards et al., 2020). According to the Drug Abuse
Warning Network, there were 75,538 emergency department visits due to PCP in 2011, up 400%
from 2005 (14,825) (SAMHSA, 2020). Of these emergency department visits, 72% of these
PCP- related patient admissions also involved other substances such as marijuana, cocaine,
analgesics, and anxiolytics (SAMHSA, 2020). The number of PCP users and subsequent medical
encounters has increased as new drug formulations emerge (Journey & Bentley, 2022). For
MDMA, hospitalizations between 2008 and 2015 rose from 55,447 to 206,180, with an estimated
$2.17 billion in hospital costs (Richards et al., 2020). Correspondingly, 60.3% of LSD users who
contacted poison control centers between 2000 and 2016 required emergency medical attention,
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 4
according to toxicity reports by poison centers in the U.S. (Leonard et al., 2018). These statistics
indicate that hallucinogen use is increasingly common in the peri-surgical patient population.
As hallucinogens evolve, anesthesia professionals should consider the short and longterm adverse physiological effects. A retrospective, cross-sectional study using the National
Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2013–2018 revealed an
increase of 45% in substance use-related emergency department visits, which was primarily
driven by hallucinogen-related presenting complaints (Beckerleg & Hudgins, 2022).
Phencyclidine (PCP)
Phencyclidine (PCP), a synthetic compound derived from piperidine, was approved, and
marketed as an anesthetic in the 1950s (Bates & Trujillo, 2021). As an anesthetic, it displayed
the benefit of decreased respiratory depression in rats and lower primates. However, it gained
little acceptance for human use due to the catatonic, bizarre, and aggressive behavior often
observed in recipients. Not long after these dissociative drugs were introduced in the research
setting, they gained popularity for recreational use. Increased usage in the community led
researchers and clinicians to identify a symptom profile of patients with PCP intoxication that
included altered mental status, agitation, violent behavior, nystagmus, and hypertension
(Dominci et al., 2015).
During the 1970s, PCP quickly garnered unprecedented, negative attention from the
media, depicting PCP users as seemingly impervious to pain, committing acts of self-mutilation
and violence, with associations to murder and suicide. Growing notoriety led to the
reclassification of PCP from Schedule 3 to Schedule 2 with the 1978 passage of the Controlled
Substance Act, garnering strict legal scrutiny. The negative publicity and subsequent
intensification of law enforcement efforts likely caused a drop in PCP use during the two
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 5
decades that followed; however, “generational forgetfulness,” a phenomenon where newer
generations forget harmful outcomes experienced by older generations, has led to a resurgence in
PCP use (Bertron et al., 2018).
Reportedly, recreational users prize this psychedelic drug for its ability to elicit euphoric
rush, sensory distortions, and visual hallucinations. Due to the growing popularity of PCP and its
derivatives, emergency room visits increased by 400% between 2005 and 2011, with the most
significant increase occurring between 2009 and 2011(Bates & Trujillo, 2021).
Usage. Phencyclidine comes as a powder, crystal, liquid, or tablet, administered in
multiple routes: intravenous injection, inhalation, oral, and nasal. For example, PCP can be
ingested orally as a pill, snorted as a white powder, injected intravenously and subcutaneously,
or smoked by lacing PCP with mint, parsley, and cannabis (Bertron et al., 2018). New, more
potent, psychoactive substance derivatives of phencyclidine have surfaced, such as 3-MeO-PCP
and the isomer 4-MeO-PCP (Berar, 2019). PCP is the basis of many other drugs, such as
methoxetamine, and is often used in conjunction with other illicit drugs (Bates & Trujillo, 2021).
Pharmacology. This synthetic compound derived from piperidine produces different
physiologic effects at various dosages (Dominci et al., 2015). PCP is a non-competitive
antagonist to the NMDA receptor, blocking the uptake of dopamine and norepinephrine. PCP has
a volume distribution of 6.2 L/kg and a pH between 8.6 and 9.4 (Journey & Bentley, 2022).
The onset of PCP depends on the route of administration. The typical dosage is 1-6 mg
for tablets, 1-10mg for a laced cigarette, 0.1-0.25 mg/kg for an intravenous solution, and 10mg
for inhalation. Inhalation and intravenous injection have the fastest onset at 0.5 to 5 minutes,
while ingestion is the slowest at 15 to 60 minutes. Depending on the dose, the half-life of PCP is
around 21 to 48 hours, with a peak effect of around 4 to 6 hours (Bertron et al., 2018). PCP users
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 6
become symptomatic at a dose of 0.05mg/kg, while a dose of 20 mg or more can cause adverse
events such as seizures, coma, and death (Journey & Bentley, 2022).
Due to its lipid solubility and potency, PCP can cross the blood-brain barrier and stay in
adipose tissue for up to four weeks. This characteristic results in an extended-release from lipid
stores and enterohepatic recirculation, leading to the potential for lingering pharmacodynamic
effects weeks after the drug is no longer detected in the plasma (Bertron et al., 2018). Thus, it
may not appear in conventional toxicology screening, making a thorough history-taking critical.
Signs and symptoms. PCP has been noted to induce schizophrenic-type symptoms in its
users (Peters et al., 2017). PCP can have both stimulant and depressive effects on the CNS.
Depending on the individual, PCP effects may manifest differently. Typically, PCP suppresses
the ability to take in information from the environment, causing a detached sense of awareness
and temporary hallucinations and psychosis (Journey & Bentley, 2022). Depressive effects
include analgesia, anesthesia, and cognitive deficits, while the sympathomimetic effects include
hypertension, tachypnea, tachycardia, bronchodilation, and agitation (Journey & Bentley, 2022;
Dominci et al., 2015). PCP can also produce symptoms of retrograde amnesia and horizontal and
vertical nystagmus (Peters et al., 2017).
At low doses, PCP has little effect on the liver, while at high doses, PCP can cause
malignant hyperthermia, leading to acute hepatic necrosis and liver failure. Hepatobiliary injury
associated with PCP overdose can have dire effects, such as severe hypoxia, seizures,
rhabdomyolysis, and renal failure. Severe hepatic impairment and ischemia can lead to coma
associated with prolonged prothrombin time, hyperammonemia, and metabolic acidosis
(“Phencyclidine,” 2016).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 7
Using a rat model to analyze short-term and long-term behavior effects of PCP, Peters et
al. (2017) noted that the short-term effects include a brief period of hyperactivity followed by a
decrease in social behavior. However, no overt long-term deficits in social interaction were
identified in the rats. The study also concluded that research is needed to analyze the behavioral
changes of chronic PCP use. In practice, clinicians have mistakenly diagnosed chronic PCP
abusers as schizophrenic patients due to auditory and visual hallucinations, delusions, and
thought disorders (Peters et al., 2017).
Social considerations. Street names for PCP include the peace pill, angel dust, crystal
joints, rocket fuel, sawgrass, zoom, sheets, and elephant tranquilizer (Journey & Bentley, 2022).
Users seek out this drug for its ability to elicit euphoria with sensory distortions and
hallucinations.
In the research conducted by Dominci et al. (2015), 50% of the patients concomitantly
used at least one other substance, such as alcohol, marijuana, and methoxetamine. Researchers
found that toxicology-screened, impaired drivers who used PCP also frequently tested positive
for cannabinoids and cocaine. Even though differing blood levels of PCP were detected, there
were no notable differences in the observed effects of PCP (Lee & Stout, 2020). Witnessing
officers described these impaired drivers as presenting with non-specific signs and symptoms
such as glassy, bloodshot eyes, unsteady gait, slurred speech, confusion, tremors, and elevated
blood pressure (Lee & Stout, 2020). All participants exhibited elevated blood pressure and
displayed at least one indicator during divided attention tests.
PCP users were largely determined to be unsafe to drive, as evidenced by the fact that
82% could not maintain balance during the ‘Walk and Turn’ test (Lee & Stout, 2020). The
number of PCP-positive driving while intoxicated (DWI) cases in studied urban centers rose 3-4
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 8
fold from 2016 to 2018 (Lee & Stout, 2020). The authors concluded that individuals who
commonly intermix PCP with other substances have developed into a public safety concern,
especially when they drive under the influence.
3,4-methylenedioxy-methamphetamine (MDMA)
The compound 3,4-methylenedioxy-methamphetamine is a synthetic amphetamine
derivative, classified as an entactogen, a group of Schedule 1 monoamine releasers and reuptake
inhibitors that induce feelings of emotional openness and interpersonal bonding (Garcia-Romeu
et al., 2016). MDMA was first synthesized in 1912 and found to be an appetite suppressant.
However, the use of the drug remained relatively obscure until the second half of the 20th
century. During the early 1970s, experimental psychologists began to incorporate MDMA as an
adjunct to psychotherapy, giving the drug the term, ‘Penicillin for the soul.’ (Papaseit et al.,
2020; Garcia-Romeu et al., 2016). It is currently experiencing a resurgence due to widespread
media coverage of the medical benefits of hallucinogens, including MDMA and Ketamine
(Palamar & Le, 2022).
Usage. MDMA is used in various forms, such as tablets, capsules, powder, or liquid.
Primarily, it is taken orally as tablets or crystals but can also be snorted as a powder or injected
intravenously (Papaseit et al., 2020). As a street drug, MDMA comes in various forms, sold
under the name "ecstasy." "Ecstasy" encompasses MDEA (N-ethyl-3, 4-
methylenedioxyamphetamine), MDA (3,4-methylendioxyamphetamine), PMA (paramethoxyamphetamine), MBDB (3,4-methylenedioxy-phenyl-N-methylbutanamine), ephedrine,
or a mixture of these (Kalant, 2001).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 9
Pharmacology. 3,4-methylenedioxy-methamphetamine is a semi-synthetic hallucinogen
amphetamine derived from methamphetamine and amphetamine. The primary structural
distinction is that MDMA has a methylenedioxy (-O-CH2-O-) group attached to positions 3 and
4 of the aromatic ring of the amphetamine molecule. This orientation causes a close structural
resemblance with the hallucinogenic material mescaline. The resulting pharmacological effects
of MDMA are consequently a mix of amphetamines and mescaline (Davies et al., 2018).
As an indirect serotonin or 5-hydroxytryptamine (5-HT) agonist, MDMA stimulates the
release of serotonin, dopamine, and noradrenaline and inhibits reuptake transporters at the
synapses (Davies et al., 2018). In addition, there is evidence suggesting that MDMA may also
increase the net release of acetylcholine. However, it remains unclear whether the increase in
serotonin or noradrenaline is responsible for the distinct mental and physical effects associated
with MDMA (Kalant, 2001).
Typical dosage of MDMA ranges from 75 to 150 mg, with onset of effects between 30 to
60 minutes and peak effects at 90 minutes (Armenian et al., 2012). In social settings, the most
common dosage is 1-2 tablets, but users may ingest as many as 10 tablets taken in combination
with other illicit drugs, leading to toxicity (Kalant, 2001). The dosage levels of tablets are highly
variable, with the current trend leaning towards more frequent availability of high-dose tablets.
While most ecstasy tablets still contain MDMA, some also include MDA, MDEA, or
amphetamine drug mixtures. Alternatively, they may contain non-amphetamine drugs like
caffeine, ephedrine, ketamine, paracetamol, or even placebos (Parrott, 2004). Most serious
toxicity or fatality cases have occurred with blood levels ranging from 0.5 mg/L to 10 mg/L,
which is up to 40 times higher than the typical recreational range (Kalant, 2001).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 10
MDMA yields subjective effects such as positive mood, increased sociability, and
decreased aggression that persists for 4 to 6 hours after oral administration; the half-life is 8
hours, but it takes five half-lives (about 40 hours) for 95% of drug clearance. The extended
elimination time of MDMA may lead to users experiencing persistent aftereffects for one or two
days (Latimer et al., 2021; Kalant, 2001). MDMA is metabolized primarily by the liver enzyme
CYP2D6. (Armenian et al., 2012)
Signs and symptoms. The effects of MDMA differ based on the dose, frequency, and
duration of use. MDMA can have acute and chronic effects on mental and physical health.
Acutely, MDMA produces wakefulness, endurance, sexual arousal, and increased energy. It is
accompanied by euphoria, increased sensory perception, greater sociability, and increased
emotionality. However, it can also cause undesirable acute effects such as bruxism, increased
muscle activity, lower back and limb stiffness, and pain.
Furthermore, in conjunction with increased muscle activity, MDMA directly affects the
thermoregulatory system in the brain, potentially leading to hyperthermia (Kalant, 2001).
Patients acutely intoxicated with MDMA may present to the hospital with the following
symptoms: tachycardia, hypertension, hyperthermia, cardiac dysrhythmias, lightheadedness or
dizziness, muscle cramping, dilated pupils, panic attacks, and loss of consciousness. Some of the
acute psychological effects include hyperactivity, flight of ideas, mild hallucination,
depersonalization, depression, anxiety, and fatigue, resembling withdrawal symptoms of heavy
amphetamine use. Two to three days after the ingestion, common adverse effects include
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 11
headache, nausea, loss of appetite, blurred vision, dry mouth, and insomnia (Emde, 2003; Kalant,
2001).
Typically, many users of MDMA report an overall positive experience, but increased
exposure through frequent and long-term use of MDMA is associated with numerous adverse
effects. The levels of serotonin and metabolites in the brains of long-term MDMA users decrease
by 50 to 80%, altering glucose metabolism and blood flow in the brain. The damage to
serotonergic neurons in the central nervous system can lead to various mental problems, such as
impairment of memory and executive function, greater impulsivity, recurrent paranoia and
hallucination, psychotic episodes, and severe depression (Hernandez et al., 2005; Kalant, 2001).
Chronic MDMA users are also associated with necrosis of globus pallidus in the brain due to
serotonin receptor stimulation and vasospasm (Hernandez et al., 2005). In addition to
psychological problems, myriad physical problems result even after the cessation of drug use.
Frequent MDMA users reported chronic effects such as bruxism, muscle aches, and pain.
In contrast to the acute hypertension of MDMA use, chronic MDMA users have
hypotension and poor control of heart rate and blood pressure by the autonomic nervous system
(Kalant, 2001). Habitual use can also lead to arterial vasospasm and alterations in coagulation,
resulting from changes in the endothelial lining of the coronary arteries, contributing to the risk
of myocardial ischemia and infarction. Additionally, prolonged exposure to elevated levels of
catecholamines and myocyte necrosis may lead to irreversible cardiomyopathy. (Klein &
Kramer, 2004).
The hemodynamic effects of MDMA are the result of increased catecholamine release,
causing tachycardia, hypertension, a rise in systemic vascular resistance, and greater myocardial
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 12
oxygen consumption. Due to the eventual, inevitable catecholamine depletion and MDMAinduced autonomic dysregulation, patients may experience severe hypotension and
dysrhythmias. There also have been case reports of arterial vasospasm, atherosclerosis, damage
to the endothelial lining of the coronary arteries, and changes in coagulation that led to
myocardial ischemia and infarction (Klein & Kramer, 2004).
Special consideration should be directed towards the link between MDMA and death in
females due to hyponatremic encephalopathy. Moritz et al. notes that MDMA may cause
hyponatremia in both females and males, however, acutely intoxicated females present with a
significantly higher incidence (26.7% compared to 3% in males), and all recorded cases that led
to encephalopathy, brain herniation, and eventually death, were female (2013).
While the exact cause of hyponatremia from MDMA is not well established, there is a
possible physiologic explanation for sex-linked differences. Outside the context of MDMA
intoxication, stronger serotonin response and vasoconstrictive effects of arginine vasopressin
(AVP) are naturally more pronounced in females and are thought to be responsible for the usual
disparity of symptomatic hyponatremia between sexes. However, within the perioperative realm,
anesthesia providers should be aware that female ingestion of MDMA has been documented to
increase secretion of AVP even further, thereby potentially increasing the risk for hyponatremic
encephalopathy during a surgical encounter (Moritz et al., 2013).
Social Considerations. 3,4-methylenedioxy-methamphetamine is commonly referred to
by street names such as ecstasy, Adam, XTC, or Molly. This recreational drug gained popularity
because it enhances energy, stamina, and sexual arousal. Unlike alcohol, cannabis,
benzodiazepines, or opioids, MDMA does not appear to be associated with dependence. Some
argue that this is due to the reduction in pleasurable effects and the increase in unpleasant effects
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 13
when used long-term (Kalant, 2001). To note, there is a significant crossover between MDMA
users and combined recreational use of other drugs, an occurrence known as polysubstance
abuse. Historically, ecstasy users concurrently use tobacco, alcohol, ketamine, cannabis,
methamphetamine, cocaine, and Gamma-hydroxybutyrate (Papaseit et al., 2020).
Lysergic acid diethylamide (LSD)
Lysergic acid diethylamide (LSD) was first synthesized in 1938 and assessed for its
psychoactive properties in 1943 (Liechti, 2017). LSD is a semi-synthetic natural drug derived
from the rye fungus Claviceps purpurea (Nichols, 2014). Clinical research in the mid-twentieth
century investigated LSD as a treatment tool for complex psychiatric cases, taking on the form of
'hallucinogen psychotherapy' garnering significant cultural momentum (Carhart-Harris &
Goodwin, 2017). Currently, LSD has solidified its position as a popular recreational drug. In
2010, an estimated 32 million U.S. residents had reported a lifetime use of LSD. Reasons for use
included curiosity, mystical experiences, and introspection (Liechti, 2017). Due to its high
potential for abuse, LSD is a Schedule I substance under the Controlled Substances Act (Nichols,
2018).
Usage. LSD is frequently consumed by adolescents and young adults, often associated
with events such as nightclub concerts, and most notably seen in raves (DEA, 2019). LSD
enhances energy, endurance, sociability, and sexual arousal (Kalant, 2001). This hallucinogen is
ingested orally and may be found in tablets, capsules, and liquid frequently found on blotter
paper. (Handen & Wood, 2019; Nichols et al., 2016). Blotter papers are sectioned into “hits” and
administered buccally or sublingually, allowing for absorption via mucous membranes (Nichols
et al., 2016).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 14
Pharmacology. The critical mechanism of action of LSD is the activation of the frontal
cortex glutamate transmission secondary to human serotonin 2A receptor (5-HT2A) stimulation.
LSD's structure is similar to the neurotransmitter serotonin, enabling it to connect with serotonin
receptors in the brain. The interaction with the 5-HT2A receptor triggers the psychedelic effects
of LSD. When activated, this receptor can lead to hallucinations and significant shifts in
consciousness typical of an LSD experience. The drug's engagement with the 5-HT2C receptor
might influence mood and could be responsible for potential side effects, such as anxiety or
panic in some users. Additionally, LSD affects the 5-HT1A receptors, leading to mood, anxiety,
and sleep alterations (Gasser, 2014). The activation of these receptors is theorized to explain the
reported anxiety-relieving properties of LSD.
Anesthesia providers should be vigilant regarding the potential clinical implications of
LSD use, as it can lead to serotonin syndrome and interact with various medications commonly
used in anesthesia practice. Thus, anesthesia providers should be aware of the following drugs
that can interact with LSD, such as selective serotonin reuptake inhibitors, meperidine, lithium,
tryptophan, or monoamine oxidase inhibitors (Singh et al., 2019). LSD has been shown to inhibit
plasma cholinesterase activity, causing a prolonged muscle relaxant effect from succinylcholine;
therefore, anesthesia providers should avoid succinylcholine in patients with suspected LSD use
(Beaulieu, 2017).
Signs and Symptoms. Acute LSD intoxication or chronic ingestion of this hallucinogen
presents many physiological and psychological symptoms. LSD mainly induces audiovisual
synesthesia, depersonalization, and altered perceptions and consciousness (Liechti, 2017).
Similar to MDMA, the effects of LSD that attract users are euphoria, openness, and trust. Due to
these effects, many researchers believe that LSD has the potential to succeed in the clinical
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 15
psychotherapy arena to benefit mental health. Physiological effects on the body include dilated
pupils, hyperthermia, tachycardia, hypertension, diaphoresis, insomnia, tremors, and xerostomia
(Drug Information DEA, 2022).
The international survey study by Kopra et al. (2022) investigated a 12-month incidence
of LSD-related adverse cases presenting for emergency medical treatment. Only 102 (1%) out of
10,293 LSD users sought medical care due to recreational use of the drug. Data from a global
survey in 2017 showed that the common crises presented to Emergency Medical Services (EMS)
involving LSD were psychological and included anxiety, paranoia, disordered thoughts, panic
attacks, and self-harming behavior (Kopra et al., 2022).
Social Considerations. Colloquially, LSD is commonly known as Acid, Mellow Yellow,
Blotter Acid, and Window Pane (Drug Information DEA, 2022). In controlled settings, Lysergic
acid diethylamide is considered physiologically safe when moderate dosages are used (50–200
μg); however, even in the review of existing case reports labeled “LSD toxicity,” few instances
of fatality were found. Nichols and Grob’s (2017) systematic case review examining published
media and scientific literature covering deaths related to LSD use found that while the drug can
influence behavior leading to dangerous activity causing fatality, only two documented cases
where post-mortem analysis indicated massive LSD overdose directly caused mortality. Other
instances of fatality were attributed to excessive restraint in response to LSD-associated
psychological agitation. In contrast, some fatal events were erroneously labeled under LSD when
other psychoactive drugs were later found to be the cause of violent behavior and death (Nichols
& Grob, 2017).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 16
Chapter Two
Methodology
An extensive literature review was conducted using the following databases: Google
Scholar, PubMed, and PsycINFO. In addition, mandatory hospital reporting surveys and
statistics by the United States government, such as the National Survey on Drug Use and Health
(NSDUH) and the DEA, were also included. The first search focused on examining the effects of
phencyclidine, d-lysergic acid diethylamide, and 3,4-methylenedioxy-methamphetamine.
"Phencyclidine, d-lysergic acid diethylamide, MDMA, ecstasy, molly, pharmacology,
emergency, intoxication, toxicity, anesthesia" were used as keywords. The initial results yielded
2737 abstracts.
Inclusion criteria included: (a) individuals under the influence of MDMA, PCP, and LSD
while undergoing surgery involving the use of anesthetics, general anesthesia, and moderate
sedation; (b) symptomatology associated with the misuse of MDMA, PCP, and LSD, and (c)
anesthesia considerations for individuals undergoing emergency and elective procedures under
the influence of MDMA, PCP, and LSD. Exclusion criteria consisted of studies before 2000,
studies in a language other than English, studies on a population other than humans, persons
younger than twelve years old, studies that did not include hallucinogens known as
phencyclidine, d-lysergic acid diethylamide, and 3,4-methylenedioxy-methamphetamine. Of the
articles returned by our search, we excluded 1,985 abstracts for languages other than English and
for addressing a population other than those under the influence of phencyclidine, d-lysergic acid
diethylamide, and 3,4-methylenedioxy-methamphetamine. The remaining 752 records were
screened, and 518 did not meet the inclusion criteria. An additional 213 articles were rejected for
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 17
not assessing the clinical effects of PCP, LSD, or MDMA use. The final analysis included 45
scholarly papers.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 18
Chapter Three
Literature Review
Phencyclidine (PCP)
The chronic and acute intoxication of PCP presents to the hospital with differing clinical
symptoms. Dominici et al. (2015) conducted a case series study at a tertiary care center that
analyzed data on 184 patients on PCP with a mean age of 32.5 years (±7 years). More than half
of the study participants (53.8%) used PCP concomitantly with at least one other substance. PCP
users presenting to the emergency department had a short stay with an average of 261.1 (±172.8)
minutes. The authors report that clinical manifestations in this population were transient, so
patients only needed to be admitted for clinical observation before getting discharged (Dominici
et al., 2015). However, in the following case reports of high-dose PCP toxicity, patients needed
emergency medical care for significant organ damage.
Acute Intoxication. A case study by Berar et al. (2019) presented the physiological
effects and medical management of a 17-year-old male with a history of polysubstance abuse
who consumed high doses of methoxyphencyclidine (3-MeO-PCP), a form of PCP. This 17-
year-old patient presented with altered mental status, hypertension, tachycardia, agitation,
mottled skin, and limb tremors. Medical management for this patient was mainly symptomatic
treatment, including sedatives (i.e., midazolam) and antipsychotics (i.e., cyamemazine and
loxapine) for hypertonia and agitation. The medical team also focused on intravenous hydration
therapy and resuscitation, giving 3000 ml per 24 hours. They found that flumazenil and naloxone
were ineffective reversal agents. In addition, hemodialysis and peritoneal dialysis were
ineffective because PCP redistributes from the lipid stores to the blood after dialysis. Berar et al.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 19
(2019) concluded that higher doses and severe intoxication levels of PCP, along with
polysubstance abuse, can result in a coma requiring tracheal intubation.
In another case study, a 25-year-old man exhibited bizarre behavior involving severe
agitation and hallucinations. This case resulted in acute liver injury induced by PCP intoxication
("Phencyclidine," 2016). On admission, he had malignant hyperthermia (108.4F), tachycardia
(160 beats/min), and tachypnea (44 breaths/min). His gastric aspirate tested positive for PCP. He
was intubated and treated with cooling measures but fell into a coma for ten days. During his
hospital admission, he suffered a severe hepatic injury complicated by a perforated duodenal
ulcer. His bilirubin rose from 0.7 to 22.5 mg/dL, Alanine transaminase (ALT) from 30 to above
9,000 U/L, and prothrombin index fell from 95% to 5%. The liver biopsy showed acute hepatic
necrosis. Thus, clinicians concluded that his hepatic injury was likely due to malignant
hyperthermia induced by PCP overdose ("Phencyclidine," 2016).
Chronic Use. In a case study by Inayat et al. (2018), researchers analyzed the clinical
course of a 41-year-old chronic user of PCP and cannabis with a history of asthma and seizure
disorder. He presented to the emergency department for atypical left chest pain, dizziness,
slurred speech, shaking in his right arm, and diaphoresis. On admission, the patient was
tachycardic with 102 beats/min and had a blood pressure of 156/89 mm Hg. His physical
examination was unremarkable. Clinicians prescribed sublingual nitroglycerin, but it did not
relieve his chest pain. Clinicians diagnosed the patient with Pseudo-Wellens' syndrome (PWS).
In this state, a temporary interruption in the anterior myocardial perfusion causes angina without
progression to myocardial infarction. PCP has sympathomimetic effects, such as vasoconstriction
on the coronary vasculature. This physiologic effect was suspected to have enhanced the
symptoms of chest pain in this patient from a coronary vasospasm in the left anterior descending
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 20
artery. The case study also noted that PWS is commonly associated with marijuana intoxication,
supporting the concept that polydrug use may complicate diagnosis in suspected PCP
intoxication. Researchers recommend urgent cardiac catheterization in cases of PWS because left
anterior descending artery stenosis is a contraindication for stress testing. The patient was
initiated on oral nifedipine 10 mg daily for blood pressure reduction and antianginal effects. His
hospital course was unremarkable, and the hospital discharged him on day 3 to a substance use
rehabilitation center. The 12-week follow-up ECG showed complete resolution of the PWS
pattern with resolution of left ventricle apex hypokinesis.
3,4-methylenedioxy-methamphetamine (MDMA)
Acute Intoxication. Elkattawy et al. (2021) conducted a case report of a 29-year-old
woman who ingested an unknown dose of MDMA. She presented to the emergency department
with a new onset of seizures. Upon admission, she was found to be hyponatremic; her sodium
level was 117 mMol/L with a creatine phosphokinase (CPK) concentration of 1123 U/L. This
case report highlights the link between MDMA and the development of hyponatremia and
rhabdomyolysis. MDMA-induced hyponatremia is typically below 120 mMol/L and is
considered one of the most severe acute complications associated with MDMA use. There are
two proposed theories for the mechanism of action in MDMA-associated polydipsia. The first
theory states that hyponatremia results from a syndrome of inappropriate antidiuretic hormone
(SIADH) and subsequent water intoxication. The structural similarity of MDMA with serotonin
causes an increase in serotonin and dopamine, which stimulate the release of arginine
vasopressin (AVP) in the brain. Consequently, this triggers SIADH, characterized by urine
osmolarity of 184 to 970 mOsm/kg and increased water intake due to hyperpyrexia. The second
theory is extreme fluid intake due to direct MDMA-induced hyperpyrexia and psychogenic
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 21
polydipsia, leading to hyponatremia. One study suggests that the heightened impact of MDMA
on females could be linked to estrogen potentially reducing the Na-K-ATPase pump, thereby
inhibiting sodium release from the brain. Additionally, research findings show that the
vasoconstrictive effects of AVP are more pronounced in females than in males.
The authors recommend the management of MDMA-induced hyponatremia based on the
severity of symptoms. In mild to moderate hyponatremia, fluid restriction and urine output
monitoring, osmolarity, and serum sodium levels are recommended. If MDMA-associated
hyperpyrexia occurs, body temperature should also be monitored and treated. In addition,
patients are prescribed hypertonic 3% saline fluid or mannitol for severe hyponatremia. Two
hours after starting hypertonic and 500 ml of normal saline, the 29-year-old patient’s serum
sodium increased from 117 mMol/L to 129 mMol/L. The IV fluids were then switched to
Dextrose 5%. However, due to a continued increase of sodium level to 134 mMol/L, two doses
of 1 mcg of Vasopressin were given at the 3-hour mark, resulting in a return of sodium level to
130 mMol/L. The patient regained her mental capacity and physical homeostasis eight hours
after the presentation. The authors concluded that MDMA toxicity should be listed as a potential
differential diagnosis when patients present with unexplained coma and hyponatremia
(Elkattawy et al., 2021).
In a case series by Armenian et al. (2013), twelve MDMA-intoxicated patients from a
single rave event presented to the San Francisco General Hospital with various life-threatening
complications: altered mental status, hyperthermia, tachycardia, seizures, acute kidney injury,
hypotension, rhabdomyolysis, and disseminated intravascular coagulation (DIC). Among these
twelve patients, eight needed emergent endotracheal intubation, seven had severe hyperthermia
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 22
(40.9 – 43 ° C), five received emergent dialysis for acute kidney failure, acidosis, and
hyperkalemia, four developed permanent neurologic, musculoskeletal, and renal complications,
and two patients died. All patients developed rhabdomyolysis during hospitalization with
creatine kinase levels of 1511 to 196,000 U/L. Five patients who developed DIC had transfusions
of red blood cells, platelets, fresh frozen plasma, cryoprecipitate, and factor seven. The duration
of hyperthermia and prolonged hypoxia caused by large doses of MDMA ingestion produced
severe outcomes.
Ten out of twelve patients suffered from hyperthermia and needed cooling treatments.
Two patients remained hyperthermic and ultimately died. The first patient, a 23-year-old male
with no past medical history, had a generalized intractable tonic-clonic seizure despite two
intravenous doses of 4 mg midazolam. His vital signs were as follows: a temperature of 43
degrees Celsius, a heart rate of 168 beats per minute, and a blood pressure of 122/96 mmHg. An
hour after his arrival, he received a surface cooling blanket and 2 liters of cold (4 degrees
Celsius) normal saline. Within three hours, his body temperature dropped to 38.7 degrees
Celsius. After eight hours, clinicians used vecuronium to induce neuromuscular paralysis. He
remained hypotensive at the ten-hour mark despite receiving three different vasopressors and a
massive transfusion of red blood cells, platelets, and fresh frozen plasma. Eventually, he began to
show signs of DIC, leading to administration of Desmopressin, factor seven, cryoprecipitate, and
prothrombin complex concentrate. Even after receiving continuous renal replacement therapy,
the patient remained hypoxic, hypotensive, and challenging to ventilate. He was pronounced
dead 20.5 hours after arrival. The second patient, a 25-year-old male with no past medical
history, became apneic, bradycardic to 20 beats per minute with a narrow QRS complex and
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 23
rigid with clenched teeth. Shortly after, he required cardiopulmonary resuscitation, and his vital
signs were as follows: a heart rate of 152 beats per minute, a blood pressure of 79/10 mmHg,
100% oxygen saturation while on 100% FiO2, and a temperature of 39 degrees Celsius. He
developed bilateral cerebral edema that progressed to narrowing of lateral ventricles and
obliteration of the gray and white matter. Over four days, he displayed decerebrate posturing and
central diabetes insipidus, leading to a transition to comfort care (Armenian et al., 2013).
Prolonged hyperthermia is suspected to have caused DIC and multiorgan system failure
in these patients. The authors describe several passive and active cooling measures: ice pack
application to the neck, groin, and axillae, evaporative cooling, ice water lavage via nasogastric
tube, chilled intravenous fluids, electronic cooling blankets, and neuromuscular paralysis.
Dantrolene, a muscle relaxant, was used to treat three of the abovementioned patients to help
with muscle hyperactivity caused by MDMA-induced hyperthermia (Armenian et al., 2013).
A case study by Politi et al. (2023) examined MDMA toxicity, both acute severe and
chronic, that led to death in two young females: one from cerebral edema due to MDMA-induced
hyponatremia; the second from acute liver failure accompanied with hyperthermia,
rhabdomyolysis, and DIC. The first case was an insulin-dependent 16-year-old girl with no prior
history of amphetamines/ecstasy use, as evidenced by the autopsy. After ingesting two MDMA
tablets, she presented with diaphoresis, bruxism, trismus, seizure, and loss of consciousness,
followed by cyanosis and cardiopulmonary arrest that led to her death. Her sodium was 118
mmol/L, and her blood glucose was 305 mg/dL. The autopsy revealed that the patient suffered
from diffuse cerebral edema with vessel congestion, pulmonary congestion with intra-alveolar
edema, slight hepatic steatosis, and pluri-visceral congestion. The exact mechanism of MDMA-
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 24
induced hyponatremia is unknown. Increased body concentration of antidiuretic hormone
(ADH), increased water reabsorption from altered aquaporin-2 channels, and extreme fluid
intake due to MDMA-induced polydipsia may all contribute to sodium loss. In this case,
underlying diabetes further exacerbated her case because amphetamines directly act on insulin
regulation, increasing the risk of hyperglycemic crises.
Chronic Use. In a case that involved a different 16-year-old girl with a history of
occasional ecstasy use, the subject collapsed after consuming one ecstasy tablet diluted in a
beverage. First responders intubated her on the field, but she died 15 hours after hospital
admission. The patient presented with metabolic acidosis, hypoglycemia (55 mg/dl), temperature
of 40.5 °C, heart rate of 148 beats per minute (bpm), and blood pressure of 135/65 mmHg. Acute
liver failure followed by DIC caused her death. The mechanisms that led to acute liver failure
include impaired metabolism due to inhibition of CYP2D6 liver enzymes by MDMA, oxidative
stress, immune responses of specific human leukocyte antigen (HLA) phenotypes, hyperthermia,
glutathione depletion, systemic hypotension, and hypoxia. Ultimately, the authors conclude that
MDMA-mediated toxicity has multiple physiological and pathological causes, so the high blood
concentration of MDMA cannot predict individual fatalities. Patient comorbidities, detectable
and undetectable tablet impurities, and concomitant ingestion of other substances can also
contribute to fatalities. Data suggests that MDMA-mediated toxicity is primarily due to oxidative
stress on cell function regardless of drug dosage (Politi et al.,2023).
Lysergic acid diethylamide (LSD)
Case reports in the literature indicate that LSD overdoses are not typically fatal. In most
instances, LSD-intoxicated users present with common physiological features such as
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 25
hyperactive visual and auditory hallucinations, tachycardia, dilated pupils, emesis, flushing, and
diaphoresis (Nichols & Grob, 2017). These symptoms were reportedly transient. Researchers
suggest that LSD can have positive effects on patients. In several case studies, LSD has
demonstrated a low toxicity profile and significantly improved users' mental health and pain
perception. One study documented a moderate and prolonged analgesic effect of low-dose LSD
without inducing a psychedelic experience. It identified the minimal effective dose for analgesic
activity and suggested further research to optimize it for maximal efficacy with minimal mental
interference. The potential use of low-dose LSD as a novel, effective, and safe treatment option,
particularly in patients with persistent pain and neuropsychiatric conditions, is postulated. These
researchers assert that exploration of tolerance development and comparative benefits to
traditional drugs like opioids is warranted (Ramaekers et al., 2021).
Acute Intoxication. In a case study detailed by Haden and Woods (2019), a 15-year-old
female ingested over 1,000 mcg of LSD, ten times the usual recreational dosage of 100 mcg. The
lethal dose of LSD in a human is around 14,000 mcg. After ingesting 1,000 mcg of LSD, she
experienced multiple seizures. Despite the overdose, her EEG was normal. Over time, her affect
and mental health improved to the point that she later reported being free from all mental illness
symptoms. After the event, she weaned off lithium, which she had been prescribed to help her
cope with symptoms of hypomania and depression from bipolar disorder. Overall, LSD proved
to have a positive effect on this patient, allowing for significant improvement in mood with a
decrease in mania and psychotic symptoms.
In a second case report detailed by Haden and Wood (2019), a 26-year-old pregnant
woman with a history of hallucinogens, cannabis, and alcohol use overdosed on 500 mcg of LSD
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 26
and reported an "intense reaction." At the time of her overdose, she was two weeks pregnant. She
did not experience any signs or symptoms of nausea, seizures, or loss of consciousness. Her
child, now 18 years old at the time of follow-up, showed no signs of any sequelae from his
mother's LSD overdose. The case suggests that neither the patient nor her child appeared to have
experienced long-term effects from an LSD overdose.
Chronic Use. A 26-year-old male university student in Israel with a history of frequent
LSD, cannabis, and alcohol use reported various visual disturbances, including macropsia,
micropsia, pelopsia, and teleopsia after LSD intoxication. Researchers Lerner and Ran (2015)
noted that these visual disturbances caused by LSD are associated with "Alice in Wonderland
Syndrome" (AIWS) or Todd's syndrome. After stopping all substance use due to social anxiety,
the patient noticed a return of some visual disturbances he had experienced when intoxicated
with LSD. The toxic effects of LSD caused temporary impairment of the lateral geniculate
nucleus, eliciting recurrent visual disturbances. According to the authors, these symptoms of
LSD intoxication during and after use were temporary, reversible, and harmless (Lerner & Ran,
2015).
In a case study reported by Haden and Wood (2019), a 46-year-old female reports microdosing LSD 25 mcg along with morphine for her foot pain. In her previous history, she had
intranasally ingested 550 times the average recreational LSD dose. Unexpectedly, the overdose
had positive effects on her pain levels, causing her to seek out an LSD-based therapeutic
program. The patient reported that her pain was significantly reduced from micro-dosing on
LSD. Eventually, she was able to stop taking morphine completely.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 27
In another study, healthy volunteers received single doses of 5, 10, and 20 mcg of LSD
and placebo. A ‘Cold Pressor Test’ assessed pain tolerance at 1.5- and 5-hours postadministration, along with monitoring mental state and safety through dissociation and
psychiatric symptom ratings and vital sign assessments. LSD at 20 mcg increased cold water
tolerance, reduced perceived pain and unpleasantness, and slightly elevated blood pressure,
dissociation, anxiety, and somatization ratings. The study suggests a long-lasting analgesic effect
of low-dose LSD without inducing psychedelic experiences. Taken together, these reports offer a
basis for further investigation in patient populations of specific interest to anesthesia
professionals.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 28
Table 1
Guide to hallucinogen duration and detection through toxicology screening
Hallucinogen PK/PD Detection
Window for a
urine drug test
Substance Causing FalsePositives
PCP Onset of action: 2-5
minutes
Peak effect: 2-5 hours
Duration: 6-48 hours
Half-life: 21 hours
8-14 d Dextromethorphan, Ibuprofen
MDMA Onset: 30-45 minutes
Duration: 4-6 hours
48 h Pseudoephedrine, Vicks inhaler
LSD Onset: 20-90 minutes 36-96 h Amitriptyline, Sumatriptan
(Moran et al., 2015)
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 29
Chapter Four
Results and Recommendation for Practice
This thorough literature review explores the broad implications of hallucinogens in
anesthesia care and offers specific considerations for PCP, LSD, and MDMA.
In non-emergent cases, the suggestion is to delay surgery until the patient undergoes
detoxification. Treatment for hallucinogen overdose involves fluid administration, correction of
electrolyte imbalances, and supportive care in a controlled environment. An optimal environment
for these patients involves a quiet setting with minimal stimulation until symptoms subside
(Emerick et al., 2024).
In emergency cases, anesthesia providers must be aware that administering anesthesia to
a patient under the influence of hallucinogens may trigger an exaggerated sympathetic response
with a symptom profile that includes tachycardia, hypertension, tachypnea, and diaphoresis.
Acutely intoxicated hallucinogen users often need a higher mean alveolar concentration (MAC)
of volatile anesthetics. In situations with a heightened risk of autonomic dysregulation, patients
will require invasive blood pressure monitoring to allow for close monitoring and management
of hemodynamic lability. Ideally, avoidance of triggering agents and proactive symptom
management should be planned (Emerick et al., 2024).
Anesthesia providers can expect patients who habitually use hallucinogens to
demonstrate prolonged analgesic and respiratory depressant effects from opioid administration.
(Harbell, 2021). Additionally, patients who use hallucinogens chronically may have decreased
endogenous catecholamine supply and may be resistant to sympathomimetic medication. These
patients frequently require direct-acting vasoconstrictors to manage persistent hypotension.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 30
Anesthesia providers must anticipate and address these considerations to ensure safety and
effectiveness if a surgical need arises (Harbell, 2021).
Phencyclidine (PCP)
Anesthesia management of PCP intoxication is primarily influenced by factors such as
route of exposure, dosage, and polysubstance use. Presenting symptoms range from unconscious
and insensate to profound agitation (Heard et al., 2022). Treatment recommendations in the
perioperative setting are centered on supportive care and close monitoring. Airway protection
with an endotracheal tube and mechanical ventilation may be needed if PCP-intoxicated patients
are unable to protect their airways. Patients should be placed on a cardiac monitor, given
supplemental oxygen, and given intravenous fluids. In cases of hemodynamic instability,
invasive blood pressure monitoring is necessary.
Rapid control of PCP-related psychomotor agitation is critical. Administering
benzodiazepines such as lorazepam 4 mg intravenously or midazolam 5 mg intravenously or
intramuscularly is recommended to control PCP-related psychomotor agitation. Butyrophenones
such as droperidol 5 mg or haloperidol 5 to 10 mg can be used as adjective therapy to
benzodiazepines if agitation persists. Use butyrophenones cautiously, as these drugs can lower
the seizure threshold and impair heat regulation. In addition, initiating a propofol or barbiturate
infusion during the perioperative period may be necessary in the case of severe refractory
agitation or status epilepticus (Heard et al., 2022).
PCP acute use and overdose can put a patient in a hypertensive emergency. Anesthesia
providers should prepare clevidipine, nicardipine, or phentolamine in advance, as these are the
drugs of choice in treating patients with a hypertensive emergency preoperatively or
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 31
perioperatively (Aronow, 2017). Refractory hypertension can be treated with short-acting agents
like nitroglycerin and nitroprusside (Heard et al., 2022). Despite the elevation in blood pressure,
these patients are often dehydrated and need intravenous hydration when under the influence of
PCP (Berar, 2019). Developing a fluid plan and carefully keeping track of fluid loss and lab
values such as electrolytes and acid-base balance is prudent. In addition, avoid the administration
of ketamine, as it is a derivative of PCP and can worsen hallucinations, especially during
emergence from anesthesia (Heard et al., 2022).
3,4-methylenedioxy-methamphetamine (MDMA)
In all elective surgeries, if acute MDMA intoxication is suspected, it is advisable to
postpone the procedure. However, in emergencies where surgery is imperative, several anesthetic
considerations require careful attention. General anesthesia proves beneficial in controlling CNS
disturbances, reducing metabolic demands, managing MDMA-induced hyperthermia, and
addressing cardiovascular issues. The recommended anesthetic technique includes a combination
of propofol, benzodiazepines, and alpha-2 agonists (Emerick et al., 2024). Nondepolarizing
muscle relaxants are also safe for use (Moran et al., 2015). It is important to note that ketamine is
not recommended for induction due to the potential for patients to be catecholamine depleted,
leading to an exaggerated increase in heart rate and blood pressure (Emerick et al., 2024). One
study supports the theory that individuals predisposed to developing malignant hyperthermia
after receiving succinylcholine or volatile anesthetics may exhibit a similar predisposition when
ingesting MDMA. Consequently, the use of succinylcholine and volatile agents should be
avoided (Klein & Kramer, 2004). Regional anesthesia can be advantageous, allowing for close
monitoring of neurological status. However, a challenge may arise in obtaining consent or
administering a block if the patient is agitated or uncooperative (Emerick et al., 2024).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 32
MDMA can induce various cardiovascular effects, including dysrhythmias and
fluctuations in blood pressure attributed to catecholamine depletion. Initially, patients may
present with tachycardia and hypertension in the emergency department, followed by subsequent
episodes of hypotension and bradycardia. Hypertension may be managed with sedation or
necessitate the administration of sodium nitroprusside or calcium channel blockers. Betablockers are avoided due to unopposed alpha effects that could exacerbate hypertension (Emde,
2003). In cases of hypotension, direct-acting vasopressors are recommended due to depleted
catecholamines. Invasive blood pressure monitoring is advisable for continuous monitoring of
hemodynamics.
Patients who have ingested MDMA may also present with severe hyponatremia, leading
to cerebral edema, seizures, and pulmonary edema due to excessive water intake and increased
antidiuretic hormone levels from serotonergic activity. Close monitoring of fluids and
electrolytes is essential in the operating room, and hyponatremia should be corrected gradually to
prevent cerebral pontine myelinolysis (Hernandez et al., 2005; Harbell, 2021).
Another serious complication of acute MDMA intoxication includes hyperthermia and
rhabdomyolysis. A study in 2003 demonstrated that MDMA induced malignant hyperthermia in
genetically susceptible swine, resulting in muscle rigidity, metabolic acidosis, and hyperthermia.
Therefore, an association between MDMA intoxication and malignant hyperthermia was
suggested (Fiege et al., 2003). Supportive measures such as ice packs, ice water lavages, chilled
IV fluids, and electronic cooling blankets can be employed (Armenian et al., 2012). Regarding
treatment, the use of dantrolene or clozapine is controversial but can be considered as a
supportive measure (Harbell, 2021).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 33
Lysergic acid diethylamide (LSD)
Because of low toxicity, patients with LSD ingestion typically present with mild
physiological effects (Kopra et al., 2022). Patients under the influence of LSD may present with
altered mental status, sensory perception disturbances, and unpredictable behavior. Other
symptoms include heightened anxiety, tachycardia, and hypertension (Drug Information DEA,
2022; Kopra et al., 2022). Anesthesia management in such cases can be challenging due to the
unpredictable nature of LSD effects, which may lead to difficulties in communication,
cooperation, and response to standard anesthetic agents.
In anesthesia management of patients under the influence of LSD, a supportive approach
is advised; oxygen therapy, fluid administration, and continuous monitoring of vital signs are all
appropriate standard measures. Sedation, if required, can be achieved using benzodiazepines,
while the administration of a serotonin antagonist like cyproheptadine may be considered to
counteract LSD effects in extreme circumstances (Beaulieu, 2017). The differential diagnosis in
these cases should include conditions such as anticholinergic syndrome, malignant hyperthermia,
and neuroleptic malignant syndrome. Careful evaluation and tailored management strategies
should be employed to investigate differential diagnoses. In managing patients under the
influence of LSD, it is important to avoid medications that can interact with LSD, such as
selective serotonin reuptake inhibitors, meperidine, lithium, tryptophan, or monoamine oxidase
inhibitors (Singh et al., 2019) (Scotton et al., 2019). Due to LSD's ability to inhibit plasma
cholinesterase activity, succinylcholine should not be administered (Beaulieu, 2017).
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 34
Table 2
Anesthesia management of hallucinogen intoxicated patients
Hallucinogen Anesthesia Considerations
PCP Toxic effects: seizure, liver failure, rhabdomyolysis, psychomotor
agitation, nystagmus, tachycardia, hypertension, psychosis, coma
Anesthesia considerations:
- Nondepolarizing muscle relaxers, benzodiazepines, propofol,
nitroprusside, and nitroglycerin are safe.
- Avoid succinylcholine and ketamine
- Prepare nitroglycerin, nitroprusside, clevidipine, nicardipine,
or phentolamine in anticipation of hypertensive crises
Management:
- Secure the airway (if patient is unable to protect airway)
- Provide supplemental oxygen
- Gain intravenous access
- Benzodiazepines and atypical antipsychotics.
- Careful note of intake and output
- Monitor electrolytes and acid base balance
MDMA Toxic effects: hyperthermia, hyponatremia, cerebral edema, seizures,
pulmonary edema, rhabdomyolysis, and multi-organ failure
Anesthesia considerations
- Nondepolarizing muscle relaxers, benzodiazepines, propofol,
nitroprusside, and nitroglycerin are safe.
- Temperature can be controlled with cold fluid or a cooling
blanket
- Treatment of dantrolene is controversial but can be used
- Correct hyponatremia slowly to prevent central pontine
myelinolysis
- Watch for spontaneous pneumothorax and
pneumomediastinum if any signs of unexplained oxygenation
or ventilation difficulty
Management
- Activated charcoal 50 grams PO/NG if < 1 hours after
ingestion
- Monitor core body temperature: watch for hyperthermia
- Labs: Full blood count, urea and electrolytes, creatine
phosphokinase, liver function tests, calcium, phosphate,
coagulation screen, and an arterial blood gas
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 35
- 12-lead electrocardiogram
- Urinalysis
LSD Toxic effects: hallucination, dilated pupils, synesthesia, tachycardia,
tachypnea, fever, hypertonia, and hyperglycemia
Anesthesia Considerations
- Avoid selective serotonin reuptake inhibitors, meperidine
lithium, tryptophan, or monoamine oxidase inhibitors
- LSD can inhibit plasma cholinesterase activity, causing a
prolonged muscle relaxant effect from succinylcholine
Management
- Treatment is supportive (oxygen, fluids, monitoring)
- Sedation with benzodiazepines and administration of a
serotonin antagonist such as cyproheptadine
- The differential diagnosis includes the anticholinergic
syndrome, malignant hyperthermia, and neuroleptic malignant
syndrome
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 36
Chapter Five
Discussion
As the use of hallucinogens increases, the likelihood of anesthesia professionals
encountering patients who have recently used these substances presenting for elective or
emergent surgeries has risen. During the preoperative evaluation, anesthesia providers should
conduct a thorough history of illicit drug use (Harbell, 2021). Anesthesia providers need to
remain strictly clinical and nonjudgmental in their questioning to encourage patients to be
forthright, providing the necessary information for an accurate anesthesia plan (Moran et al.,
2015). Unfortunately, these patients may not be reliable historians and are often not forthcoming
about recent drug use (Gallagher et al., 2022). For unconscious or trauma patients, toxicology
testing should be considered (Moran et al., 2015). However, since many hallucinogens are
undetectable on toxicology screens, diagnosis and care depend on an accurate assessment by a
well-informed provider. These patients may present with symptoms ranging from mild
alterations in thinking and judgment to severe perioperative morbidity and mortality, potentially
leading to life-threatening conditions requiring emergent surgeries (Gallagher et al., 2022). If
toxicology tests are positive, Moran et al. recommend delaying the procedure and informing the
patient of the anesthesia risks associated with hallucinogen use (2015). However, in the case of
emergent surgery, strong competence in the anesthesia implications for hallucinogen-intoxicated
patients is critical, as no rapid and reliable antidote exists (Emerick, 2024).
Findings
Anesthesia providers must consider various aspects of hallucinogen use, as it can impact
their practice in multiple ways. Illicit drugs often lack purity standards and are frequently diluted
with inert materials such as talc to increase profits. These drugs may also contain other active
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 37
ingredients, including fentanyl or cocaine, making it difficult to ascertain a complete
understanding of the substances ingested, even if the patient is forthright. This threatens the
validity of a preoperative evaluation, even if it is performed thoroughly. Frequent or recent use
can interfere with anesthetic agents, either by requiring higher doses due to tolerance or by
exaggerating the patient's response to anesthesia (Emerick, 2024). Although it is recommended
to delay surgery for seven days after the last recreational drug use, it is often unrealistic to expect
chronic users to remain abstinent even for a few days (Bryson, 2022).
The basic pharmacology information, toxic effects, drug interactions, anesthetic
considerations, and management for PCP, MDMA, and LSD are summarized in Tables 1 and 2.
The cognitive aid presented in Appendix can be summarized into four main points: patient
assessment, substance identification, what to avoid, and how to medically manage the patient.
Anesthesia providers need to identify the specific substance used (PCP, MDMA, or LSD) and be
aware of the associated toxic effects and safe anesthetic agents for each. They should avoid
certain medications that can exacerbate complications and prepare for potential crises, such as
hypertensive emergencies with PCP or temperature control with MDMA. Management includes
supportive treatment, securing the airway if necessary, and monitoring vital signs, electrolytes,
and other relevant parameters to ensure patient safety. Most of all, it is crucial for anesthesia
providers to be familiar with hallucinogens, their mechanisms of action, clinical presentations
and effects, and possible interactions with other drugs (Gallagher et al., 2022).
Strengths
This research article provides an extensive comprehensive literature review, detailed case
studies, and an actionable decision tool on the clinical relevance of hallucinogens in anesthesia
care.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 38
The strength of this report lies in the analysis of case studies, which allow for real-world
examples of the application and outcomes of different management strategies for patients under
the influence of hallucinogens. Using data from the hallucinogen drug profile and case study
reports, this analysis provides practical recommendations for anesthesia providers on whether to
delay surgery in non-emergent cases and specific considerations for emergency situations. The
focus on patient safety and the clinical importance of understanding the pharmacology, effects,
and societal impacts of hallucinogens ensures that the recommendations and actionable decision
tools are geared towards making informed decisions and minimizing risks during anesthesia.
Limitations
The use of case reports may not be representative of the anesthetic care for the broader
population of hallucinogen users, limiting the generalizability of this review. Other limitations
include the lack of comprehensive data on illicit drug composition, variability in anesthetic
responses, and difficulty implementing recommendations.
The study highlights that illicit drugs are frequently diluted with other ingredients and in
different concentrations, making it difficult to determine the complete composition and effects of
the substances ingested. This variability complicates the use of standardized anesthesia protocols
for hallucinogen users. This inquiry has led to the development of recommendations and
considerations rather than protocols when faced with hallucinogen users requiring anesthetic
care.
Many hallucinogens are undetectable in standard toxicology screens and may need
additional testing, which complicates the timing of diagnosis and care of patients under the
influence of these substances. In cases of emergent surgeries, the lack of a rapid and reliable
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 39
antidote for hallucinogen intoxication poses a significant challenge. Ideally, anesthesia providers
would be well-versed in the implications and management of these substances; however, this
may not always be feasible in clinical situations. Depending on the chronic or recent use of
hallucinogens, patients can have an increased tolerance or exaggerated physiological response to
anesthesia. This variability adds another complex layer to anesthesia management.
Recommendations
Future research should focus on developing more robust diagnostic tools and the
development of adaptable anesthesia guidelines and rapid response protocols to better manage
the unique challenges posed by hallucinogen use in surgical patients. The advancement of
toxicology screening techniques to detect hallucinogens and hallucinogen levels in the body
would enable more accurate preoperative evaluations and tailored anesthetic management. The
increased prevalence of hallucinogen use may lead to increased opportunity to use longitudinal
studies to create more detailed cognitive aids.
Conclusion
In conclusion, patient safety concerns and anesthesia care optimization for hallucinogen
users requires anesthesia providers to have a comprehensive understanding of the pharmacology,
physiologic effects, and societal impact. The synthesized executive summary and decision tool in
this paper aims to aid anesthesia clinicians in providing safe and effective care for patients
reporting recreational hallucinogen use during elective and emergency surgical cases.
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 40
References
Addy, P. H., & D'Souza, D. C. (2019). Hallucinogen use disorders. In M. H. Ebert, J. F.
Leckman, & I. L. Petrakis (Eds.), Current diagnosis and treatment: psychiatry (3rd ed.,
pp. 735–743). New York, NY: McGraw-Hill Education.
Armenian, P., Mamantov, T. M., Tsutaoka, B. T., Gerona, R. R. L., Silman, E. F., Wu, A. H. B.,
& Olson, K. R. (2013). Multiple MDMA (Ecstasy) overdoses at a rave event: A case
series. Journal of Intensive Care Medicine, 28(4), 252–258.
https://doi.org/10.1177/0885066612445982
Aronow, W. S. (2017). Treatment of hypertensive emergencies. Annals of Translational
Medicine, 5(Suppl 1). https://doi.org/10.21037/atm.2017.03.34
Bates, M., & Trujillo, K. A. (2021). Use and abuse of dissociative and psychedelic drugs in
adolescence. Pharmacology, Biochemistry, and Behavior, 203, 173129.
https://doi.org/10.1016/j.pbb.2021.173129
Beaulieu, P. (2017). Anesthetic implications of recreational drug use. Implications anesthésiques
de l’usage de drogues dans un but récréatif. Canadian Journal of Anaesthesia = Journal
Canadien d'anesthésie, 64(12), 1236–1264. https://doi.org/10.1007/s12630-017-0975-0
Beckerleg, W., & Hudgins, J. (2022). Substance use-related emergency department visits and
resource utilization. Western Journal of Emergency Medicine, 23(2), 166.
https://doi.org/10.5811/westjem.2022.1.53834
Berar, A., Allain, J. S., Allard, S., Lefevre, C., Baert, A., Morel, I., ... & Gicquel, T. (2019).
Intoxication with 3-MeO-PCP alone: A case report and literature review. Medicine,
98(52)]. https://doi.org/10.1097/MD.0000000000018295
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 41
Bertron, J. L., Seto, M., & Lindsley, C. W. (2018). DARK classics in chemical neuroscience:
Phencyclidine (PCP). ACS Chemical Neuroscience, 9(10), 2459–2474.
https://doi.org/10.1021/acschemneuro.8b00266
Bruna de, S. B., Jair, S. F., Nonemacher, K., Samilla, D. S., Marcelo, D. A., & Kéttulin, Z. R.
(2020). New psychoactive substances (NPS) prevalence over LSD in blotter seized in
State of Santa Catarina, Brazil: A six-year retrospective study. Forensic Science
International, 306. https://doi.org/10.1016/j.forsciint.2019.110002
Carhart-Harris, R. L., & Goodwin, G. M. (2017). The therapeutic potential of psychedelic drugs:
Past, present, and future. Neuropsychopharmacology, 42(11), 2105–2113.
https://doi.org/10.1038/npp.2017.84
Davies, N., English, W., & Grundlingh, J. (2018). MDMA toxicity: Management of acute and
life-threatening presentations. British Journal of Nursing, 27(11), 616–622.
https://doi.org/10.12968/bjon.2018.27.11.616
Dolder, P. C., Schmid, Y., Steuer, A. E., Kraemer, T., Rentsch, K. M., Hammann, F., & Liechti,
M. E. (2017). Pharmacokinetics and pharmacodynamics of lysergic acid diethylamide in
healthy subjects. Clinical Pharmacokinetics, 56(10), 1219–1230.
https://doi.org/10.1007/s40262-017-0513-9
Dominici, P., Kopec, K., Manur, R., Khalid, A., Damiron, K., & Rowden, A. (2015).
Phencyclidine intoxication case series study. Journal of Medical Toxicology, 11(3), 321–
325. https://doi.org/10.1007/s13181-014-0453-9
Drug Information | DEA.gov. (2022, November 25). U.S. Government Drug Enforcement
Agency. https://www.dea.gov/drug-information
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 42
Elkattawy, S., Mowafy, A., Younes, I., Tucktuck, M., & Agresti, J. (2021).
Methylenedioxymethamphetamine (MDMA)-induced hyponatremia: Case report and
literature review. Cureus, 13(5), e15223. https://doi.org/10.7759/cureus.15223
Emde, K. (2003). MDMA (Ecstasy) in the emergency department. Journal of Emergency
Nursing, 29(5), 440–443. https://doi.org/10.1016/s0099-1767(03)00292-7
Emerick, T., Marshall, T., Martin, T. J., & Ririe, D. (2024). Perioperative considerations for
patients exposed to hallucinogens. Regional Anesthesia and Pain Medicine. Advance
online publication. https://doi.org/10.1136/rapm-2023-104851
Fiege, M., Wappler, F., Weisshorn, R., Gerbershagen, M. U., Menge, M., & Schulte Am Esch, J.
(2003). Induction of malignant hyperthermia in susceptible swine by 3,4-
methylenedioxymethamphetamine ("ecstasy"). Anesthesiology, 99(5), 1132–1136.
https://doi.org/10.1097/00000542-200311000-00020
Gasser, P., Holstein, D., Michel, Y., Doblin, R., Yazar-Klosinski, B., Passie, T., & Brenneisen,
R. (2014). Safety and efficacy of lysergic acid diethylamide-assisted psychotherapy for
anxiety associated with life-threatening diseases. Journal of Nervous and Mental Disease,
202(7), 513–520. https://doi.org/10.1097/NMD.0000000000000113
Hall, W. (2022). Why was early therapeutic research on psychedelic drugs abandoned?.
Psychological medicine, 52(1), 26–31. https://doi.org/10.1017/S0033291721004207
Heard, K., Hoppe, J., Stolbach, A., Ganetsky M. (2022). Phencyclidine (PCP) intoxication in
adults. UpToDate. Retrieved January 26, 2024, from https://www-uptodatecom.libproxy1.usc.edu/contents/phencyclidine-pcp-intoxication-inadults?source=mostViewed_widget
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 43
Hernandez, M., Birnbach, D. J., & Van Zundert, A. A. (2005). Anesthetic management of the
illicit-substance-using patient. Current opinion in anaesthesiology, 18(3), 315–324.
https://doi.org/10.1097/01.aco.0000169241.21680.0b
Inayat, F., Riaz, I., Ali, N. S., & Figueredo, V. M. (2018). Pseudo-wellens' syndrome secondary
to concurrent cannabis and phencyclidine intoxication. BMJ Case Reports, 2018 doi:
https://doi.org/10.1136/bcr-2018-225755
Kalant H. (2001). The pharmacology and toxicology of "ecstasy" (MDMA) and related drugs.
CMAJ : Canadian Medical Association journal = journal de l'Association medicale
canadienne, 165(7), 917–928.
Klein, M., & Kramer, F. (2004). Rave drugs: pharmacological considerations. AANA journal,
72(1), 61–67.Kopra, E. I., Ferris, J. A., & Rucker, J. J. (2022). Adverse experiences
resulting in emergency medical treatment seeking following the use of lysergic acid
diethylamide (LSD). Journal of Psychopharmacology, 36(8), 956–964.
https://doi.org/10.1177/02698811221099650
Latimer, D., Stocker, M. D., Sayers, K., Green, J., Kaye, A. M., Abd-Elsayed, A., Cornett, E. M.,
Kaye, A. D., Varrassi, G., Viswanath, O., & Urits, I. (2021). MDMA to Treat PTSD in
Adults. Psychopharmacology Bulletin, 51(3), 125-149.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8374929/
Lee, D., & Stout, P. (2020). Toxicological and demographic profiles of phencyclidine-impaired
driving cases in Houston. Journal of Analytical Toxicology, 44(5), 499–503.
https://doi.org/10.1093/jat/bkz111
Leonard, J. B., Anderson, B., & Klein-Schwartz, W. (2018). Does getting high hurt?
Characterization of cases of LSD and psilocybin-containing mushroom exposures to
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 44
national poison centers between 2000 and 2016. Journal of psychopharmacology
(Oxford, England), 32(12), 1286–1294. https://doi.org/10.1177/0269881118793086
Lerner, A., & Lev-Ran, S. (2015). LSD-associated "Alice in Wonderland Syndrome" (AIWS): A
hallucinogen persisting perception disorder (HPPD) case report. The Israel Journal of
Psychiatry and Related Sciences, 52(1), 67–68.
Liechti, M. E. (2017). Modern clinical research on LSD. Neuropsychopharmacology, 42(11),
2114–2127. https://doi.org/10.1038/npp.2017.86
Livne, O., Shmulewitz, D., Walsh, C., & Hasin, D. S. (2022). Adolescent and adult time trends
in U.S. hallucinogen use, 2002-19: Any use, and use of ecstasy, LSD and PCP. Addiction
(Abingdon, England), 117(12), 3099–3109. https://doi.org/10.1111/add.15987
Moran, S., Isa, J., & Steinemann, S. (2015). Perioperative management in the patient with
substance abuse. The Surgical Clinics of North America, 95(2), 417–428.
https://doi.org/10.1016/j.suc.2014.11.001
Moritz, M. L., Kalantar-Zadeh, K., & Ayus, J. C. (2013). Ecstacy-associated hyponatremia: why
are women at risk?. Nephrology, dialysis, transplantation : official publication of the
European Dialysis and Transplant Association - European Renal Association, 28(9),
2206–2209. https://doi.org/10.1093/ndt/gft192
NIDA. (2022, August 22). Marijuana and hallucinogen use among young adults reached an alltime high in 2021. Retrieved September 4, 2023, from https://nida.nih.gov/newsevents/news-releases/2022/08/marijuana-and-hallucinogen-use-among-young-adultsreached-all-time-high-in-2021.
Nikoomanesh, Phan, A. T., Choi, J., Arabian, S., & Neeki, M. M. (2022). Dantrolene
administration in the management of the prehospital patient with
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 45
methylenedioxymethamphetamine overdose: A case series and literature review. Case
Reports in Critical Care, 2022. https://doi.org/10.1155/2022/5346792
Nichols, D. E. (2016). Psychedelics. Pharmacological Reviews, 68(2), 264–355.
https://doi.org/10.1124/pr.115.011478
Nichols, D. E., & Grob, C. S. (2018). Is LSD toxic?. Forensic Science International, 284, 141–
145. https://doi.org/10.1016/j.forsciint.2018.01.006
Palamar, J. J., & Le, A. (2022). Media coverage about medical benefits of MDMA and ketamine
affects perceived likelihood of engaging in recreational use. Addiction Research &
Theory, 30(2), 96–103. https://doi.org/10.1080/16066359.2021.1940972
Parrott, A. C. (2004). Is ecstasy MDMA? A review of the proportion of ecstasy tablets
containing MDMA, their dosage levels, and the changing perceptions of purity.
Psychopharmacology, 173(3-4), 234–241. https://doi.org/10.1007/s00213-003-1712-7
Papaseit, E., Pérez-Mañá, C., Torrens, M., Farré, A., Poyatos, L., Hladun, O., Sanvisens, A.,
Muga, R., & Farré, M. (2020). MDMA interactions with pharmaceuticals and drugs of
abuse. Expert Opinion on Drug Metabolism & Toxicology, 16(5), 357–369.
https://doi.org/10.1080/17425255.2020.1749262
Phencyclidine. (2016). In LiverTox: Clinical and Research Information on Drug-Induced Liver
Injury. National Institute of Diabetes and Digestive and Kidney Diseases.
Peters, S. M., Tuffnell, J. A., Pinter, I. J., van der Harst, J. E., & Spruijt, B. M. (2017). Short- and
long-term behavioral analysis of social interaction, ultrasonic vocalizations and social
motivation in a chronic phencyclidine model. Behavioural Brain Research, 325(Pt A),
34–43. https://doi.org/10.1016/j.bbr.2017.02.027
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 46
Politi, C., Gabbin, A., Cecchetto, G., Montisci, M., Viel, G., & Pascali, J. (2021). A case study
on MDMA. Two fatal cases involving young adults. Australian Journal of Forensic
Sciences, 55, 1-11. https://doi.org/10.1080/00450618.2021.1921267
Ramaekers, J. G., Hutten, N., Mason, N. L., Dolder, P., Theunissen, E. L., Holze, F., Liechti, M.
E., Feilding, A., & Kuypers, K. P. (2021). A low dose of lysergic acid diethylamide
decreases pain perception in healthy volunteers. Journal of Psychopharmacology
(Oxford, England), 35(4), 398–405. https://doi.org/10.1177/0269881120940937
Richards, J. R., Placone, T. W., Wang, C. G., van der Linden, M. C., Derlet, R. W., & Laurin, E.
G. (2020). Methamphetamine, amphetamine, and MDMA use and emergency department
recidivism. The Journal of Emergency Medicine, 59(2), 320–328.
https://doi.org/10.1016/j.jemermed.2020.04.051
SAMHSA, C. for B. H. S. and Q. (2020). National Survey on Drug Use and Health. Results from
2020 national survey on drug use and health: Detailed tables, Samhsa, CBHSQ.
Retrieved October 9, 2022, from
https://www.samhsa.gov/data/sites/default/files/reports/rpt35323/NSDUHDetailedTabs20
20v25/NSDUHDetailedTabs2020v25/NSDUHDetTabsSect1pe2020.htm
Scotton, W. J., Hill, L. J., Williams, A. C., & Barnes, N. M. (2019). Serotonin Syndrome:
Pathophysiology, Clinical Features, Management, and Potential Future Directions.
International Journal of Tryptophan Research : IJTR, 12, 1178646919873925.
https://doi.org/10.1177/1178646919873925
Singh, A., Puskoor, S., & Saunders, R. (2019). Prolonged lysergic acid diethylmide induced
serotonin syndrome. Chest, 156(4), A2132. https://doi.org/10.1016/j.chest.2019.08.2076
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 47
Zuflacht, J. P., Caplan, R. A., Barash, J. A., & Fehnel, C. R. (2020). Neurotoxicology Syndromes
Associated with Drugs of Abuse. Neurologic Clinics, 38(4), 983–996.
https://doi.org/10.1016/j.ncl.2020.08.005
HALLUCINOGENIC DRUGS ON ANESTHESIA CARE 48
Appendix
Cognitive Aid
Abstract (if available)
Abstract
Hallucinogens, a class of psychoactive substances, are increasingly used as recreational drugs, posing unique challenges in the context of anesthesia. They are among the oldest known intoxicants used for their ability to alter perception, mood, and cognitive processes, leading to profound changes in sensory experiences, thought patterns, and awareness. Hallucinogens can be found in nature or produced synthetically. However, the increasing prevalence of synthetic formulations of hallucinogenic agents, specifically phencyclidine (PCP), 3,4-methylenedioxy-methamphetamine (MDMA), and lysergic acid diethylamide (LSD), raises the need to evaluate evidence and address knowledge gaps for anesthesia providers.
PCP, MDMA, and LSD are popular yet understudied recreational drugs that can produce adverse effects in patients undergoing general and sedation anesthesia. The literature supports thorough patient assessment, testing, monitoring, and use of short-acting agents, as synthetic hallucinogens can last for an extended period in the body. This paper serves as a resource for anesthesia practitioners during the perioperative setting, providing insights into the pharmacology, clinical implications, and social considerations associated with MDMA, LSD, and PCP.
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
Anesthetic considerations for patients on hallucinogenic drugs
PDF
Development of a perioperative drug screening algorithm for patients with a history of cocaine and methamphetamine use presenting for an elective procedure with anesthesia
PDF
Development of a perioperative drug screening algorithm for patients with a history of cocaine and methamphetamine use presenting for an elective procedure with anesthesia
PDF
The AIDEN acronym: Increasing nurse anesthetists’ knowledge of preoperative care for children with autism spectrum disorder
PDF
Addressing financial support for nurse anesthesia residents: literature review with policy recommendations
PDF
The AIDEN acronym: increasing nurse anesthetists' knowledge of preoperative care for children with autism spectrum disorder
PDF
Achieving global health understanding among medical learners: a literature review with profession-based recommendations
PDF
Effective methods for addressing psychological challenges among anesthesia providers returning from practice in austere environments: a literature review with professional recommendations
PDF
Best practice recommendations for anesthesia providers managing surgical patients on buprenorphine medication assisted treatment
PDF
The disparity in neuraxial analgesia use for Black parturients: an integrative review
PDF
The AIDEN acronym: increasing nurse anesthetists' knowledge of preoperative care for children with autism spectrum disorder
PDF
Integration of point-of-care ultrasound (POCUS) simulation curriculum in nurse anesthesia education
PDF
The reclassification of propofol as a controlled drug: a comprehensive literature review and recommendations for practice
PDF
Addressing financial support for nurse anesthesia residents: literature review with policy recommendations
PDF
Instagram as an engagement tool for awareness of the environmental impacts of anesthesia
PDF
The reclassification of propofol as a controlled drug: a comprehensive literature review and recommendations for practice
PDF
Examining the current diversity, equity, and inclusion initiatives from nurse anesthesia programs in California to support nurse anesthesia residents: an exploratory observational study
Pdf
The most reliable method of noninvasive blood pressure monitoring in obese patients undergoing general anesthesia: an extensive literature review with best practice recommendations
PDF
Instagram as an engagement tool for awareness of the environmental impacts of anesthesia
PDF
The disparity in neuraxial analgesia use for Black parturients: an integrative review
Asset Metadata
Creator
Kang, Hannah Jiyoung
(author)
Core Title
Anesthetic considerations for patients on hallucinogenic drugs
School
Keck School of Medicine
Degree
Doctor of Nurse Anesthesia Practice
Degree Program
Nurse Anesthesiology
Degree Conferral Date
2025-05
Publication Date
10/03/2024
Defense Date
10/03/2024
Publisher
Los Angeles, California
(original),
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anesthesia,Drug abuse,hallucinogen,LSD,MDMA,OAI-PMH Harvest,PCP,psychedelic,recreational drug
Format
theses
(aat)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Bamgbose, Elizabeth (
committee member
), Carr, Joshua (
committee member
), Kennedy, Audra (
committee member
)
Creator Email
kanghj@usc.edu,kgy5926@gmail.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC11399BMJM
Unique identifier
UC11399BMJM
Identifier
etd-KangHannah-13578.pdf (filename)
Legacy Identifier
etd-KangHannah-13578
Document Type
Capstone project
Format
theses (aat)
Rights
Kang, Hannah Jiyoung
Internet Media Type
application/pdf
Type
texts
Source
20241004-usctheses-batch-1217
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Repository Email
cisadmin@lib.usc.edu
Tags
anesthesia
hallucinogen
LSD
MDMA
PCP
psychedelic
recreational drug