Many substances that are not typically thought of as “substances of abuse” possess—when adequate­ly dosed—clinically meaningful psychoactive properties. In addition to the more familiar effects of alcohol, psychostimulants, opioids, Cannabis, and hallucinogens, you may encounter psychiatric phenomena resulting from abuse of more obscure substances, including culinary spices.

The clinician treating a patient in an apparent intoxicated state who has a negative drug screen might ask that patient if he (she) abuses spices. This might be particularly relevant when treating patients thought to have limited access to il­licit substances or those with ready access to large amounts of spices, such as prisoners, young patients, and those working in the food service industry.



Abuse of spices can be a problematic diagnosis

Patients may misuse culinary spices to achieve euphoria, or a “natural high.” They may present with medical or psychiat­ric symptoms, including acute altered mental status, but the psychoactive substances are not identified on routine toxicol­ogy studies. In addition, patients may not attribute their use of spices for psychoactive effect to “drugs,” because these materials are legal and readily available. This may lead to misdiagnosis of a systemic medical disorder or a primary psy­chiatric illness to explain the patient’s symptoms and initiat­ing a psychotropic agent and other psychiatric services when a substance abuse program might be a more appropriate clini­cal intervention.

Some spices contain psychoactive compounds that can alter CNS function (Table1-7), might be abused for recreational purposes, and can be toxic in an excessive amount. Internet resources, including anonymous web-based communications, and anecdotal materials about non-traditional recreational drugs, are available to anyone with Internet access.8 However, little research has been conducted into the preva­lence of abuse (Box)9 and spices’ psychoactive properties. The lack of toxicology detection of spices in the medical setting presents a di­agnostic challenge.

The psychoactive plants used in “natural high” products mainly are psychoactively inactive in their natural form, but extracts or alkaloids obtained from them might induce 1 or more of 3 classifications of psychoactivity:

• stimulant

• sedative

• hallucinogenic.

Many of these substances are considered to be aphrodisiac, and some may be abused to increase sexual function.

The following is a review of common spic­es that have been reported to possess poten­tial psychoactive properties.

Nutmeg

Nutmeg (Myristica fragrans) is a common and easily accessible means of reaching euphoria in adults.10 The aromatic oil of nutmeg contains myristicin, a psychoactive substance that is chemically similar to hal­lucinogenic compounds such as mescaline. Its psychoactive effects could be attributed to metabolic formation of amphetamine de­rivatives from its core ingredients, elemicin, myristicin, and safrole.11,12

Nutmeg and its active component, my­risticin, produce central monoamine oxi­dase (MAO) inhibition as evidenced by the ability to lower the convulsive dose of IV tryptamine in mice and to increase brain 5-hydroxytryptamine concentra­tions.13,14 Although myristicin’s potency is not comparable to that of the more potent MAO inhibitors such as tranylcypromine and iproniazid (which is not available in the United States), it seems adequate when compared with its low toxicity.14 Nutmeg extract is associated with a significant anti­depressant effect in mice, which seemed to be mediated by interaction with the adren­ergic, dopaminergic, and serotonergic sys­tems.13 Nutmeg is associated with sustained increase in sexual activity in animal studies, with no evidence of adverse effects and toxicity, suggesting that nutmeg possesses clinically significant aphrodisiac activity.15

Psychoactive effects can be achieved by ingesting 5 to 15 g of nutmeg.11 Acute nut­meg intoxication produces palpitations, dizziness, anxiety, and hallucinations, mostly resolving within 24 hours, while effects of chronic abuse are reported to be similar to Cannabis use, including euphoria, giddiness, anxiety, fear, sense of impending doom, detachment, confabulation, and hal­lucinations.11,16 Urine drug screens are nega­tive unless other psychoactive substances have been ingested.17

Suspected nutmeg intoxication or poison­ing should be treated with supportive treat­ment. Use sedatives with caution because of alternating periods of delirium and obtunda­tion during nutmeg intoxication.17

In case reports, myristicin poisoning induced CNS neuromodulatory signs that mimicked an anticholinergic hyperstimula­tion state.12,18 Fatal myristicin poisoning is rare; 2 cases have been reported, 1 in com­bination with flunitrazepam (not available in the United States).19,20 Nutmeg also has sedative properties and can cause GI symp­toms when ingesting excessive amounts.1,20,21 Grover et al21 described no harmful effects on blood pressure and electrocardiogram; how­ever, Shah et al22 reported palpitations and dry mouth.

Vanilla

Vanilla (species of the genus Vanilla) con­tains piperonal, also known as heliotropin.1 Piperonal has aromatherapeutic qualities that might elevate mood and well-being. In the early 1990s, the Memorial Sloan- Kettering Cancer Center in New York City described heliotropin as a powerful aroma­therapy tool. Patients who were undergo­ing an MRI in an environment scented with heliotropin demonstrated a 63% reduction in anxiety compared with those who were not exposed to fragrance.23 The Smell and Taste Treatment and Research Foundation in Chicago found that vanilla can promote sexual arousal.24