Gas Station Mushrooms

With the proliferation of both cannabis and cannabinoid/hemp derivatives now easily available in almost every gas station, a new category of products is gaining momentum: mushrooms.

Psilocybin is emerging from the fringes of medical research and gaining traction as a potential treatment option for a range of conditions, such as cocaine use disorder, depression, and anxiety. However, with the emergence of psychedelic research, there has also been an increase in the proliferation of commercially available products with a multitude of health and wellness claims, existing in a legal “gray area.”

By simply stating that their products have not been evaluated by the FDA, companies producing various “supplements” are able to bypass traditional pharmaceutical testing standards and laws, sending out an endless supply of unknown and untested substances to the public under the guise of “buyer beware.”

Your patients' most trusted advocate: the Influencer

One of the biggest victims of the COVID-19 pandemic was the population's trust in the healthcare system, specifically medical professionals, fueled by economic angst, chronic stress, fearmongering, and misinformation, combined with tribalist loyalism across party lines. This resulted in a perfect storm that has left many people with a deeply ingrained sense of skepticism and hesitancy that we as healthcare providers are still trying to combat on several fronts.

And from this chasm of misinformation and mistrust, a new generation of snake-oil peddlers has emerged. Self-prescribed “health and wellness experts” tout their beliefs and messages loudly for the world to see and hear across the breadth of social media, while simultaneously selling their personal brand of products and services to their audiences.

As this trend continues to grow, more and more people are turning to mushrooms for both their potential health benefits as well as their potential psychedelic properties. While there are likely some benefits in both of these areas, as clinicians, it's our job to sort through the noise to find the truth and to help guide our patients to therapies that are safe and evidence-based.

4-AcO-DMT: the “delta” of psilocybin

4-AcO-DMT (4-acetoxy-N,N-dimethyltryptamine) is a synthetic tryptamine structurally related to psilocin. It is often referred to as “synthetic mushrooms” or psilacetin. It is believed to function as a prodrug for psilocin, producing similar psychedelic effects to psilocybin mushrooms. However, given that 4-AcO-DMT is a synthetic analog, there are several important differences to consider when comparing it to naturally occurring psilocybin. Since these compounds are synthetic and unregulated, there can be significant differences in dosage and purity, as well as potential co-ingestants or adulterants.

This means that for people experimenting with these compounds, there is no way to predict things like onset, duration, and concentration, given the propensity for variance, not only between different commercial products, but also between individual “batches” of the same branded product.

Coming soon to an ED near you

With the rise in legal cannabis combined with the increased public interest in psychedelics, EDs are seeing an increase in patients presenting with a myriad of negative effects of experimenting with untested and unregulated substances. With so many unknown factors, patients may present with a myriad of symptoms:

• Anxiety, agitation, panic attacks
• Visual or audible hallucinations
• Generalized confusion
• Paranoia
• Tachycardia
• Hypertension
• Diaphoresis
• GI symptoms: nausea, vomiting, abdominal pain/cramping

While uncommon, clinicians should be aware that patients can present with severe symptoms such as:

• Severe agitation and/or psychosis
• Seizures
• Hyperthermia
• Rhabdomyolysis
• Serotonin syndrome

Treatment is going to center primarily around supportive care, and while the patient's ABCs are generally going to be stable, this is where we need to remember the D and E:

• Was the patient exposed to severe elements for a prolonged period of time?
• Did the patient sustain a significant head injury or other trauma while intoxicated?
• Is the patient on any other medications that may increase the risk of serotonin syndrome?
• Is there any concern for possible co-ingestion of other substances, specifically alcohol or excessive energy drinks?

If possible, have the patient monitored in a calm, quiet environment; these are not ideal patients for hallway beds or chairs, if your boarding situation allows. Provide IV fluids for dehydration and/or tachycardia, and remember that while the patient initially may not be in acute rhabdo, this condition could evolve during the “wash out” period. Benzodiazepines may be useful for controlling agitation and treating sympathomimetic features.

When clinically sober, most patients will be able to be discharged, assuming they have been otherwise medically cleared. Patients with severe psychosis, prolonged AMS, or evidence of rhabdomyolysis may require admission for observation.

The bottom line

Psychedelic therapy in the appropriate clinical setting is an evolving area of medicine with some great potential. The growing public interest in psychedelics, combined with the scarcity of clinical trials and complicated legal considerations, has paved the way for the explosion of pseudo-legal synthetic analogs. We are going to continue to see more and more of these products hitting the market every day, and likewise, more and more patients checking into our EDs after “rolling the dice” with unknown substances.

Do you have any pearls of wisdom to share about synthetic psychedelics? Reach out to us at emvertical@hippoeducation.com and let us know your story!