See reply by Mittal, et al.
Can Using a Detoxification Kit Result in Bizarre Behavior and Hallucinations?
To the Editor: I read with great interest the study by Mittal et al in which the authors present the case of a 19-year-old cannabis-addicted Asian man who experienced bizarre behavior and hallucinations after using a detoxification kit in a desperate effort to apply for a job. The authors noted the patient’s history of cannabis smoking 2 to 3 times per week for the last year. The patient was treated with lorazepam and haloperidol. They interestingly attributed the patient’s signs and symptoms to the contents of the detoxification kit.
Ingredients of the kit used by the patient included riboflavin (vitamin B2), cyanocobalamin (vitamin B12), dandelion, cascara sagrada, turmeric, burdock, milk thistle, guarana extract, green tea, Echinacea purpurea, potassium, proprietary blend, creatine monohydrate, alfalfa leaf, slippery elm bark, reishi mushroom, uva ursi leaf, cayenne pepper, licorice, peppermint leaf, red root, schisandra, and sorbitol. Interestingly, none of the above-mentioned ingredients can result in such a presentation as that exhibited by the patient.
Riboflavin and cyanocobalamin have been reported not to have any significant side effects except for an anaphylactoid reaction when given parenterally.2 Dandelion may cause ragweed allergy.3 Cascara sagrada has been reported to cause abdominal pain, allergic rhinitis, immunoglobulin E-mediated asthma, diarrhea, melanosis, steatorrhea, vomiting, change in urine color, fluid and electrolyte abnormalities, and osteomalacia.4 Turmeric has been shown to slow blood clotting.5 Burdock has resulted in diaphoresis and increased perspiration because of its oily ingredient.6 Milk thistle may cause diarrhea, nausea, bloating, and upset stomach.7 Guarana extract contains caffeine, theobromine, and theophylline in varying quantities. Guarana is currently thought to have no adverse effects other than potential caffeine toxicity.8
Echinacea purpurea has been accompanied by nausea, allergic reactions, asthma, skin rashes, trouble in breathing, and dizziness.9 No side effects have been reported for proprietary blend,10 while the reported side effects for creatine monohydrate include gastrointestinal distress; muscle strain, cramp, and tear; flatulence; and renal distress in those with previous history of renal disease.11 Only isolated reports of allergy with alfalfa leaf have been published.12 To date, there is no report of side effects of slippery elm bark.13 The reported side effects of reishi mushroom are dryness of the mouth, stomach upset, nose bleed, and allergy.14 Uva ursi leaf contains arbutin and hydroquinone as well as tannin and may cause nausea and vomiting, insomnia, and irritability.15 Cayenne pepper is prohibited in pregnancy and has resulted in allergy in those allergic to chestnut, banana, kiwi, and avocado.16 Side effects associated with licorice are increased blood pressure, water storage (hence, may worsen the condition of patients with congestive heart failure), hypokalemia, sexual problems in men, and worsening kidney diseases.17 Peppermint leaf is thought to be safe; however, its enteric-coated tablets may cause diarrhea and anal burning.18 Red root and schisandra are thought to be safe.19,20 Finally, sorbitol may induce allergy, blurred vision, chest pain, confusion, diarrhea, nausea, seizure, shortness of breath, thirst, tiredness, and vomiting.21
Although the manufacturers of such commercial compounds may exaggerate their safety, there is another point about this patient that may cause the reader to doubt that the detoxification kit caused his psychosis. As the authors mentioned, the patient’s urine drug screen showed a tetrahydrocannabinol level of 268 ng/mL when he was admitted to the psychiatric ward. How do the authors know that his symptoms were not due to acute cannabis intoxication? Thank you for this interesting study.
References
1. Mittal MS, Kalia R, Khan AY. A case of psychosis after use of a detoxification kit and a review of techniques, risks, and regulations associated with the subversion of urine drug tests. Prim Care Companion CNS Disord. 2011;13(5):doi:10.4088/PCC.11r01178 doi:10.4088/PCC.11r01178. PubMed
2. Howland MA. Hydroxocobalamin. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, et al, eds. Goldfrank’s Toxicologic Emergencies. 8th ed. New York, NY: McGraw-Hill; 2006:1731-1733.
3. Dandelion. http://www.webmd.com/vitamins-supplements/ingredientmono-706-dandelion.aspx?activeIngredientId=706&activeIngredientName=dandelion. Accessed October 8, 2012.
4. Cascara sagrada: drug interactions, side effects and precautions of use. http://www.ayurvedic-medicines.org/herbal-medicines/cascara-sagrada.htm. Accessed October 8, 2012.
5. Turmeric. http://www.webmd.com/vitamins-supplements/ingredientmono-662-TURMERIC.aspx?activeIngredientId=662&activeIngredientName=TURMERIC. Accessed October 8, 2012.
6. Burdock root uses, benefits and side effects. http://www.naturalherbsguide.com/burdock.html. Accessed October 8, 2012,
7. Milk thistle. http://www.webmd.com/heart-disease/milk-thistle-benefits-and-side-effects. Accessed October 8, 2012.
8. Sanaei-Zadeh H. With which mechanism the overuse of energy drinks may induce acute myocardial ischemia? 2012 [published online ahead of print February 21, 2012]. Cardiovasc Toxicol. PubMed doi:10.1007/s12012-012-9160-4
9. Echinacea. http://www.webmd.com/vitamins-supplements/ingredientmono-981-ECHINACEA.aspx?activeIngredientId=981&activeIngredientName=ECHINACEA. Accessed March 26, 2012.
10. Are there acai berry side effects? http://organic-acai-berry.com/acai-berry-side-effects.html. Accessed October 8, 2012.
11. Creatine side effects and risks. http://www.creatinemonohydrate.net/creatine-side-effects. Accessed October 8, 2012.
12. Alfalfa. http://www.vitamins-supplements.org/herbal-supplements/alfalfa.php. Accessed October 8, 2012.
13. Slippery elm. http://www.webmd.com/vitamins-supplements/ingredientmono-978-SLIPPERY%20ELM.aspx?activeIngredientId=978&activeIngredientName=SLIPPERY%20ELM. Accessed October 8, 2012.
14. Reishi mushroom. http://www.webmd.com/vitamins-supplements/ingredientmono-905-REISHI%20MUSHROOM.aspx?activeIngredientId=905&activeIngredientName=REISHI%20MUSHROOM. Accessed October 8, 2012.
15. Uva ursi leaf side effects. http://www.livestrong.com/article/114785-uva-ursi-leaf-side-effects/. Accessed October 8, 2012.
16. What are the side effects of cayenne pepper? http://www.cayennepepper.info/side-effects-of-cayenne-pepper.html. Accessed October 8, 2012.
17. Licorice. http://www.nlm.nih.gov/medlineplus/druginfo/natural/881.html. Accessed October 8, 2012.
18. Peppermint. http://www.webmd.com/vitamins-supplements/ingredientmono-705-PEPPERMINT.aspx?activeIngredientId=705&activeIngredientName=PEPPERMINT. Accessed October 8, 2012.
19. Red root Ceanothus americanus. http://www.anniesremedy.com/herb_detail491.php. Accessed October 8, 2012.
20. Schisandra. http://www.webmd.com/vitamins-supplements/ingredientmono-376-SCHISANDRA.aspx?activeIngredientId=376&activeIngredientName=SCHISANDRA. Accessed October 8, 2012.
21. Sorbitol side effects. http://www.drugs.com/sfx/sorbitol-side-effects.html. Accessed October 8, 2012.
Author affiliation: Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Potential conflicts of interest: None reported.
Funding/support: None reported.
Published online: December 27, 2012.
Prim Care Companion CNS Disord. 2012;14(6):doi:10.4088/PCC.12lr01366.
© Copyright 2012 Physicians Postgraduate Press, Inc.
