What recreational drugs can induce anticholinergic syndrome?

Recreational Drugs That Cause Anticholinergic Syndrome

Jimsonweed (Datura stramonium) is the most commonly reported recreational plant causing anticholinergic syndrome, containing atropine, hyoscyamine, and scopolamine. 1, 2, 3

Plant-Based Recreational Substances

The FDA identifies several plants that produce anticholinergic syndrome when ingested recreationally 1:

• Jimson Weed (Datura stramonium) - most frequently abused by teenagers seeking hallucinogenic and euphoric effects 2, 3
• Deadly Nightshade 1
• Devil's Apple 1
• Black Henbane 1
• Loco Seeds or Weeds 1
• Night Blooming Jessamine 1
• Matrimony Vine 1
• Stinkweed 1

Pharmaceutical Drugs Misused Recreationally

The FDA lists numerous medications that can produce anticholinergic syndrome when taken recreationally or in overdose 1:

Antihistamines

• Diphenhydramine - commonly abused for sedative and hallucinogenic effects at high doses 4, 1
• Carbinoxamine 1

Tricyclic Antidepressants

• Amitriptyline 1
• Doxepin 1
• Imipramine 1
• Nortriptyline 1
• Desipramine 1
• Protriptyline 1
• Trimipramine 1

Muscle Relaxants

• Cyclobenzaprine - has strong anticholinergic properties and is sometimes misused 4, 1

Anticholinergic Agents

• Benztropine 4, 1
• Biperiden 1
• Scopolamine (Hyoscine) 1, 5
• Atropine 1

Benzodiazepines

• Lorazepam - can contribute to anticholinergic burden when combined with other agents 1

Clinical Recognition

The classic mnemonic for anticholinergic toxidrome is "Red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hatter, full as a flask." 4

Key distinguishing features include 4, 6:

• Dry mucous membranes and hot, dry, erythematous skin - pathognomonic findings
• Mydriasis (dilated pupils) - characteristic feature
• Agitated delirium with visual hallucinations - the "mad as a hatter" component
• Hypoactive or absent bowel sounds - differentiates from serotonin syndrome
• Mild hyperthermia with tachycardia
• Urinary retention

Critical Management Pitfalls

Avoid physical restraints in patients with anticholinergic toxidrome, as they exacerbate hyperthermia and worsen lactic acidosis. 6

Benzodiazepines are first-line treatment for agitation, not antipsychotics, which may worsen anticholinergic effects. 4, 6

Physostigmine is the specific antidote and can produce dramatic reversal within minutes, but reserve it for life-threatening complications such as severe hyperthermia, refractory seizures, or hemodynamic instability. 6, 1, 3

Monitor serial ECGs for QRS widening, which suggests co-ingestion of tricyclic antidepressants requiring sodium bicarbonate therapy 4, 6.