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SPICE, BATH SALTS, SALVIA, DABBING, FLAKKA, KROKODIL, AND AYAHUASCA
GWEN LEVITT, DOADULT AND FORENSIC PSYCHIATRIST
DIPLOMATE AND FELLOW, AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY
DISTRICT MEDICAL GROUPASSOCIATE PROFESSOR, UNIVERSITY OF ARIZONA MEDICAL SCHOOL‐
PHOENIXPRIVATE PRACTICE, FORENSIC PSYCHAITRY
DISCLOSURE I HAVE NO RELEVANT FINANCIAL INTERESTS OR RELATIONSHIPS WITH MANUFACTURER(S) OF ANY COMMERCIAL PRODUCT(S) AND/OR PROVIDER(S) OF COMMERICAL SERVICES IN THIS PRESENTATION.
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OBJECTIVES UNDERSTAND COMPOSITION, PROCESS OF USE, AND EFFECTS OF NEW ILLICITS
EXTEND YOUR KNOWLEDGE ABOUT THE LIKELY PRESENTATION OF A PATIENT ON THESE DRUGS
IMPROVE YOUR ASSESSMENT SKILLS RELATING TO CURRENT SUBSTANCES OF ABUSE
LEARN WHAT YOUR KIDS ARE UP TO
TAKE HOME MESSAGE‐ IN THE FACE OF ADVERSE CONSEQUENCES, ADDICTION IS SO STRONG THE USER WILL CONTINUE TO USE
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BY THE TIME YOU READ THIS… ANEW ILLICIT IS BORN
Your patients will have to tell you what they are using and how
Routine drug screens do not always detect new illicits
Formulations vary and manufacturing of illicits is not regulated
Each illicit has its own vocabulary and culture
HOW DO WE KNOW? New illicits are often discovered in the ER or; find a clever teenager!
Poison control is often the first agency that starts to catalogue the incidence and effect of new illicits.
By the time the medical literature has begun to publish information, the drug is “old news”, illegal, or no longer in vogue.
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SYNTHETIC CANNABINOIDSALSO KNOWN AS
SPICE/Spice Gold, Silver, Diamond Algerian Blend K2/K3 Chill X SerenityNow/ArcticSerenity Spike 99 Genie Kronic Kind Acapulco 2 Spicy Smoke Sence Skunk Yucatan Fire Spice for Life
VARIATIONS ON A THEME Once Spice was made illegal, other bioactive herbs were on the streets: Beach Bean, Blue Lotus, Dwarf Skullcap, Indian Warrior, Lion Tail, Maconhabrava, Pink Lotus, Sacred Lotus, Honeyweed, and Motherwort
Another trend is to combine the illicit with ketamine, called “k‐holing” or with cannabis and even Raid, the insect spray
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“A MORE INTENSE HIGH”
Sold as Herbal Incense Product or Potpourri
Labeled “NOT FOR HUMAN CONSUMPTION”
( As a way to avoid legal regulations)
It may be flavored
On the market since 2002. The “original” brand was Spice (in UK, Egyptian eye symbol)
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Internet expanded the commercial market around 2006, which is when it became readily available in the U.S.
$10‐15 a package (one gram)
Users do not view it as a “street drug” as it is found in commercial establishments
CHEMISTRY 101
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RECIPE ON THE LOOSE
Synthetic cannabinoids are liquids originally formulated at Clemson University in 1995 to be used in research on animal models
Pharmacologically similar to Delta9 THC, it binds to the brain cannabinoid receptor CB1 and the peripheral cannabinoid receptor CB2 with agonist properties
Researchers looked at four effects to predict the psychoactivity of THC in humans: decrease in overall activity, analgesia, decrease in body temperature and catalepsy. Most synthetics produce the first three actions and inconsistent activity in the fourth area
Journal of Mass Spectrometry – Ten minutes after use subjects had red conjunctiva, elevated pulse rate, xerostomia, altered mood and perception. There was a subjective feeling of being moderately impaired
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WHAT EXACTLY IS SPICE? The liquid synthetic cannabanoid is sprayed on a green leafy like substance such as kitchen spices, garden clippings, or tobacco. It looks like the marijuana your roommate was smoking in college (This variety is now called “flower” on the streets)
It is a smoked as a “joint”, pipe or in a “bong”, but the compound is converted into a volatile gas, rather than smoke being absorbed in the lung like “flower” which is why Spice is more potent and dangerous.
THE HIGH Onset of action in about 5 minutes after smoking: dry mouth, reddening of eyes, increased heart rate and blood pressure
Duration of action 2‐3 hours, up to 6 hours with poor sleep and a slight hangover the next day
Effects: energizing, euphoria, disinhibiting
Tolerance develops quickly‐ within weeks to months
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LABORATORY TESTING Synthetic cannabinoids are constantly changing, so we are not able to single‐out one core compound to identify in a common test. There are some commercially available tests, but it is unclear how accurate they are. The detection of urine metabolites is not fully developed.
It will be missed in standard drug screen testing
PRESENTATION Seizures
Hallucinations and other psychotic symptoms
Rages and severe agitation
Withdrawal symptoms: restlessness, tremors, nightmares, sweats, cravings, headaches
Nausea and vomiting
Blackouts
Cardiac arrest
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Arizona was seventh in number of calls related to synthetic cannabinoid exposure in 2011 per a report from U.S. Poison Control
March, 2011 – Five synthetic cannabinoids were categorized as Schedule I substances under the Controlled Substances Act.
In 2011, Arizona adopted laws to ban synthetic cannabinoids (HB 2167)
The National Institute of Drug Abuse found synthetic cannabinods to be the second most frequently used drug by high school seniors after marijuana
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BATH SALTS So named as the first available drug was packaged and looked a lot like what you would put in a relaxing bath.
The main compund is a phenethylamine‐Methylenedioxypyrovalerone (MDPV)
Derivative of cathinone‐ a substance from an African plant‐ known as Khat
Labeled “Not for Human Consumption” or for “Novelty Use Only” so it could be sold commercially
Sold as “bath salts” and “plant food,” but as the laws catches up, the “form” in which it is sold changes‐decorative sand, research chemicals and toy cleaner.
Was marketed as a unique, legal stimulant alternative to methamphetamine and MDMA (Ecstasy)
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MARKETING
AKA 8Balls, MDPK, MTV, Magic, Maddie, Black Rob, Super Coke, PV, Aura, Blue Silk, Bonzai Grow, Charge Plus, Euphoria, Hurricane Charlie, Ivory Wave, Lovey Dovey, Ocean, Pixie Dust, Red Dove, Scarface, Vanilla Sky, White Dove, White Girl, White Lightening, White Rush, Blow, Zues2, Zoom, Bliss, Cosmic Blast, Cloud 9, Energy, Purple Wave, Bloom,Ocean Snow, Lunar Wave, Meow‐Meow, Miaow, MCAT, Bubbles, Sunshine, NRG‐1
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SIMILAR STRUCTURE TO METHAMPHETAMINES AND MDMA (ECSTACY)
Was sold in liquor stores, mini‐marts and head shops. One gram for about $20
DEA lists as Schedule I in 2011
Became illegal in Arizona in 2012
Been in popular use in U.S. since about 2008
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Average dose 5 to 250 mg
Can be taken orally (mix with water and drink or put in food), snorting, smoking, IV, or rectally/vaginally. Smoking most popular route
No drug test is available
THE HIGH A stimulant‐like effect akin to cocaine or amphetamines
Users describe intense stimulation, alertness, euphoria, elevated mood, sense of closeness, sociability, and sexual arousal
Reported to be aphrodisiac
Onset of action in 15‐ 30 minutes
Duration of action about 3 to 4 hours
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PRESENTATION Pupil dilation, teeth grinding, impaired short‐term memory, tightened jaw muscles, tremors, shortness of breath, nausea, vomiting, sweating, peripheral vasoconstriction, rhabdomyolysis, tachycardia, hypertension, arrhythmias, seizures, stroke, chest pain, MI, and death
Bleeding and ulceration of nose/throat from snorting
PSYCHIATRIC SYMPTOMS Intense panic and extreme agitation
Paranoia, hallucinations, and delusions
Aggressive or violent behavior‐self mutilation, suicide attempts, and homicidal behaviors
Insomnia, anorexia, depression and delirium also reported
Withdrawal and intense cravings
Tolerance develops quickly
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ONE OF THE FIRST REPORTS One of the first reports was in Michigan of two men found nude and dead from exposure at a campsite
As with other illicits, stripping off clothing is a common theme, as users feel extremely hot
(? Activates homeostatic mechanisms in the brain)
Users often present with dehydration/ hypothermia related to exposure as a result
SALVIA DIVINORUMPerennial herb in the mint family. Native to certain areas Mexico, and can grow in your yard! Up to three feet tall, large green leaves, hollow square stems, white flower with purple calyces.
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AKA: Maria Pastora, Sage of the Seers, Diviner’s Sage, Salvia, Sally‐D, Magic Mint
Sold on the internet and in local shops as seeds, plants, fresh and dried leaves, and extracts for about $15 per gram
Chewed, smoked, or made into a tea
Used by the Mazatec in spiritual rituals
No approved uses in U.S.
Promoted as legal alternative to cannabis or mescaline
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Active compound is Salvinorin A –a potent natural hallucinogens
Unique in that its primary interaction is not directly with serotonin, but is a kappa opioid receptor agonist
Opioid receptors cause analgesia and the K subtype elicits psychomimetic effects and in humans modulates perception, cognition and mood
There is no drug test
THE HIGH
Onset in about 5 to 10 minutes if eaten or drank Stomach acids deactivate the compound Peaks in 1 hour and subsides in 2 hours
If inhaled – onset is in 30 seconds Peaks 5 to 10 minutes and subsides in 20 to 30 minutes
Perceptions of bright lights, vivid colors and shapes, body movements, visual distortions, traveling through time and space, floating, twisting, spinning.
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PRESENTATIONMood dysregulation‐dysphoria, hysteria, uncontrolled laughter
Hallucinations
Derealization‐sense of loss of body and overlapping realities
Ataxia, poor coordination, and dizziness
Slurred or incoherent speech
Reduced heart rate
Chills
LOC
Due to its short duration of action, the patient may be lucid and asymptomatic by the time he/she is evaluated
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REGULATION 2002‐ made Schedule I in U.S.
No federal statute as yet to deem it illegal
As of 2015‐ Twenty seven states have made it illegal. Arizona is not one of them
Five states made it legal if not used for human consumption
Three states make it legal as long as not sold to minors (California is one of them)
It is illegal in a number of countries
BUTANE HASH OIL
AND
DABBING
A LITTLE DAB WILL DO YAOR YABBA DAB‐A‐DO
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DIY BHO is made by pushing butane through “flower” marijuana, dissolving the plant matter, producing an oily/waxy substance
Heat the screw until red hot to prime the screw. Dip in water to cool. Repeat.
Place a piece of wax on the end of the heated screw
Insert into the rig and inhale.
$600 an ounce
THE HIGH “The biggest positive of concentrates ( ie. BHO) are that they give a powerful dose of medicine to those who truly need it. Patients dealing with severe or chronic pain or extreme nausea report that dabbing can be one of the best ways to get immediate and effective relief.”
“Awesome and becoming a great way to take one hit and be done for.”
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AKA EARWAX OR WAX
BHO‐BUTANE HASH (HONEY) OIL OR HASH OIL
CRACK OF POT
710 (“OIL” UPSIDE DOWN‐DIGITAL)
HONEY OIL
BUDDER
SHATTER
BLACK GLASS
“FLOWER” – THE LEAFY MARIJUANA HAS 15% THC CONCENTRATION
OIL BASED MARIJUANA CAN BE AS HIGH AS 60‐90 % THC CONCENTRATION
THESE OILS ARE READILY AVAILABLE IN MEDICAL MARIJUANA DISPENSARIES
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OIL BASED PRODUCTS CONTAIN BUTANE AND OTHER NEUROTOXINS
IN 2014 THERE WERE 49 CONFIRMED EXPLOSIONS RELATED TO MANUFACTURING OF THESE PRODUCTS
THERE HAVE BEEN REPORTS OF SEVERE ALLERGIC REACTIONS AND POISONINGS
SAMPLE OF BHO CONTENTS Cannabinoids: THC (~ 30%) and THCA (~ 60%).
Monoterpenes (~ 5%): β‐pinene, myrcene, β‐phellandrene, cis‐ocimene, terpinolene, and terpineol.
Sesquiterpenes (~ 5%): β‐caryophyllene, humulene, δ‐guaiene, γ‐cadinene, eudesma‐3,7(11)‐diene, and elemene.
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PRESENTATION ELEVATED HEART RATE AND BLOOD PRESSURE
“BLACKOUTS”
TACTILE HALLUCINATIONS –FORMICATION
CLOSED HEAD INJURIES
LOC
VOMITING – ASPIRATION
PARANOIA
EXPLOSIONS/BURNS (FACIAL BURNS)
ANXIETY & PANIC ATTACKS
INCREASED TOLERANCE
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ACCORDING TO THE DEA MARIJUANA CONCENTRATES FACT SHEET‐MARIJUANA “INTERFERES WITH LEARNING AND MEMORY WHICH INCREASES THE RISK OF POOR GRADES AND DROPPING OUT OF SCHOOL. RESEARCH SHOWS REGULAR MARIJUANA USE BY TEENS REDUCES IQ LEVELS AND TEST SCORES.”
FROM 2008 TO 2013 PAST‐MONTH MARIJUANA USE INCREASED FROM:
5.8% TO 7% IN 8TH GRADERS;
13.8% TO 18% AMONG 10TH GRADERS;
19.45 TO 22.7% IN SENIORS
IN 2015, IT WAS ESTIMATED THAT 11‐21% of 18‐21 YEAR OLDS USE MARIJUANA PRODUCTS
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FLAKKA AKA FLOCKA, OR GRAVEL
NAMED FOR THE CUBAN TERM FOR A SLENDER ATTRACTIVE WOMEN
CALLED “THE DEVIL IN CRYSTAL FORM” BY EROWID
FLAKKA IS A GRAY CRYSTALLINE SUBSTANCE
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ON THE STREETS IT IS DESCRIBED AS BEING A HEROIN/CRACK OR HEROIN/METH COMBINATION
ACTUALLY IT IS A NEW GENERATION OF BATH SALTS
CHEMICAL COMPOUNDS KNOWN AS CATHINONES: A‐PVP: ALPHA‐PVP‐1‐PHENYL‐2‐(1‐PYRROLIDINYL)‐1‐PENTANONE (DOPAMINERGIC NEURON ACITVITY)
CHEMISTRY 101
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FLAKKA USERS OFTEN DISROBE & ARE OUT OF CONTROL ON THE STREETS
PRESENTATION BEHAVIORAL CHANGES AND EXTREME AGITATION‐ “SUPER HUMAN STRENGTH”
“JERKING MUSCLES”
DELIRIUM
PROFOUND PARANOIA ‐‐OFTEN EXPRESSED AS A FEAR OF BEING CHASED OR KILLED
HYPERTHERMIA AND RHABDOMYOLYSIS
TASER BURNS FROM POLICE INTERVENTIONS
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FLAKKA WAS FIRST SEEN IN FLORIDA IN AROUND SEPTEMBER 2014
REPORTS NOTED IN KT, LA, IL, OH, TX, AND CA
NO CONFIRMED REPORTS OF FLAKKA IN
ARIZONA AS OF JUNE 2015
$150 PER EIGHTH OF AN OUNCE
KROKODIL Desomorphine (dihydrodesoxymorphine, former brand name Permonid, is a morphine derivative with fast‐acting effects. First synthesized in 1932 and patented in 1934, desomorphine was used in Switzerland and described as a short duration of action.
Dose‐by‐dose it is eight to ten times more potent than morphine
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CHEMISTRY 101
Krokodil is presumed to contain desomorphine, but due to illicit, home‐based, manufacturing, it may contain other unknown ingredients, or in fact, no desomorphine at all.
Homemade versions of the drug start with codeine, and can be ‘cooked’ like methamphetamines. Gasoline, paint thinner, lighter fluid, iodine, hydrochloric acid, and red phosphorus (from matches) are used. These dangerous chemicals are not always fully “cooked out” when used to make Krokodil.
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Krokodil is a fairly new drug that first appeared in Russia in 2002 but has now been found among Russian immigrants in Germany and in at least six other European countries.
Russia has a severe problem with heroin addiction. Addicts resort to Krokodil which has a stronger kick and costs about a tenth the price of heroin.
The life expectancy of a Moscow heroin addict is four to seven years, the life expectancy of a Krokodil addict is just 1‐2 years.
Krokodil gets its name from the fact that the very toxic drug causes an addict's skin to become green, scaly and bumpy like a crocodile's. If the drug misses a vein and is injected into flesh, that flesh will develop abscesses. It is common for addicts to develop gangrene and require amputations. The flesh on some body parts affected by krokodilinjections will rot off completely, leaving bare bone.
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ARIZONA CASES… Per the U.S. DEA the first three “Krokodil” cases in AZ – at Banner & JCL – actually proved to be black tar heroin based…but yielded the same results
The MMC Burn Center treated a woman reporting “Krokodil” use as early as November 2013 & DVBH has had at least two female admissions reporting “Krokodil” use –one with & one without open lesions
TERROS Crisis recently responded to a young woman reporting “Krokodil” use who had bandaged body sores, but was described as having “the hands of an 80 year old woman”
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It is estimated that somewhere between a few hundred thousand and a million people are injecting this deadly drug. Between 2009 and 2011, the amount of krokodilseized by law enforcement increased 23‐fold.
Two Illinois women were among the first documented U.S. users of krokodil in 2013
February 2014, Mexican officials confirmed in Nogales.
In November 2014, a 17 year old American was treated in Puerto Vallarta after injecting krokodil into her genitals.
Although there have been reports of Krokodil use in the U.S. since 2013, the DEA has yet to confirm the presence of that precise codeine based drug.According the U.S. Department of Justice, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute on Drug Abuse (NIDA), the U.S. FDA, and the CDC, it is one of the biggest drug threats in the U.S.
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AYAHUASCA
South American beverage used in Brazilian indigenous people’s spiritual ceremonies and known since 1600’s.
AKA‐ Diame (after Santo Diame Church), Vegetal (after Uniao de Vegetal Church) Yaje, and Natema, and Aya
In 2010 it was estimated that there are 20,000 Ayahuasca churches
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Typically made from two plants:
Banisteriopsis caapi (a vine): contains MAOI (A) inhibitors, B‐carboline akaloids‐harmine, tetrahydroharmine, harmaline, harmol, and harmolol
Psychoria vindis: Idole‐N,N‐dimethyltryptamine(DMT)
Urine metabolites: Found in 0‐24 hours after use‐VMA, HVA, 5‐HIAA
Stimulates release of dopamine in presynapticneurons in the mesolimbic brain
DMT has a high affinity for 5HT receptors
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CHEMISTRY 101
Right hemisphere activity‐ anterior insula, anterior cingulate/frontomedial cortex
Left hemisphere activity‐ amygdala and parahypocampal areas
Dose dependent EEG changes
Disruption of sleep initiation and maintenance
Inhibition of REM
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Schedule I in U.S.
Arguments for its safety:
Higher safety profile than other illicits
Little known dependency issues
Serotonergic effects‐ “after glow”‐ useful in treatments for depression, anxiety, PTSD, and addiction
Been in use in South America for hundreds of years and most recently in several known substance abuse facilities worldwide.
THE HIGH “High” or “rush”
Body feels different
Visual effects, vision vibrating or jiggling
Changes distinctiveness of objects or sounds
Time distortion
Change in quality and rate of thinking
Sounds sound different
Excited feeling
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PSYCHOLOGICAL IMPACT Review of one’s past
Insight into one’s patterns of behavior
Powerful emotional experiences
Special experiences with nature
Death experiences
Transpersonal or transcendental experiences
Recover repressed memories
One study showed “sustained” improvement (180 minutes) in depression scores regardless of the severity of the depression reported
One study demonstrated that under the acute effects of Ayahuasa subjects reported lower scores on panic and hopelessness feelings
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PRESENTATION Peak onset in 6 to 24 hours, average about 4.5 hours
Significant purgative and emetic properties‐onset within 20 minutes of ingestion as a tea
Practitioners say this is detoxifying and “an expression of morbid emotions and mental conditions”
Moderate increase in heart rate and pulse
Increase in prolactin, cortisol, growth hormone
Decrease in CD4 and CD3‐transient
Increase in natural killer cells
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“I spent Saturday night rolling on the floor of a loft apartment… When I wasn't rolling, I was in the bathroom shoving my fingers down my throat, or sitting on the john trying to take a dump. I cried like a mother at a wedding. I kicked my feet in the air like dogs do when they're sleeping, and on one occasion—in tandem with the feet—I let my hands dance in front of my face like the last raver in the field on the last night of summer.”
Reports of seizures, MIs, coma, torn aorta, and fatalities
Transient psychosis that lasts “a few days”
GI lesions from the significant emesis
Suicide (explained away as a very disturbed person)
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Many practitioners will admit that they have been involved in “critical” situations with Ayahuasca use
Impaired working memory, decrease stimulus response interferences (Lessens with increased exposure)
Contraindicated in:
Liver and kidney impairment
History of CVA
HTN
SSRI use and other supplements and illicits
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Gonzales v. Centro Espirita Beneficente Uniao De Vegetal: U.S. Supreme Court 2005‐ Ayahuasca tea approved under the Religious Freedom Restoration Act
Oregon case in U.S. District Court, 2009‐ ruled in favor of the tea
TAKE A TRIP *****focuses on your evolution, growth and transformation. In the last 14 years we have successfully guided over 5,000 people through amazing Ayahuasca healing journeys, becoming the most renowned shamanic center in the world. National Geographic Agrees!
5 Consciousness‐shifting Ayahuasca ceremonies
A safe ceremonial environment, including a fully trained staff of helpers
4 Star accommodations
All meals, coffee, teas, fresh juices & filtered water
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Participation in the Ayahuasca cooking process Discussions about medicinal plants and their curative properties
Personal shamanic healing, Shamanic journeying & Soul retrievals
One‐on‐one time with the shamans Group talks on shamanism, mysticism, and personal experiences
Shamanic skills course, integration, relaxation and release
Yoga classes
Variety of excursions including jungle hikes, Amazon river boat trips, pink dolphin viewing, piranha fishing, trips to local communities, and more