Not long ago, hospital emergency room staff summoned a Drug Abuse Recognition (DAR) trained officer to investigate claims a patient’s claims that her spouse was trying to kill her. The patient was alleging that her husband had been poisoning her bottled water and that she was becoming very ill because of it. The DAR trained officer met with the doctor and the charge nurse. He was told that the patient had been admitted to the emergency room with fatigue, nausea, migraine headaches, tingling sensations in her extremities and severe stomach cramps. The hospital lab had analyzed some blood and urine samples she provided and they were awaiting the results. The police had been called to investigate the patient’s claim that her husband had been poisoning her; the patient’s symptoms were posited as being the result of poisoning.

When the officer arrived, he saw a frail woman in her 50’s who exhibited drug use signs consisting of droopy eyelids (ptosis), dilated pupils and a rapid heart rate of 100 beats per minute. The patient told the officer that she was suffering from bad headaches, nausea and vomiting; she communicated her strong belief that her symptoms were the result of poisoning undertaken by her husband. The patient told this story several times. The stories built on one another and resulted in the creation of what appeared to be a fantasy-conspiracy involving her otherwise loveable husband and some of his nefarious friends. The patient seemed to be extremely paranoid and delusional; she could have easily been mistaken for someone who’d experienced a nervous breakdown. The officer had a gnawing feeling that he was dealing with someone who was experiencing the effects of hallucinogen use, but he needed to more closely assess the signs and symptoms exhibited by the patient.

The officer began to more carefully evaluate and take in the patient’s symptoms. The officer observed eyelid tremors every time the patient closed her eyes, in his mind this was a telltale sign. The temperature in the room felt normal, yet the patient exhibited goose bumps (piloerection) on both arms. The observed symptoms fit with the information provided by the doctor, this situation was becoming very clear to the DAR trained officer, all signs and symptoms were pointing to hallucinogenic drug intoxication.

The officer proceeded with a methodical DAR evaluation of the patient. Adhering to the DAR 7 Step evaluation, the officer worked through the screening process. The patient’s internal clock was 10 seconds (very fast clock); pupils were equal and dilated to 8.0 mm in room, the reactions to light were normal. There was “no” nystagmus and “no” non-convergence present. There were no signs of rebound dilation or hippus during the direct light phase of the eye exams. The patient’s pulse held steady (fast) at 100 beats per minute. These signs are all classic findings associated with the use of hallucinogens, drugs such as LSD, “Magic Mushrooms,” Morning Glory seeds, DMT and peyote. The lack of nystagmus ruled out the use of other hallucinogen-like drugs such as ketamine and inhalants.

After a short dialog, the officer learned the following:

The patient had not slept or eaten anything for three days. She had been suffering with a migraine headache that began three days prior. Her doctor had prescribed medication for the migraine headaches, but she could not remember the name of it. She did recall that the medicine contained caffeine along with some other chemical. The woman grabbed a brown prescription bottle from her purse and handed it to the officer. The medication label listed the contents as Cafergot, the prescription was three days old; Cafergot is a chemical blend of ergot and caffeine. Inside the bottle were half a dozen tablets, the original prescription was for 30 tablets. The patient couldn’t remember how many tablets she’d taken, she did relate however that she’d taken a tablet every time that her head had hurt. It appeared that this patient was taking 2-3 tablets every four to six hours.

The officer then realized that this patient had probably overdosed on Cafergot, the drug that she’d been prescribed for her migraines. Leaving the patient’s bedside, the officer headed to the nurses station to ask for a PDR reference book. The officer looked through the guide and learned that Cafergot is an effective therapy for some types of people who suffer migraine headaches. He learned that in high or overdose amounts, some very negative side effects can occur. The officer waited for the examining doctor to return. The officer told the doctor that he believed the patient was not a victim of poisoning, but rather she was “high” on Cafergot.

Cafergot is an odd drug with a very unique chemical constitution, it is a compound made up of caffeine and ergotamine. The latter is a member of the family of ergot alkaloids. The first of these was isolated from the ergot fungus in 1921 by Arthur Stoll. The drug was initially sold and marketed under the product name of Gynergen. The drug was used to induce childbirth, prevent post-partum hemorrhage and to treat migraine headaches. Digging a little deeper, the officer learned that LSD, a potent hallucinogen, is derived from that very same ergot fungus. In fact, there’s a rich history involving nefarious behaviors as a result of unintended ergot ingestion. There are epic stories of accidental ingestion of ergot contaminated bakery bread by people who subsequently complain of hallucinations and out of body experiences. Ergot poisoning and resultant bizarre behaviors are alleged by some to be at the heart of the events that prompted the Salem Witch-Hunt Trials of 1692. It was evident that the patient in this situation had ingested much more Cafergot than she should have, she had in fact overdosed on the drug. Considering Cafergot’s pharmacology and chemical lineage to LSD, this patient was exhibiting a classic set of hallucinogen signs and symptoms. The patient was stabilized and later released into the custody of her husband. (Her broom was impounded by the police for safekeeping.)
This case involving a DAR trained police officer points out the need for evaluators to ask about prescribed and over the counter medications that may have been ingested by someone who is otherwise suspected of being under the influence of a drug. Cafergot is an unusual drug, one that’s not often prescribed. Newer and safer drugs are now available to treat migraine headaches. Drugs such as Imitrex, Zomig and Relpax represent a new genre of migraine drugs that are safer and more effective than Cafergot. But in some situations, cases where these newer drugs are ineffective, it is quite possible that a reader may find Cafergot.

Mr. Rich Ulrich provided the material for this essay. Rich is a Drug Recognition Expert (DRE) and a veteran MEDTOX Drug Abuse Recognition (DAR) instructor. Rich was the officer involved in this vignette. Rich’s appropriate use of the DAR 7-step screening system is what led him to the unusual diagnosis that was made of hallucinogen intoxication. For questions you have regarding this case or of others like it, Rich can be reached at rulrich@medtox.com.

Reproduced with permission from The MEDTOX® Journal April 2009