CASE REPORT

PSYCHIATRY & BEHAVIORAL SCIENCES

Andres Jovel,1 M.D.; Alan Felthous,1 M.D.; and Anjan Bhattacharyya,1 M.D.

Delirium Due to Intoxication from the NovelSynthetic Tryptamine 5-MeO-DALT

ABSTRACT: Synthetic tryptamines have gained popularity for their hallucinogenic properties, unscheduled status, and availability from“head shops” and through the internet. Here, we present a case of synthetic tryptamine-induced delirium secondary to 5-MeO-DALT ingestionin a previously healthy young male. 5-MeO-DALT led to the hospitalization of our patient after ingestion of a standard dose, presenting withextreme agitation, tachycardia, diaphoresis, and combativeness leading to physical restraint and intravenous sedation. A search of PubMed,Ovid, and Google Scholar for keywords of “5-MeO-DALT,” “5-methoxy-N,N-diallyltryptamine,” or “Lucy-N-Nate” found no case reports orclinical articles in the literature. Rapid emergence and commercialization of this novel synthetic tryptamine 5-MeO-DALT points to the impor-tance of health care and forensic professionals keeping abreast of the latest drugs of abuse and their clinical features. The authors hope thisreport leads the way in disseminating the potential risks associated with unscheduled and unregulated substances, synthetic tryptamines such as5-MeO-DALT in particular.

KEYWORDS: forensic science, 5-MeO-DALT, Lucy-N-Nate, tryptamines, indolealkylamines, hallucinogens, delirium

Tryptamines, or indolealkylamines, have long been used fortheir psychogenic properties. They share a substituted mono-amine group and can be endogenous (e.g., melatonin and seroto-nin) or naturally occurring such as N,N-dimethyltryptamine(DMT), bufotenine, and psilocybin (1). Used by Native Ameri-cans for thousands of years, psilocybin-containing mushroomsgained popularity in recent decades for their hallucinogenicproperties (2). More recently, synthetic tryptamines have gainedcurrency, as illicit drug manufacturers have tried to stay one stepahead of the law by synthesizing new tryptamines that are notyet recognized for schedule I status and legal control. One suchnovel drug is 5-MeO-DALT, the consumption of which led tothe emergency hospitalization of the patient presented here.

Case Report

“Mr. C” was a 20-year-old Caucasian male college studentwith a history of attention deficit and hyperactivity disorder(ADHD) who was brought to the emergency department of acommunity hospital by his parents an hour after ingesting onecapsule of a new “dietary supplement” because he “wanted to trysomething new.” This capsule was bought at a convenience storeunder the name “Lucy-N-Nate.” The pill contained an unknownamount of a novel synthetic tryptamine: 5-MeO-DALT. He alsohad a history of smoking marijuana occasionally and was onAdderall® therapy for ADHD. He denied any other substanceuse such as other illicit drugs or alcohol. His urine toxicologyscreen was positive for cannabinoids and amphetamines. He

complained of feeling ill while at home as though his “heart wascaving in,” near fainting, consciously falling to the ground andscreaming “I’m going to die!,” while flailing all four extremitiesin his parents’ presence. He reported his muscles were “goingback and forth” with extraordinary strength; there was no loss ofconsciousness.In the ED of the referring hospital, he was reported to be agi-

tated, combative, warm, flushed, and diaphoretic. He had markedtachycardia (180–200 bpm) and tachypnea. More than eight peo-ple attempted to restrain him; he was given several benzodiaze-pines intramuscularly for sedation (lorazepam and diazepam) aswell as a dose of IM haloperidol with little response. A decisionwas made for deeper sedation and intubation to ensure protectionof the airway. The initial team diagnosed “bath salt intoxica-tion,” as his parents had this suspicion because they had foundsome bath salts at home.He was quickly transferred to the University Hospital and

admitted to the intensive care unit where a propofol drip was ini-tiated. He was found to have rhabdomyolisis and acute renalfailure, both of which resolved with supportive measures only.On hospital stay day three, Mr. C was transferred to the inpatientpsychiatric unit for stabilization and further assessment, wherehe showed no major mood, psychotic, or anxiety symptoms. Headmitted then to ingestion of “Lucy-N-Nate,” a synthetictryptamine (Fig. 1), for recreational purposes. The authors con-tacted the manufacturer who confirmed that the active compoundis 5-MeO-DALT. Mr. C was discharged the following day instable condition.

Discussion

In recent years, the abuse of newer, designer hallucinogenshas dramatically increased replacing the use of the older, classichallucinogens (3). One of the major reasons for this has been the

1Department of Neurology and Psychiatry, Saint Louis University Schoolof Medicine, 1438 South Grand Boulevard, St. Louis, MO 63104.

Received 27 June 2012; and in revised form 7 Dec. 2012; accepted 10Feb. 2013.

© 2013 American Academy of Forensic Sciences 1

J Forensic Sci, 2013doi: 10.1111/1556-4029.12367

Available online at: onlinelibrary.wiley.com

wide availability of these drugs through local stores and internetdistributors. Moreover, many of these drugs have not beenscheduled by the United States Drug Enforcement Agency (USDEA) or made illegal by state law, making them even moreaccessible to the public.Here, the authors report a case of ingestion of a novel synthetic

tryptamine: 5-MeO-DALT (Fig. 2), branded as “Lucy-N-Nate”with the development of drug-induced excited delirium. 5-MeO-DALT is the latest substituted synthetic tryptamine in a line ofdrugs that have been flagged by the US DEA for abuse liability:5-MeO-AMT, 5-MeO-DET, 5-MeO-DMT (Fig. 3), and 5-MeO-DIPT (aka “Foxy”) (4). Containing an indole ring, tryptaminesare related to the amino acid tryptophan. These monoamine alka-loids are present in plants and animals and include the neurotrans-mitters serotonin (5-HT) and melatonin. Tryptamine stimulant/hallucinogens such as a-ethyltryptamine (AET), N,N-dimethyl-tryptamine (DMT), a-methyltryptamine (AMT), 5-methoxy-N,N-diisopropyltryptamine (5-MeO-DIPT), 5-hydroxy-N,N-dimeth-yltryptamine (bufotenine, a potent hallucinogen similar to psilocy-bin), and 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT) areearlier tryptamine phenylalkylamines that share chemical andpharmacological properties (5).The synthesis and use of 5-MeO-DALT was first reported by

Shulgin in 2004 and subsequently published online by EROWID(6). The commercialization of this compound in the UnitedStates is more recent through an internet distributor that wascontacted by telephone and was willing to sell at the time ofsubmission of this article. Although 5-MeO-DALT has beenscheduled in Japan as a controlled substance (7), the US DEAhas not addressed it to date. In May 2012, the US Congresspassed a bill to amend the Controlled Substances Act to placesynthetic drugs in Schedule I that mentions synthetic cannabi-noids and includes some cathinones (“bath salts”), but leaves outthe new synthetic tryptamines (8).Limited information on the molecular and clinical effects of

these drugs is available in the medical literature. 5-MeO-AMT

and 5-MeO-DET have been found to be 5-HT1A and 5-HT2receptor agonists, respectively (9). Numerous cases regarding theabuse of “Foxy” have been reported in the literature. Clinicalfeatures reported were similar to those of Mr. C, including “hal-lucinations, hypertension, rhabdomyolysis, tachycardia, mydria-sis, and catalepsy” (10, 11).A search of PubMed, Ovid, and Google Scholar for key-

words of “5-MeO-DALT,” “5-methoxy-N,N-diallyltryptamine,”or “Lucy-N-Nate” found no case reports or clinical articles in theliterature at the time of submission. Only one report on its molec-ular effects was found wherein 5-MeO-DALT was found to havethe highest potency among drugs in its class in terms of “G-pro-tein activation via serotonin 5-HT1 receptors” in rodents (12).The pharmacodynamic characteristics (tolerance dose, mediantoxic dose) of this new tryptamine as well as a standardizedscreening for its consumption and/or abuse in bodily fluids, espe-cially useful in urgent situations, have yet to be determined. Dueto the reported serotonin agonist activity of 5-MeO-DALT, sero-tonin syndrome must be part of the differential diagnosis andconsidered possible in future cases with similar presentationalthough there is no current experimental or clinical evidence thatsupports this. In the case presented here, the patient did not havean increase in body temperature, hyperreflexia, clonus, nor gas-trointestinal symptoms. Although this does not entirely rule outserotonin syndrome, it makes the clinician consider it less as aplausible cause of delirium.If the reported substance gains popularity in the future,

treating and forensic clinicians should be aware of the similar-ity of signs and symptoms shared with PCP intoxication, eventhough the active substances are pharmacodynamically different(13).Although the present case did not result in a response by law

enforcement offices or in later forensic issues, police are oftenthe first to be called and to respond when an individual in anexcited delirium (such as the case presented here) is agitated andassaultive. Cases of excited delirium create major concerns forlaw enforcement managers and challenges for the officers whorespond. When police engage an individual who is psychoticand violent due to excited delirium, the interaction can escalate(14), occasionally resulting in in-custody deaths with cocaine,methamphetamine, PCP, and LSD as the typical agents (15).In-custody deaths associated with excited delirium can result incivil lawsuit with causes of action such as deliberate indifferenceto the medical needs of the subject and failure to assess his med-ical condition or to transport the subject to the nearest hospital(16).Drug-induced excited delirium can also result in criminal

charges against the subject who commits a criminal act such asassault. The insanity defense is of no protection for the accusedif the drug was taken voluntarily (17). However, depending upon

FIG. 1––Tryptamine.

FIG. 2––5-MeO-DALT.

FIG. 3––5-MeO-DMT.

2 JOURNAL OF FORENSIC SCIENCES

the facts and jurisdictional law, diminished capacity could resultin a lesser included charge (17). As a mitigating factor, deliriumcould bring the defendant a less severe punishment (18, 19). Thedoctrine of settled insanity has been used where psychosis wasarguably the result of chronic marijuana use (20), but the experi-ence with this defense is too limited to project its applicabilityto a newer, less used substance such as 5-MeO-DALT. Con-founding the investigative and forensic efforts is the lack ofreadily available drug testing for 5-MeO-DALT, although suchtests could be outsourced if the subject of forensic interest isdeceased. This could be carried out with liquid chromatography–mass spectrometry, but would require prior analysis of the com-pound, it is costly, and its use for these uncommon drugs notwidespread (21).This lack of readily available drug testing for 5-MeO-DALT,

other synthetic tryptamines, synthetic cannabinoids, and othernewly synthesized psychoactive agents has resulted in suchdrugs being used by individuals who are subject to drug testingwith adverse consequences if they were to result positive. Mem-bers of the military, parolees, and probationers, among othergroups, may use such substances to get high while avoidingdetection (22).It behooves emergency room physicians, consultation-liaison,

and inpatient psychiatrists to become aware of excited deliriumcaused by 5-MeO-DALT and other drugs that are not commonlytested for. Just as important, law enforcement officers, correc-tional healthcare professionals, and forensic psychiatrists andpsychologists should be familiar with excited and paranoid statesinduced by relatively new substances on the drug scene includ-ing 5-MeO-DALT. Often the clinical and forensic assessmentsimply begins with asking the subject about the use of drugs toobtain “legal highs.” In conclusion, the rapid emergence andcommercialization of this novel synthetic substituted tryptamine5-MeO-DALT emphasizes the necessity for health care provid-ers, law enforcement officers, and forensic evaluators to stayabreast of the latest drugs of abuse and their clinical features.Both treating and forensic mental health professionals, in partic-ular, must consider these new trends in their respective clinicalsetting, especially when evaluating and treating youngersubjects.

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Additional information and reprint requests:Andres Jovel, M.D.Department of Neurology and PsychiatrySaint Louis University School of Medicine1438 S Grand BlvdSaint Louis, MO 63104E-mail: jjovel@slu.edu

JOVEL ET AL. . DELIRIUM DUE TO SYNTHETIC TRYPTAMINE 3