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Complementary and Alternative Medicine

Evaluation of Herbal Dietary Supplements Marketed on the Internet for Recreational Use Cathi E Dennehy, Candy Tsourounis, and Amy E Miller

BACKGROUND:

The Internet is a popular tool for marketing and purchasing herbal dietary supplements (DS). Various Web sites sell these products purely for recreational use.

OBJECTIVE: To describe the content of Web sites that advertise and market herbal DS for recreational use (ie, for the purpose of altering mood/behavior/or perception, “getting high,” or as a substitute for a drug of abuse). METHODS: Four major search engines and the search terms “buy herbal high” and “buy legal high” were used to identify Web sites selling herbal DS for recreational use. Web sites were evaluated for their country of origin and for compliance with the Dietary Supplement Health and Education Act (DSHEA). Products were evaluated for their ingredient lists, effect claims, comparisons with illicit drugs, adverse effects, drug interactions, and contraindications. RESULTS:

Twenty-eight unique Web sites with 119 products were evaluated. Most sites were in the US (54%) and were in compliance with DSHEA. Forty-seven percent of the products were likened to illicit drugs, typically marijuana (48%) or 3-,4methylene dioxyamphetamine (Ecstasy; 23%). The most common product ingredients were ephedra alkaloids (27%), Salvia divinorum (17%), kava (10%), guarana (10%), Acorus calamus (10%), and damiana (10%). Effect claims frequently involved the products’ use as a hallucinogen (51%) or stimulant (39%). Sixty-four percent of the sites mentioned adverse effects, and 54% mentioned drug interactions. CONCLUSIONS: This study demonstrates that herbal DS are being marketed for use as legal alternatives to illicit drugs of abuse. Healthcare professionals need to be aware of this trend and the products that are involved. KEY WORDS: Internet, recreational dietary supplement, recreational herb.

Ann Pharmacother 2005;39:1634-9. Published Online, 13 Sept 2005, www.theannals.com, DOI 10.1345/aph.1G185

he 2003 National Survey on Drug Use and Health T (NSDUH) indicated that 8.2% of Americans use illicit drugs, with the highest prevalence among those 18–20 years old. Marijuana was used most frequently, followed by psychotherapeutic agents (eg, prescription pain relievers, tranquilizers, stimulants, sedatives), cocaine, hallucinogens (including lysergic acid diethylamide, phencyclidine, peyote, mescaline, mushrooms, 3-,4-methylene dioxymethamphetamine [Ecstasy]), and inhalants.1 Herbal dietary supplements (DS) have also been used for recreational purposes (eg, to alter mood, perception,

Author information provided at the end of the text. This research was presented as a poster at the American College of Clinical Pharmacy Annual Meeting, September 2004, Dallas, TX.

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behavior). Emergency care and hospitalizations have been reported in persons ingesting moonflower (Datura inoxia), Hawaiian baby woodrose (Argyreia nervosa), and “Herbal Ecstasy” products.2-5 DS are regulated by the Food and Drug Administration (FDA) under the Dietary Supplement Health and Education Act (DSHEA). DSHEA requires that products being sold as DS be labeled as such. It also requires manufacturers making product structure–function claims to state the FDA disclaimer, “This statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.”6 The Internet is a discreet and easy method of marketing and purchasing supplements. Given the popularity of this market, there has been an emergence of Web sites marketing DS purely for recreational use. The objective of this

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study was to describe the content of these Web sites and their products. Methods

quired that these supplements be removed from the market by April 12, 2004.10,11 After the study was completed, Web sites distributing ephedra products were revisited to check for compliance with this ban.

Results

In February 2004, an Internet search was performed using Google, Yahoo!, AOL, and MSN.7,8 Search terms were “buy herbal high” and “buy legal high.” These terms were chosen after testing numerous search term combinations and determining that these terms retrieved the most sites. The first 100 Web sites for each search term and search engine were screened, and the first 20 unique sites were reviewed. Web sites were included if they claimed to sell herbal DS to US consumers for recreational use. “Recreational use” was defined as the use of a product for the purpose of altering mood/behavior/or perception, “getting high,” or as a substitute for an illicit drug. Products marketed solely as aphrodisiacs or sexual stimulants were excluded. Our selection of products for review was based on Web site presence (ie, prominence of an item on the Web site) until a maximum of 5 products had been evaluated. Products that appeared on the home page and received a majority of the advertising space were evaluated first, followed by the “top seller” or “best seller” links, then followed by the first product appearing under the links provided. Web site coding took place in February and March. Two investigators evaluated each site separately. Web sites were evaluated for location (US or other), presence of seller’s contact information, and, if located in the US, compliance with the DSHEA. Web sites were considered compliant if they identified their products as DS and listed the FDA disclaimer if a structure–function claim was present. Products were evaluated for their ingredient list, effect claims (eg, hallucinogen, stimulant, sedative), presence of testimonials or journal articles to support effect claims, comparisons with illicit drugs, adverse effects, drug and disease interactions, contraindications, and formulation. If no ingredient list was provided but contact information was present, one investigator E-mailed the company with the phrase, “I’m interested in trying this product. Can you tell me what’s in it?” If no reply was received and the company was located within the US, we attempted to phone the manufacturer. Effect claims were grouped (Table 1). SURVEY TOOL AND INTERRATER RELIABILITY

The survey tool was designed so that, if a particular item (eg, structure or function claim, adverse effect claim) appeared on the Web site, it would be recorded as “yes” or, if absent, as “no.” Additional descriptive information was recorded using the terminology listed on the Web site. After both investigators had completed their coding, all responses were compared for interrater reliability. If discrepancies existed, the investigators met, revisited the Web site, and came to a consensus. Interrater reliability was performed using Cohen’s kappa statistic, where a value of >0.7 was considered satisfactory.9

WEB SITE SUMMARY

Twenty-eight Web sites were identified, and 119 products were evaluated (average 4.3 products per Web site). The majority of the suppliers were located in the US (54%, n = 15) and the UK (36%, n = 10). There was one site in the Netherlands and one in Canada; another did not specify a location. Products on all foreign Web sites stated that they would ship products to the US. The 15 US-based sites were evaluated for compliance with DSHEA. Among these, 73% (n = 11) identified one or more product as a DS, 93% (n = 14) made at least one structure–function claim, and 67% (n = 10) included the FDA disclaimer. PRODUCTS AND INGREDIENTS

Products that occurred with a frequency of ≥2% are listed in Table 2. Of the 119 products evaluated, Salvia divinorum was the most prevalent. Web sites that sold Salvia often included an “S-A-L-V-I-A scale,” where the “trip” was described in levels dependent on the amount ingested (Table 3).12 Many sites selling Salvia recommended that the user have a “sitter” (a person not under the influence of any mind-altering substance) to oversee their behavior for safety reasons. Seventy-seven percent (n = 92) of the products provided an ingredient list; ingredient lists for an additional 9% (n = 11) were obtained by contacting the company by E-mail or phone. No ingredient list was identified for 16 products. The most common product ingredients are listed in Table 4. Ephedra was the most common product, followed by Salvia. The majority of products were single- (59%) versus multi-ingredient (41%). EFFECT CLAIMS

COMPLIANCE WITH EPHEDRA BAN

In February 2004, the FDA had just published a final rule declaring that DS containing ephedra alkaloids were adulterated because of the risk of illness and injury to consumers. The ban prohibited the sale of DS containing ephedra, ma huang, Sida cordifolia, or Pinellia spp. and re-

Table 1. Characterization of Effect Claims Effect Claim Sedatives Euphorics Hallucinogens Stimulants

Description have sedative or relaxing effects; decrease stress and anxiety enhance mood; produce a state of euphoria expand the mind; produce hallucinations; have psychedelic properties increase energy; have stimulant, cocaine, or speed-like effects

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Forty-seven percent (n = 56) of the products were likened to a specific illicit drug. The most common were marijuana (48%), Ecstasy (23%), LSD (14%), cocaine or speed (13%), and mushrooms (5%). A small percentage (5%) of suppliers also likened their products to benzodiazepines, opium, and “roofies” (ie, flunitrazepam). In 7% of the cases, more than one illicit drug was cited as being similar to a DS product. Seventy-nine percent (n = 94) of the products advertised effect claims. The claims were generally supported by testimonial evidence (94%, n = 15) compared with journal citations (6%, n = 1) and were present on 57% (n = 16) of the 28 Web sites. Fifty-one percent (n = 48) of the products were categorized as hallucinogens, 39% as stimulants, 31% as euphoria producing, and 24% as sedatives. Products that qualified as stimulants most commonly contained

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ephedra and made claims such as increasing emotional energy or mental clarity. Adverse Effects, Contraindications, and Drug Interactions Sixty-four percent (n = 18) of the Web sites stated at least one or more potential adverse effect, with the most common (68%, n = 14) being impaired motor coordination, which was implied by the disclaimer, “Do not drive or operate machinery after using this product.” Thirty-nine percent of the sites also reported nausea as a possible adverse effect. Other adverse effects that were listed with a frequency ≥10% included nervousness (22%), tremor (22%), insomnia/sleeplessness (22%), loss of appetite (22%), headache (22%), increased heart rate (17%), dizziness (11%), and mucous membrane irritation (11%). Fifty-seven percent (n = 16) of the Web sites reported at least one contraindication to product use and 54% (n = 15) reported one or more drug interaction. The most common contraindication was a standard disclaimer present on 75% (n = 12) of sites that stated, “Do not use this product if you are pregnant or nursing, or if you have heart disease, thyroid disease, diabetes, high blood pressure, depression or other psychiatric condition, glaucoma, difficulty urinating, prostate enlargement, or a seizure disorder.” Similarly, the

most common drug interaction was also part of the above disclaimer and included the phrase, “Do not use this product if you are using a monoamine oxidase inhibitor (MAOI), any other prescription drug, or an over-the-counter drug containing ephedrine, pseudoephedrine, or phenylpropanolamine (ingredients found in certain allergy, asthma, cough/ cold, and weight control products).” Of the Web sites stating this disclaimer, 50% (n = 8) sold ephedra-containing products and 38% (n = 6) sold Salvia. Other contraindications that occurred with a frequency ≥10% included hepatitis (13%), liver disease (13%), and the use of alcohol (13%). FORMULATION

Products were most often delivered as pills for oral administration (52%, n = 62) or in a cigarette-based or loose, leaf form that could be smoked (47%). Four percent of products did not state a delivery method, 4% recommended use as incense, and 1% recommended sublingual administration. In 8% of the cases, products listed more than one delivery method (eg, ingested orally or smoked). INTERRATER RELIABILITY

Kappa values for interrater reliability met our predefined cut-off level for satisfactory agreement, except for

Table 2. Commonly Encountered Products Product Salvia

Frequency, % (n) 15 (18)

Ingredient

Likened to

Claim

Salvia divinorum

marijuana, LSD

hallucinogen

Bliss Extra

5 (6)

Acorus calamus, Sida cordifolia, Siberian ginseng, L-phenylalanine, GABA

Ecstasya

euphoric, hallucinogen, stimulant

EX-1

5 (6)

Sida cordifolia

speedb

euphoric, stimulant

Druids Fantasy

3 (4)

morning glory, Hawaiian baby woodrose (Argyreia nervosa), Acorus calamus, Siberian ginseng, kava kava

LSD

hallucinogen

Trip2Night

3 (3)

ma huang, guarana, 5-HTP, Bioperine, Indian bromine, cinnamon, cola nut, niacin, Fo-ti

Ecstasy,a LSD

stimulant hallucinogen

Absinthe herb

2 (2)

Artemisia absinthium

marijuana, LSD

Damianac

2 (2)

damiana herb

marijuana

aphrodisiac, euphoric, sedative

Hawaiian baby woodrose

2 (2)

Argyreia nervosa

LSD

euphoric, hallucinogen, stimulant

Hawaiian Herbal Hybrid Buds

2 (2)

lettuce opium (Lactusa virosa)

marijuana

euphoric

Kanzak

2 (2)

Kanna

NA

euphoric, sedative

Kratom

2 (2)

Mitragyna speciosa

marijuana

euphoric, hallucinogen, stimulant

Red Dawn

2 (2)

guarana, 5-HTP, Bioperine, Indian bromine, cinnamon, cola nut, niacin, Fo-ti

NA

aphrodisiac, euphoric, stimulant

Road Runner Super

2 (2)

Sida cordifolia, Siberian ginseng, GABA, d L-taurine, Paulina cupana

speedb

stimulant

Uraeus Liquid Speed

2 (2)

guarana, gotu kola, Ginkgo, lemon balm

speedb

hallucinogen, stimulant

GABA = γ-aminobutyric acid; 5-HTP = 5-hydroxytriptophan; LSD = lysergic acid diethylamide; NA = not applicable. a 3-,4-methylene dioxymethamphetamine. b Amphetamine or methamphetamine. c There were 2 single-ingredient damiana products and an additional 8 products that included damiana as part of a multi-ingredient list. d A form of Brazilian guarana.

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the 3 questions related to compliance with DSHEA. An overall kappa statistic of 0.48 was calculated for these 3 questions, as there were only 15 responses (ie, based on number of US sites) for each. COMPLIANCE WITH EPHEDRA BAN

Initially, 54% (n = 15) of the sites had been selling ephedra products; 7 of these were located in the US. By May 2004, 6 of those suppliers had removed these products from their Web site. Among the 8 foreign distributors of ephedra, one Web site was no longer operational, one no longer shipped ephedra-containing products to US customers, and 6 continued to sell the products to US consumers. Therefore, 47% of Web sites continued to market ephedra products after the ban.10,11 Discussion After this study was completed, the FDA released a warning to consumers not to purchase or consume DS products that claimed to be “safe legal highs” or that were being marketed as “street drug alternatives.” The warning stated that DS products promoted as such were considered to be misbranded and qualified as unapproved new drugs. They recognized the potential for misuse and abuse and identified this market as a potential public health concern.10,11 Our findings substantiate this concern.

PRODUCTS AND INGREDIENTS

Many of the product names seemed to coincide with the concept of producing a blissful or fantasy-like state (eg, Bliss Extra, EX-1, Druids Fantasy, Trip2Night). The pharmacology of commonly encountered ingredients also coincides with the potential for central nervous systems (CNS) alteration. Specifically, S. divinorum is a type of sage that results in psychedelic effects when smoked.13 Kava kava has sedative and anxiolytic properties, while guarana contains 2.5–7% caffeine and acts as a CNS stimulant.13 A. calamus contains asarone, which is converted to trimethoxyamphetamine in the body, a psychedelic compound and the basic building block of amphetamines.14 Damiana and lettuce opium are both smokeable herbs with relaxing effects.13 Bioperine is an extract of the black pepper fruit and has been shown to significantly increase the bioavailability of some nutrients.15 Lastly, Fo-ti may enhance mental clarity, A. nervosa may have hallucinogenic properties, and γ-aminobutyric acid may relieve anxiety and elevate mood.13,16 EFFECT CLAIMS

Products were most often likened to marijuana, which was not surprising given the results of the NSDUH.1 On the other hand, product effect claims most commonly fell into the hallucinogen category, which did not coincide with the NSDUH survey, where stimulant use exceeded that of hallucinogens.1

WEB SITE SUMMARY ADVERSE EFFECTS, CONTRAINDICATIONS, AND DRUG

As the study was under development, we expected that a large number of Web sites would be promoting DS for recreational use; however, only 28 unique sites were identified. We had anticipated finding more, given the popularity of the Internet and DS. The large number of sites outside the US may be reflective of the popularity of herbal DS in Europe. It is unclear where Americans would preferentially buy their products from US manufacturers, but a foreign site might be preferred if it is perceived to be more discreet. Our overall kappa score for the presence or absence of information relating to DSHEA was 0.48. This represents a moderate level of agreement and the difficulty in interpreting and assessing compliance with DSHEA.

Level 1 2

3 4 5 6

INTERACTIONS

The Salvia scale was included as part of these results because we were alarmed by the “loss of consciousness” described in level 6 and by the recommendation that a “sitter” may be necessary. Given these 2 claims, it is clear that this herb has a serious potential for harm. It also raises concerns if it is taken with other CNS-acting agents that affect consciousness or respiration. More than half of the Web sites evaluated stated an adverse effect, with impaired motor coordination being the most common. Given that these products were being recommended for the purpose of altering mood, perception, or behavior, this disclaimer seems warranted. Other common adverse effects, such as nervousness, insomnia, and increased heart rate, coincided Table 3. SALVIA Scale12 with the stimulant nature of ephedra and caffeine, which were frequently present in these Effect products. Of course, with any ephedra product, Subtle effects, such as relaxation and increased sensual appreciation the greatest concern remains its ability to proAltered perception, such as more pronounced colors and textures; thinking becomes less logical and more playful; may be short-term duce myocardial infarction, stroke, or death, memory loss which was the impetus behind the FDA ban.10,11 Light visionary state, such as closed-eye visuals Kava was a commonly encountered ingrediVivid visionary state, such as complex 3-dimensional realistic scenes ent. Healthcare providers should be aware that appearing; shamanistic journeying to other lands; “dream time” Immaterial existence, in which one is no longer aware of having a body this herb has been associated with cases of livand identity is lost er toxicity and failure, leading to a ban on its Anesthesia, in which consciousness is lost for several minutes sale in several countries.17 Altered mental sta-

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tus and ataxia have also been observed in cases of acute kava ingestion.18 LIMITATIONS

All of the Web site coding was performed within a 2month time period, but site changes occurred during this time that may have affected investigator coding. Our overall kappa scores, however, were good to excellent in most areas (>0.7), suggesting that these differences were minor. Our method of defining search terms was somewhat random. The terms we eventually decided upon may not have been optimal and could have led us to identify fewer Web sites than actually exist. Researchers interested in duplicating this type of study may wish to include other search terms, such as those described by the FDA in their warning to consumers about these products (ie, “safe legal highs,” street drug alternatives). Finally, we never attempted to purchase any DS products. As a result, it is difficult to verify whether all of these sites would actually ship products to US consumers, even though all sites stated that they would. COMPLIANCE WITH EPHEDRA BAN

The majority of US Web sites were in compliance with the ephedra ban, whereas only 25% of foreign distributors were. This is not surprising, as the ban was issued by the FDA and was limited to products being sold within the US or to US residents. Given the large number of ephedrabased products that we identified, this legislation is likely to have a positive effect on this market. It is apparent that the FDA is continuing to conduct surveillance of DS products that may pose a risk to con-

Table 4. Commonly Encountered Product Ingredients Frequency, % (n)a

Product Ephedra Sida cordifolia ma huang Ephedra alkaloids

27 (28) 17 (17) 6 (6) 5 (5)

Salvia divinorum

17 (18)

Acorus calamus

10 (10)

Damiana

10 (10)

Guarana

10 (10)

Kava kava

10 (10)

Lettuce opium (Lactusa virosa)

9 (9)

Siberian ginseng (Eleutherococcus senticosus)

8 (8)

Argyreia nervosa

6 (6)

Bioperine

6 (6)

Fo-ti

6 (6)

GABA

6 (6)

GABA = γ-aminobutyric acid. a Total number is 103; we were unable to obtain an ingredient list for 16 products.

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sumers. In February 2004, they issued a release not to purchase an herbal Ecstasy product known as Green Hornet due to case reports of seizures, tachycardia, and hypertension.19,20 Although our study did not identify this product, it does fall within the category of DS marketed for recreational use. Conclusions The findings from this study indicate that herbal DS are being marketed for recreational purposes and as alternatives to illicit drugs. Most of the products were likened to marijuana or Ecstasy, and most claimed to have hallucinogenic or stimulating properties. Products containing ephedra and S. divinorum were the most commonly encountered. Even after the FDA ban on the distribution of ephedra-containing DS in the US, we were able to identify a number of sites that continued to sell them. Healthcare professionals should be familiar with these products so that they are better able to identify products, ingredients, and causes of toxicity in persons utilizing DS for recreational purposes. Cathi E Dennehy PharmD, Associate Clinical Professor, School of Pharmacy, University of California, San Francisco (UCSF), San Francisco, CA Candy Tsourounis PharmD, Associate Professor, School of Pharmacy, UCSF Amy E Miller PharmD, at time of study, Pharmacy Practice Resident, UCSF; now, Primary Care Specialty Resident, University of Colorado Health Sciences Center, Denver, CO Reprints: Dr. Dennehy, Department of Clinical Pharmacy, University of California, San Francisco, 521 Parnassus Ave., Ste. C-152, Box 0622, San Francisco, CA 94143-0622, fax 415/476-6632, dennehyc@ pharmacy.ucsf.edu

References 1. Substance Abuse and Mental Health Services Administration (2003). Results from the 2003 National Household Survey on Drug Abuse: Volume 1. Summary of national findings. www.oas.samhsa.gov (accessed 2005 Mar 5). 2. Suspected moonflower intoxication—Ohio, 2002. MMWR Morb Mortal Wkly Rep 2003;52:788-91. 3. Al-Assmar SE. The seeds of the Hawaiian baby woodrose are a powerful hallucinogen. Arch Intern Med 1999;159:2090. 4. Yates KM. “Herbal Ecstasy”: a case series of adverse reactions. N Z Med J 2000;113:315-7. 5. Zahn KA, Li RL, Purssell RA. Cardiovascular toxicity after the ingestion of “Herbal Ecstasy.” J Emerg Med 1999;17:289-91. 6. Dietary Supplement Health and Education Act of 1994. 103rd Congress, 2nd session report 103-410, January 25, 1994. 7. Sullivan D. Nielsen NetRatings search engine ratings. February 25, 2003. www.searchenginewatch.com/reports/article.php/2156451 (accessed 2003 Aug 23). 8. Sullivan D. ComScore Media Metrix search engine ratings. August 1, 2003. www.searchenginewatch.com/reports/article.php/2156431 (accessed 2003 Aug 23). 9. Chuang JH. Agreement between categorical measurements: kappa statistics. http://www.dmi.columbia.edu/homepages/chuangj/kappa (accessed 2004 Aug 21). 10. Questions and answers about FDA’s actions on dietary supplements containing ephedrine alkaloids. February 6, 2004. www.fda.gov/oc/initiatives/ ephedra/february2004/qa_020604.html (accessed 2004 Nov 14). 11. FDA announces rule prohibiting sale of dietary supplements containing ephedrine alkaloids effective April 12. April 12, 2004. www.fda.gov/ bbs/topics/NEWS/2004/NEW01050.html (accessed 2004 June 10).

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Evaluation of Herbal Dietary Supplements Marketed for Recreational Use 12. Legal highs—Salvia divinorum—information on Salvia divinorum and effects of Salvia. www.legal-highs.co.uk/legal-highs-info-salvia-divinorum. htm (accessed 2004 May 19). 13. Jellin JM, Gregory P, Batz F, Hitchens K, Burson S, Shaver K, Palacioz K, eds. Pharmacist’sletter/prescriber’s letter. Natural medicines comprehensive database. 3rd ed. Stockton, CA: Therapeutic Research Faculty, 2000. 14. King Bong. www.kingbong.com (accessed 2004 Feb 25). 15. Bioperine. www.gorillavitamins.com/bioperine.cfm (accessed 2004 June 10). 16. Grow this beautiful vine, Fo-Ti to increase your mental clarity. www. taoherbfarm.com/herbs/herbs/fo-ti.htm (accessed 2004 June 10). 17. Clouatre DL. Kava kava: examining new reports of toxicity. Toxicol Lett 2004;150:85-96. 18. Perez J, Holmes JF. Altered mental status and ataxia secondary to acute kava ingestion. J Emerg Med 2005;28:49-51. 19. FDA warns consumers not to purchase Green Hornet, promoted as herbal version of “Ecstasy.” February 25, 2004. www.fda.gov/bbs/topics/ NEWS/2004/NEW01026.html (accessed 2004 Feb 27). 20. FDA expands warning about “Green Hornet” to include all other products by Cytotec Solutions, Inc. April 9, 2004. www.fda.gov/bbs/topics/ NEWS/2004/NEW01049.html (accessed 2004 May 3).

EXTRACTO TRASFONDO: La red de informática Internet es una herramienta popular de mercadeo y venta de suplementos nutricionales. Varios sitios de la red Web sites venden estos productos para uso puramente recreativo. OBJETIVO: El objetivo de este estudio es describir el contenido de los sitios de la red Web sites que anuncian y mercadean suplementos botánicos para uso recreativo, específicamente con el propósito de alterar el estado de ánimo (alegría, relajamiento o euforia), el comportamiento, la percepción, ó como un substituto de una droga de abuso. MÉTODOS: Se utilizaron 4 motores de búsqueda con los términos “comprar euforia/nota/arrebato herbal” y “comprar euforia/nota/arrebato legal” para identificar los sitios de la red Web sites vendiendo los suplementos de uso recreativo. Los sitios de la red se evaluaron para determinar su país de origen y el cumplimiento con la Ley de Salud y Educación de Suplementos Nutricionales, conocido por sus siglas en inglés DSHEA. Se evaluaron los productos para determinar si tenían lista de ingredientes, reclamo de efecto, comparación a drogas ilícitas, efectos adversos, y contraindicaciones. RESULTADOS: Se evaluaron 28 sitios de la red con 119 productos. La mayoría de los sitios se encontraban en los Estados Unidos de América

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del Norte (54%) y estaban en cumplimiento con el DSHEA. Cuarenta y siete por ciento de los productos se compararon con drogas ilícitas, típicamente marihuana (48%) o éxtasis (23%). Los ingredientes más comunes hallados en los productos fueron alcaloides de efedra (27%), Salvia divinorum (17%), kava (10%), guarana (10%), Acorus calamus (10%) y damiana (10%). El reclamo de efectos frecuentemente involucraba productos con acción alucinógena (51%) o estimulante (39%). Un 64% de los sitios mencionaron efectos adversos y 54% mencionaron interacciones a con medicamentos. CONCLUSIONES: Este estudio demostró que algunos suplementos nutricionales botánicos se están mercadeando como alternativas legales para sustancias ilícitas de abuso. Los profesionales de la salud deben conocer esta tendencia y los productos que están involucrados. Jorge R Miranda Massari RÉSUMÉ

L’objectif de cette étude est de décrire le contenu des sites internet qui annoncent et vendent des suppléments diététiques pour usage récréatif. MÉTHODES: Quatre moteurs de recherche et les mots clés suivants “buy herbal high” et “buy legal high” ont été utilisés afin d’identifier les sites internet qui vendent ces produits. Les sites internet ont été évalués selon leurs pays d’origine et la conformité avec le “Dietary Supplement Health and Education Act (DSHEA).” Les éléments suivants ont été évaluées: la liste des ingrédients, les effets annoncés, la comparaison avec les drogues illicites, les effets indésirables, les interactions médicamenteuses, et les contre indications. RÉSULTATS: Un nombre de 28 sites internet avec 119 produits ont été évalués. La majorité de sites était retrouvé aux États-Unis (54%) et étaient conformes avec le DSHEA. Quarante-sept pour cent des produits étaient associés à des drogues illicites, typiquement la marijuana (48%) ou l’ectasie (23%). Les ingrédients les plus souvent retrouvés étaient l’éphédra (27%), la Salvia divinorum (17%), le kava (10%), le guarana (10%), l’Acorus calamus (10%), et le damiana (10%). Les effets annoncés impliquaient souvent les produits utilisés comme hallucinogènes (51%) ou stimulants (39%). Soixante-quatre pour cent des sites décrivaient les effets indésirables et 54% les interactions médicamenteuses. CONCLUSIONS: Cette étude démontre que les suppléments diététiques sont utilisés comme alternative aux drogues illicites. Les professionnels de la santé doivent être au courant de cette tendance et connaître les produits impliqués. OBJECTIF:

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