Research letter
Trip-killers: a concerning practice associated with psychedelic drug use
warnings about the potential adverse effects of trip-killers. We have used novel methods to identify an emerging trend in recreational drug use. Reddit users frequently recommend benzodiazepines and antipsychotics to counter the effects of psychedelic drugs (table 1) but only rarely discuss the potential harms of these agents. Benzodiazepines and antipsychotics are logical choices for trip-killers. The anxi- olytic effect of benzodiazepines may help a ‘bad trip’ to feel less frightening. The antipsychotics favoured in our results are antagonists at the 5-hydroxytryptamine 2A (5-HT2A) receptor, which is the primary site at which psychedelics act. Alprazolam and quetiapine were the drugs named most frequently by posters. This finding may be explained by geography. In the USA, where the majority of Reddit members are based, alprazolam and queti- apine are the most commonly prescribed drugs in their class. However, illicit access to these substances has increased in Europe. 5 The popularity of benzodiazepines raises concerns. Benzodiazepines are addictive and have been repeatedly implicated in overdose deaths. 6 The doses described on Reddit (table 2) risk over-sedation, hypo- tension, and respiratory depression. Queti- apine doses were also high and only a few posts differentiated between immediate and modified-release preparations. We recommend that emergency physi- cians ask patients about trip-killers if psyche- delic drug use is suspected. This conversation should occur promptly on arrival to hospital, and before any benzodiazepines or antipsy- chotics are prescribed. Doing so could offset an indirect risk to these patients—iatrogenic overdose—and will improve understanding of their mixed toxidrome. Gregory Yates , Emily Melon Manchester Royal Infirmary, Manchester, UK Correspondence to Dr Gregory Yates, Manchester Royal Infirmary, Manchester M13 9WL, UK; g regory.yates@m ft.nhs.u k Contributors GPY and EM contributed to planning, data acquisition, interpretation, and reporting. The authors are grateful for the input of an expert patient who suggested online resources to assist with the design of this study after being admitted to hospital with a 2-CB overdose. Funding The authors have not declared a specific grant for this research from any funding agency in the Patient consent for publication Not applicable. Provenance and peer review Not commissioned; externally peer reviewed. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have public, commercial or not-for-profit sectors. Competing interests None declared.
Table 1 Trip-killers recommended by Reddit users Drug class Drug name N Benzodiazepines, n=440 (46%) Alprazolam 137 Diazepam 50 Lorazepam 24 Clonazepam 24 Etizolam 20 Clonazolam 6 Deschloroetizolam 5 Other 24 Not specified 150 Antipsychotics, n=171 (18%) Quetiapine 98 Olanzapine 14 Chlorpromazine 5 Other antipsychotic 18 Not specified 36 Antidepressants, n=100 (10%) Trazodone 77 Mirtazapine 14 Other 4 Not specified 5 Alcohol (5%) N/A 49 Opioids, n=30 (3%) Kratom 23 Other 7 Herbal remedies, n=33 (3%) Valerian 15 Pipe root 6 Chamomile 5 Other 7 Antihistamines, n=30 (3%) Benadryl 15 Diphenhydramine 6 Other 8 Unspecified 1
Psychedelic drugs such as lysergic acid diethylamide (LSD) and psilocybin (‘magic mushrooms’) induce hallucinations and distort thought-processes. The intensity of a psychedelic ‘trip’ can cause distress, agitation, and even psychosis. A recent report showed that at least 8.4% of drug- related presentations to European emer- gency departments involve psychedelics. 1 This proportion may increase as the clin- ical use of these agents expands. 2 There are multiple ways to control a ‘bad trip’ and avoid hospitalisation. One is to take psychedelics under the supervision of a ‘trip-sitter’—a non-intoxicated friend who can provide psychological support. Another is to use additional psychoac- tive drugs—‘trip-killers’—to attenuate or prematurely end the psychedelic expe- rience. Trip-killers are not new, but have received increased attention on social media in recent years. 3 Information on trip-killers is not avail- able through drug advice services, despite the probable risks they pose. To our knowledge, no relevant papers have been published in the medical literature. It was the aim of our study to gather descriptive data on the use of psychedelic trip killers by analysing posts made on Reddit, a publicly accessible, anonymous social media website. Reddit contains several sub-forums for discussion of recre- ational drugs, such as ‘r/LSD’ (716 752 users), and ‘r/MDMA’ (237 622 users). The content of Reddit posts has been used previously in psychedelic research. 4 Formal ethical approval was not required to conduct this study due to the use of publicly available and anonymous online data. We conducted a systematic keyword search of the entirety of Reddit using the website’s internal search tool and a site- specific Google query (online supple- mental information). We aimed to include English-language threads in which one or more posters had recommended a trip-killer by starting a new thread or responding to an open question from another poster. One hundred and twenty- eight relevant threads were identified (2015–2023) yielding 709 posts from which the following data were extracted: trip-killer(s) recommended, psychedelic drug(s) described, dose(s), safety warn- ing(s). Descriptive statistics were calcu- lated using Microsoft Excel 2016.
Prescription sleep medications, n=24 (3%)
Melatonin Z-drug (eg, zopiclone, zoldpidem)
13 11
Cannabidiol (2%) Cannabis (2%)
N/A N/A N/A
21 11 44
Other (5%)
A summary of results is provided in table 1. Most commonly recommended were benzodiazepines and antipsychotics. Dose ranges can be found in table 2. Trip-killers were mostly discussed in reference to LSD (n=235), psilocybin mushrooms (n=143), and MDMA (3,4-methylenedioxymethamp hetamine) (n=21). Only 58 posts contained Table 2 Trip-killer doses recommended by Reddit users Drug name Dose range Alprazolam 0.5–4 mg Diazepam 3–20 mg Quetiapine 25–600 mg Trazodone 50–150 mg
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Emerg Med J February 2024 Vol 41 No 2
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