Is LSD toxic?

The extracted text does not provide a separate Methods section or an explicit description of a systematic search strategy. Instead, the paper operates as a narrative review of the historical clinical literature, pharmacokinetic studies, and selected forensic case reports related to deaths associated with LSD. Nichols and colleagues synthesise published case reports, toxicology findings, human pharmacokinetic studies (including Upshall and Wailling and Dolder et al.), and forensic/epidemiological work on restraint-related deaths and "excited delirium" to evaluate whether reported fatalities can be attributed to LSD toxicity. Because the extraction lacks procedural detail about literature selection, inclusion criteria, or quality assessment, it is not possible from the provided text to determine whether the review used systematic methods, which databases were searched, or how cases and studies were chosen for inclusion.

The paper reviews three broad categories of fatalities linked in the literature or media to LSD: deaths after massive overdose, deaths that occurred in the context of severe agitation followed by maximal physical restraint (hog‑tying/PMR), and deaths likely caused by other substituted psychoactive drugs (for example NBOMe‑type compounds). On massive overdose, early estimations of lethal doses were highly variable. Gable initially estimated a lethal oral dose of 14 mg in humans based on animal data and later revised a human lethal oral dose estimate to 100 mg. Case reports cited include one with a very high reported liver concentration (extraction text gives ‘‘31.2 mg/mL’’ but units and exact meaning are unclear in the extracted text) and another fatality where ante‑mortem serum was 14.4 ng/mL; details in some reports were insufficient to precisely determine timing or amount of ingestion. Conversely, Klock et al. describe eight patients who insufflated putative pure LSD tartrate powder (believed by them to be cocaine) with blood LSD concentrations up to 26 ng/mL and gastric concentrations reported as high as 7.0 mg/100 mL (70,000 ng/mL); despite severe acute symptoms, all eight recovered after supportive care. Several fatal cases originally attributed to LSD are examined in detail. A 14‑year‑old in a severe ‘‘bad trip’’ was restrained and hogtied and later died after respiratory arrest; only LSD was reportedly detected in blood. A 28‑year‑old male who was combative and hogtied during arrest was found postmortem with LSD 3.2 ng/mL and blood alcohol 0.12 g/100 mL; death was attributed to positional asphyxia. A 30‑year‑old male who was tasered, bitten by a police dog, hogtied and heavily strapped to a stretcher later died with a post‑mortem subclavian blood LSD concentration of 1 ng/mL; the medical examiner reported death as due to ‘‘complications of LSD toxicity,’’ but the authors note that such a plasma concentration is inconsistent with known toxic levels. A 20‑year‑old woman at a music festival presented with extreme hyperthermia (reported temperatures 105 F pre‑hospital, 103 F in hospital), massive pulmonary oedema (about 4,800 mL fluid removed), and postmortem blood LSD levels of 0.22–0.47 ng/mL; initial coroner’s report listed acute LSD toxicity but later was amended to multi‑organ failure, hyperthermia and dehydration, with ‘‘possible LSD intoxication’’ noted. The authors emphasise that extreme hyperthermia is not characteristic of LSD and that toxicology panels in some cases did not include likely hyperthermia‑causing compounds such as 25I‑NBOMe, PMA or PMMA. Human pharmacokinetic data summarised in the paper indicate modest plasma concentrations after typical experimental doses. Upshall and Wailing reported average plasma LSD concentrations of 3.19 and 4.16 ng/mL at 60 and 130 minutes after oral administration of what the extracted text describes as 160 units of LSD tartrate in 13 subjects. Dolder et al. found comparable values after 100 and 200 units of LSD free base (reported t1/2 of 2.6 h; Cmax 1.3 ng/mL for the 100 dose and 3.1 ng/mL for the 200 dose; Tmax approximately 1.4–1.5 h). The authors use these pharmacokinetic benchmarks to argue that many reported postmortem concentrations attributed to ‘‘LSD toxicity’’ are inconsistent with the high exposures required for lethality. On positional restraint and ‘‘excited delirium’’, Nichols and colleagues summarise the forensic literature indicating that several deaths linked to LSD occurred after prone maximal restraint (PMR) or hog‑tying. They review experimental work by Savaser et al., who studied PMR with and without 50‑ or 100‑pound weights in 25 healthy male volunteers for only three minutes and observed no change in cardiac output or evidence of hemodynamic compromise; the authors critique these experiments for short restraint durations and lack of agitation. The narrative then outlines the concept of Excited Delirium Syndrome (ExDS), historically associated with stimulant drugs such as cocaine, methamphetamine and PCP, with characteristic features including profound agitation, hyperthermia, insensitivity to pain and sudden collapse. The paper notes that acute LSD acts primarily at serotonin 5‑HT2 receptors and would not be expected to produce the dopaminergic changes associated with ExDS observed in chronic cocaine cases. A large police use‑of‑force dataset (Hall et al.) covering August 2006–March 2013 and 4,828 events is cited: 499 individuals had three or more ExDS features, 86 had six or more features, and the incidence of sudden in‑custody death in cases with known final position was 1/4,373 (0.02%) with a 95% CI of (0.0005, 0.1%). That cohort contained a single death, occurring in a non‑prone position; no agency in that study had used hog‑tying, so the effect of PMR could not be directly assessed. Overall, the results section collates case evidence, toxicology data, and human pharmacokinetics to argue that (1) only massive, non‑recreational LSD exposures have been plausibly lethal by drug toxicity alone; (2) several fatalities temporally linked to LSD followed aggressive restraint measures that are known or suspected to precipitate respiratory or cardiac collapse; and (3) in some cases a different psychoactive substance substituted for LSD could plausibly explain the clinical picture (for example severe hyperthermia).

Nichols and colleagues interpret the assembled evidence as indicating that LSD is of low physiological toxicity at typical recreational or investigational doses, and that many recent attributions of death to ‘‘LSD toxicity’’ are mistaken. They argue fatalities historically linked to LSD fall into three categories: deaths after massive overdoses, deaths precipitated by extreme agitation followed by positional or maximal restraint, and deaths caused by other psychoactive substances that were mistaken for or sold as LSD. The pharmacokinetic benchmarks from controlled human studies are used to support the contention that postmortem concentrations reported in several forensic cases do not reflect a lethal exposure to LSD. The authors place their conclusions in the context of the contested literature about PMR and Excited Delirium Syndrome, noting that experimental studies claiming PMR is safe may not generalise to agitated, drug‑intoxicated individuals and that ExDS has been most clearly linked to stimulants rather than serotonergic psychedelics. They also highlight limitations in some forensic investigations, such as incomplete toxicology panels that failed to test for NBOMe compounds, PMA/PMMA, or other agents that can cause hyperthermia and death. The discussion acknowledges ongoing debate about mechanisms of in‑custody collapse and restraint‑related deaths and stresses that available epidemiological data (for example the Hall et al. cohort) do not support a large risk of sudden death attributable solely to prone positioning in the general population of use‑of‑force encounters. Implications emphasised by the authors include the need for careful forensic investigation before attributing deaths to LSD, and the importance of accurate risk characterisation as clinical research into psychedelics expands. They recommend distinguishing deaths truly caused by LSD pharmacology from those caused by massive overdoses, physical restraint, or other substituted drugs, because misattribution can confuse both public discourse and medical decision‑making.

In their concluding statement, Nichols and colleagues assert that LSD does not possess the degree of physiological toxicity attributed to it in some recent professional and media reports. The authors contend that confusion has arisen because certain deaths temporally associated with LSD ingestion were more plausibly due to excessive physical restraints or to other psychoactive drugs rather than to LSD itself. Given renewed interest in LSD and other psychedelics as discrete therapeutic tools for refractory psychiatric disorders, the paper calls for a clear and accurate understanding of the drug's genuine toxicity, which they state has consistently been demonstrated to be very low in humans.