Abyssinian Tea
Want to know what substance is used by 20 million people a day worldwide, but almost unknown in Western countries. What movie might’ve included US drug policy and what plant’s potency decreases rapidly once it’s picked?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Our episode today is called Abyssinian tea. Want to know what substance is used by 20 million people a day worldwide, but almost unknown in Western countries. What movie might’ve included US drug policy and what plant’s potency decreases rapidly once it’s picked? Listen to find out!
Today's episode starts in the emergency department. Your intern presents the case of a 45-year-old man with chest pain, noting the patient has had intermittent pain for the past few days. Today the pain became intractable, prompting his visit. He notes the pain increases with exertion, like walking and improves with rest ie sitting down. The pain radiates to his left arm and left neck. It’s associated with sweating and some shortness of breath. She sums up the history of present illness by saying it’s a classic presentation. Of what kind of chest pain? That’s question number 1.
A. acid reflux or a stomach ulcer
B. Aortic dissection, or a tear in the aorta
C. Myocardial infarction, or a heart attack
D. A collapsed lung
Answer: C. this is the classic description of myocardial infarction or heart attack. Specifically, the location of the pain radiating to the neck and arm and especially pain exacerbated by exertion and improved with rest. In fact, it sounds like several days of angina, with concern now for a heart attack.
You agree with her assessment. Moving onto the past medical history, she notes however, the patient doesn’t have many typical cardiac risk factors. He is over age forty, but doesn’t have any history of hypertension, diabetes, high cholesterol or significant family history. He’s not overweight. You ask about this last medical visit. Some patients avoid a diagnosis of comorbidities because they don’t see doctors or practitioners, to have their blood pressure and blood work checked, though side note this doesn’t work in their favor. She notes normal primary care screenings in the recent past.
She says his physical exam is unremarkable and moves on to his EKG. It shows T wave inversions, nonspecific, but can indicate ischemia. She treated him with aspirin and nitroglycerin, his chest pain is now resolved. She’s still awaiting his lab results, specifically a troponin to determine if indeed this is a heart attack.
You agree with her excellent handling of the case and go to see the patient. Walking in the room, you recognize both the patient and his wife. They own your favorite Yemeni coffee shop, a popular local hangout and one you visit routinely to fuel up on the way into shifts for extra-large coffees with extra shots of expresso.
The patient is sitting comfortably on the stretcher. He gives you the same history as the intern. He denies taking any medicines, anything over-the-counter, or any supplements.
His vital signs are as follows temperature 98.6 Fahrenheit or 36 nine Celsius, heart rate 112 bpm, blood pressure 150/98, respiratory rate 18 and oxygen saturation 100% on air. So, Mildly elevated heart rate and blood pressure. You examine him, noting brown discoloration of his teeth. He has a few green leaves stuck in them. But otherwise, you agree with the intern, unremarkable.
You tell him and his wife you're waiting for the lab results. You exit the room and move on to the next patient. An hour later, the resident stops you in the hall telling you his troponin is high, diagnosing him with an NSTEMI, a non-ST elevation MI. She says the history fit, but is surprised given his lack of risk factors.
You and the intern return to the room to discuss the results, the diagnosis and the next steps, including admitting him to the hospital. His heart rate and blood pressure are back to normal. The patient who was perfectly calm and pleasant is now cranky and irritable, refusing to stay in the hospital and complaining about the IV in his arm hurting. He starts pulling off the monitor leads attached to his chest.
It seems surprising, at the coffee shop he’s always been warm and hospitable. But one of the difficult parts of emergency medicine is seeing patients at their worst, sometimes in pain, sometimes anxious and fearful. They feel terrible, they fear the diagnoses we may give them, they fear the cost of medical care, they fear mortality, morbidity like not being able to take care of their families and probably 1001 other concerns. The patient's wife speaks to him in what you assumed to be Yemeni and slaps the monitor leads back on his chest. The patient calms down, saying he’ll stay, but doesn’t seem at all happy about it.
When you step out of the room, his wife follows, pulling the door shut behind her and asking for another minute of your time. She insists on apologizing for the patient’s cranky behavior though you insist there’s no need. She says it’s due to his frequent use of something which he hasn’t had for the several hours in which he's been in the emergency department.
Question number two, time to pick your poison. What substance is causing our patient symptoms?
A. caffeine
B. Cocaine
C. Hashish
D. Khat
Answer: this is D khat. Certainly, caffeine withdrawal could make our patient cranky, a situation with which I’m extremely familiar, and you may have suffered from as well. Massive amounts of caffeine are required for toxicity. Even if he drinks tons of coffee per day, its not enough. He doesn't or didn’t have other signs including shakiness and a narrow pulse pressure meaning a small gap between the upper and lower numbers on the blood.
Cocaine definitely causes heart attacks and withdrawal symptoms, but his initial presentation wasn’t consistent with a sympathomimetic toxidrome. He was only very mildly tachycardic and hypertensive, and not sweating. Hash is cannabis, and there's a lot of interesting recent data showing that cannabis significantly increases risk of heart attack, but it doesn’t really cause these withdrawal symptoms.
Leaving us with khat. What’s khat? It’s a plant from East Africa and the Arabian Peninsula. It has many names and the names have many different spellings. Often you’ll see it khat, but it can be chat or gat, just to name a few. It's also called Abyssinian or Arabian tea. So, did I hear you ask is there an antidote? Let’s talk about what it is and does, then come back to this question.
Khat’s Latin name Catha Edulis, it’s a bush or a small tree. Khat use is extremely popular in the horn of African and the Arabian Peninsula especially in countries like Yemen, Ethiopia, Somalia. It’s noted to be particularly popular in Muslim countries where alcohol is outlawed. Khat use is very social, it's often used in café settings, like coffee shops, most commonly by men promoting friendship and business connections. In some places, it’s reported 90% of men use it.
It’s even used by children as young as 12 and commonly in school students because it improves alertness and concentration. It’s so prevalent in Yemen, one person reported during the war hostilities stopped between 1-4pm, a popular time for using khat. I doubt that’s true, but does make an interesting point about use patterns and ubiquity.
What is true is a study at a hospital in Yemen noted an interesting pattern in the presentation of heart attacks. In users the peak presentation times was in the early hours of the day. But khat users had heart attacks in the late afternoon and evening, concurrent with the time khat is most commonly used.
Question # 3. Khat is primarily used in which form:
A. Pill
B. Powder
C. Gum
D. Leaves
Answer: D. leaves. Khat is mostly commonly used by chewing the fresh green leaves. It’s typically sold in bundles or bags. Users chew the leaves and leave them inside their cheek, like chewing tobacco. My rideshare driver once had green leaves in his teeth. Could’ve been anything, but was probably khat he was using to stay awake.
Unlike tobacco, users typically swallow the liquid. It has a bitter astringent taste so its often taken with tobacco and sugary drinks or sugar cubes. A typical quantity is 100-200 grams of leaves in a session. Symptom onset occurs in about 30 minutes after chewing the leaves and typically last for around three hours. Users’ teeth are stained brown from the juice, as with our patient. There is an increased risk of cavities, tooth loss and oral cancers.
What’s in khat? It’s naturally occurring cathinone. You might’ve heard of cathinone, or it’s synthetic derivates like methcathinone, the drugs in bath salts during the early 2000s. Cathinone is a phenylethylamine. It’s related to amphetamines as well as epinephrine and norepinephrine. Leaves contain anywhere from 30-100 mg cathinone/100 grams. It’s a natural product so it’s no surprise the potency varies with location, climate, etc. Cathinone has about half the potency of amphetamine.
Knowing khat is related to amphetamine, you can guess it's effects. It works like amphetamines by inhibiting the reuptake of epinephrine and norepinephrine in nerve endings, resulting in increased levels of these neurotransmitters and in turn causing increased blood pressure and heart rate. It causes mild euphoria, increased alertness and decreased appetite. Gastrointestinal effects can be prominent and include constipation, gastritis and stomach ulcers.
The effects are relatively mild, it’s often compared to drinking a strong cup of coffee. There's a debate as to whether or not khat is truly addictive, there are however, withdrawal symptoms reported. It appears to have the side effect of moderate psychological dependence, but without physical dependence symptoms. According to the world health organization, it's less addictive than alcohol and tobacco. But as we know in toxicology, it’s the does that determines the poison.
Back to the question of an antidote. No, one doesn’t exist. We do treat things like cocaine intoxication and other sympathomimetic toxidromes with benzodiazepines for sedation. If he had a hypertensive emergency, for example, that’s what I would use, but khat’s effects only last for a few hours, so you’re not likely to treat the compound directly, but rather treat its effects as the intern did in this case, administering treatment for the heart attack itself.
Chronic use can result in psychosis, though this is reversible with cessation. There’s an increased risk of heart attack, especially in younger users aged 30-40s, with frequent use and/or an underlying predisposition. This is also an increased risk of stroke. Long-term use is associated with liver problems, including hepatitis and cirrhosis.
Why fresh leaves? Better taste? No, better high. Cathinone starts to break down as soon as the leaves are harvested. It’s converted to cathine which is way less potent. In fact, in the US cathinone is a schedule I drug, vs. cathine which is schedule IV.
Ok, Question #4. A bit of an aside, but today’s Pop Culture Consult. What movie depicts khat use and has been said to have influenced khat becoming a schedule I drug in the US?
A. Zero Dark Thirty
B. Black Hawk Down
C. Lawrence of Arabia
D. Captain Phillips
Answer: B. Black Hawk Down. Somali fighters high on khat are shown in the movie about Marines in Mogadishu. Is this really true? Cathinone was made schedule I in the US the same year the movie was released in 1993. Coincidence? Some think not. My first thought was the idea American drug enforcement policy could be influenced by the movies was ridiculous. Then I remembered reefer madness about marijuana in the 1930s. So, who knows. Your guess is as good as mine.
Anyway, back to the facts. People can and do use dried leaves and powder, but it’s not as potent. This leads to interesting issues with distribution. If you’re using the fresh leaves, you need a bunch or a bag of them per single session. It’s hard to smuggle a big quantity of fresh plants. This isn’t highly concentrated fentanyl powder for example that can be cut when it reaches its destination. Kaht is legal in much of the Middle East in east Africa like Yemen and Ethiopia, but it’s not legal in the US, the UK and it’s restricted in Canada.
If you look online, you’ll see pictures of bundles of slender red branches wrapped in banana leaves. The bundles are often in duffle bags and the photos are from law-enforcement after confiscation at the airport for example. You can get dried leaves, which have been smuggled as tea and powder which has been reported on shipping manifests as henna. The fresh leaves are preferred, however.
Khat is a valuable cash crop, leading to higher revenue than coffee. It grows in similar regions, khat can be harvested four times per year and coffee only once. However, it uses significant amounts of water, raising environmental and humanitarian concerns in places like Yemen and Ethiopia, where water is in short supply. One bag of khat leaves can require 130 gallons or 500 L of water.
It's estimated 20 million people worldwide use khat on a daily basis, with the Yemeni market alone estimated worth of 12 billion dollars. One seller said he sells 150 pounds (70 kg) of leaves per day. It’s not cheap in Africa, Arabia or the west. A bundle of fresh leaves in the UK sells for 30 or 40 pounds. Occasionally allegations khat is used to fund terrorist organizations arises, though as far as I know they haven’t been substantiated.
Back to our patient. You tell him about the link between khat and heart disease, making him more irritable. Khat isn’t associated with physical withdrawal like opioids for example, but some users report symptoms after stopping with mild depression, a dysphoric mood, irritability, and increased appetite. They don’t affect everyone and typically lasts hours to days. He’s admitted to the hospital for further care by cardiology.
Khat use is a very, very old social custom in East Africa and Arabia. Use dates at least as far back as the 11th century when it’s noted in a Persian medical reference. The author wrote khat was a coolant, it relieved biliousness and was a refrigerant for the stomach and liver. It’s use in medicine isn’t just ancient history. French, English and Swiss pharmaceutical companies touted khat as a drug in the early 1900s, but it’s use failed as transport of fresh leaves was disrupted by WWI.
In 1958 Yemeni revolutionary and poet Mohammed Mahmoud Al-Zoubairi gave this colorful description of khat as a devil that “made the Yemeni people lust after it, and is fighting in their stomachs against valuable nutrients for the human body. Then it runs in their veins like Satan, and enters their pockets to steal their money.”
A week later, you see your patient and his wife at the coffee shop. You are happy to note his teeth are less stained and there’s no green leaves in his mouth. For the next few months, you have to turn down their generous offers of free coffee and pastries at the café.
This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings. That brings us to the end of the podcast and the last question. What writer compared use of khat in the east to tea drinking in Europe?
A. Charles Dickens
B. Mark Twain
C. Rudyard Kipling
D. Thomas de Quincy
Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.