Nausea, Lion's Breath, and Ondansetron

Nausea and Psychedelics: A Common Bother

Nausea is one of the most common and unpleasant sensations associated with use of almost all psychedelic agents. In this video and written blog post I share my perspective on the occurrence of nausea with psychedelic, strategies that persons could use to manage nausea, and somatic techniques and mindful visualizations to potentially deepen therapeutic benefits or provide an avenue for cathartic experience.

In clinical trials of MDMA and psilocybin-assisted therapies, nausea is one of the top reported transient side effects associated with use. Similarly, nausea is commonly reported as a side effect of ketamine use. Vomiting or emesis is also possible with the use of these psychedelics and occurs even more commonly with psychedelics such as ayahuasca, which can induce emesis in over half of persons that use it. A one-time episode of emesis is also relatively common with mescaline containing cacti like Huachuma or Peyote as well as Iboga.

Side Effects, Nausea, Somatic Messages, and Therapeutic Opportunities

Side effects could be defined as an effect of a drug or other type of treatment that is in addition to or beyond its desired effect. Side effects are usually experienced as unwanted or negative. They may dissipate over time or be able to be managed with other changes to therapy or with use of other drugs. While use of additional drugs is oftentimes helpful in reducing the side effect it is targeted at treating, it oftentimes carries risks of its own side effects. Many persons feel additional side effects and use of a larger number of substances generally outweighs any benefit granted or creates a domino pattern. Side effects are not always unwanted or negative though and can sometimes be beneficial or otherwise leveraged for beneficial effects.

The underlying mechanisms involved in nausea are complex. Psychological states, the central nervous system, autonomic nervous system, gastric dysrhythmias, and the endocrine system all play roles in contributing to sensations of nausea or coordination of emesis. Stimuli giving rise to nausea and vomiting originate from visceral (gut and vagus nerve), vestibular (inner ear), and chemoreceptor trigger zone (brain stem) inputs which are mediated by neurotransmitters such as serotonin/dopamine or histamine/acetylcholine.

Psychedelics have mechanisms of action that influence psychological states as well as the central and autonomic nervous system. They tend to act upon the serotonergic nervous system and could conceivably give rise to nausea or emesis via a variety of mechanisms. In a straightforward and reductionistic manner it is reasonable to conclude that nausea or emesis could be an expected physiological response to psychedelic use and not carry any deeper meaning or opportunity.

Another perspective could be that nausea is a feeling that occurs when a toxic stimulus is present and emesis is an act of the body that is attempting to rid itself of something toxic. In traditional cultures, psychedelics are oftentimes viewed as purgatives or agents that act to clean and clear the body. While nausea and emesis are viewed as undesired effects or ‘side effects’ in the eyes of Western culture, other cultures view purgative effects as desired qualities of psychedelic use. In that case, by definition, they would cease to be side effects altogether.

I think there is room to reconcile and integrate these perspectives and come to an understanding that there are many obvious and straightforward mechanisms in which psychedelics could induce nausea or emesis AND that the psychedelic experience is typically one that people strongly feel to have a high level of personal meaning and significance that can deeply reflect their lives in metaphorical ways. Many people may experience nausea intermittently or transiently as part of their lives associated with a variety of potentially toxic or noxious physical or psychological stimuli.

Could nausea in the psychedelic experience be a valuable clue as to habits, persons, places, lifestyles, or substances that are making them feel sick?

Could focusing our awareness upon nausea result in a shift of our perspective that allows viewing it as an invitation from the body to release toxicity it is carrying?

May one lean into the sensation of nausea to aid their body in releasing energy and triggering gag reflexes until the energy driving the nausea has been discharged?

I tend to think that the answers to the questions above are ‘yes’ and ‘yes’ and ‘yes’ although also recognize that some persons do not have intentions of facing nausea, have already attempted somatic techniques for leveraging nausea without success, or otherwise experience intense and prolonged vomiting that is an adverse reaction rather than a side effect and may carry risks of dehydration, electrolyte imbalances, and subsequent complications. Some may have advanced and progressive illnesses that create risks for aspiration if emesis occurred. Therefore, I think it’s important to discuss ways persons could manage nausea with anti-emetics as well as explore somatic approaches to leveraging nausea.

Anti-Emetics, Ondansetron, and Psychedelics

There are many different types of antiemetic medications available and I often get asked about anti-emetics in the context of using psychedelics. One class of anti-emetic medications are the serotonin 3 (5HT3) receptor antagonists of which ondansetron (Zofran) is the most commonly used agent. Ondansetron works by blocking 5HT3 receptors found in the chemoreceptor trigger zone of the brain stem. Due to the specificity of ondansetron for these receptors and its lack of influence upon serotonin receptors involved in psychedelic mechanisms of action, it could be considered an option to manage or prevent nausea or emesis associated with psychedelic use. Standard doses of 4-8mg sublingually around 30 minutes prior to psychedelic use may be helpful in reducing or preventing nausea. Of note, ondansetron is associated with QTc prolongation, especially with higher doses (>8mg) via intravenous administration, therefore may not be safe with psychedelics that prolong the QTc interval such as ibogaine.

Use of other anti-emetics such as antihistamines, anticholinergics, and antidopaminergic agents may carry more risks of modulating subjective effects of psychedelics or otherwise introducing unwanted effects such as drowsiness. They may also not be as effective as the serotonin antagonist if the goal of anti-emetic use is specifically to reduce nausea associated with use of a serotonergic psychedelic. Consideration of antihistamine or anticholinergic anti-emetics may still be reasonable under some circumstances (e.g. treatment of a vestibular condition).

Leveraging Nausea and Lion’s Breath

Due to the unpleasant nature of nausea and our adversity to vomiting, the standard response of the mind when it experiences nausea is to try and avoid or downplay the sensation and wait for it to pass in hopes that it never reaches a threshold potential in which the coordination of autonomic vomiting reflexes occurs. In general, this is an avoidant type of mechanism and involves focusing the mind in opposition of the feeling that is presently occurring. This ‘resistance’ could present in similar or parallel ways with a range of unpleasant stimuli or sensations (psychic material, pain, anxiety). Discourse in use of psychedelics typically discourages or tries to reduce avoidant behavior of the mind as it’s recognized that if the mind is psychologically opposed to the unfolding effects of the psychedelic that it tends to create a rough, dysphoric, and challenging state that may result in the sensation persisting longer.

If one experienced nausea as part of their psychedelic experiences, they could instead acknowledge the presence of nausea and focus their attention upon it. If the person is laying down on their back, they could respond by sitting up so that if emesis occurred they'd be safe from aspiration. If unable to sit up, rolling on the side can also at least reduce aspiration risks. They could breath deeply and ask the feeling to expand and communicate any messages it may have as to why it’s occurring or wanting your attention. External palpation of the viscera (tummy) or throat area may reveal places that heighten nausea or induce gagging reflexes. Massage of sensitive areas and allowing and accepting any gagging or emesis that results may bring about the resolution of nausea and provide a feeling of catharsis and gratitude in its wake.

Another effective technique involves practice of a yogic breathing technique called ‘Lion’s Breath’. Lion's breath, or Simhasana Pranayama, is a breathing technique that can help relieve stress and tension, clear the throat, and stretch the muscles in your face, neck, and throat. To practice lion's breath, you can sit comfortably with your back straight and your hands on your knees or thighs or down on all fours like a big cat.

Inhale deeply through your nose as your head slowly moves down so that your eyes are towards the ground. You may try closing your eyes and envisioning rejuvenative energy filling your body. Then exhale forcefully through your mouth, sticking out your tongue and making a "ha" sound. You may try opening your eyes widely along with your mouth as you exhale while envisioning sick, stale, and unwanted energy leaving the body.

You may repeat the technique for five to ten breaths per round or until you can do five in a row without inducing a gagging response. Take a few normal breaths in between rounds and end by breathing deeply for at least one minute. 

To Manage or Leverage Nausea Associated with Psychedelics?

Overall, it’s not really my place to make meaning of the nausea that people experience or tell them what they should do (or not do) about it. Some persons have fairly extreme emetic responses to psychedelics that seem to go beyond ‘side effects’ and are truly adverse reactions. Others may have circumstances in which nausea is part of their life, but their intentions are not to deal with it using psychedelics or to otherwise think about other things. For example, it may be more reasonable to consider use of comfort medications in the setting of using psychedelics for depression and anxiety associated with life threatening illness. However, if a person is coming to psychedelics and preparing to navigate the gamut of emotional and physical responses the substances can cause with intentions of encountering life in deep and different ways, then attempting use without the aid of anti-emetics and trying different techniques for interacting with themselves and their bodies could really yield important discovery and therapeutic benefits. To this end, it’s critical hat persons consider a more expansive perspective to psychedelic mechanisms and the evocation of nausea that they occasion as either an intended effect of purgative use or a side effect that may be beneficial when leveraged.