Pharmacists address the hidden risks of legal substances like nitrous oxide and kratom, emphasizing the need for public education and safety measures. Substances marketed as “legal” or “natural” alternatives are increasingly accessible to adolescents through gas stations, convenience stores, and vape shops. Although legality may reassure consumers, pharmacists are seeing a growing disconnect between regulatory status and clinical risk. Products such as nitrous oxide inhalants, kratom, Delta-8 and Delta-9 tetrahydrocannabinol (THC), and Salvia divinorum are associated with dependence, neurologic injury, psychiatric effects, and accidental harm—particularly in younger populations.1,2
As medication experts, pharmacists are uniquely positioned to recognize the public health implications of these products and to educate patients, caregivers, and policymakers on risks that often remain hidden in plain sight.
Nitrous Oxide: Retail Availability, Clinical Consequences
Nitrous oxide—commonly referred to as “whippets” or “laughing gas” and increasingly marketed under brand names such as “Galaxy Gas”—has gained popularity among adolescents through social media exposure. Although intended for culinary use, flavored nitrous oxide canisters are frequently misused for their euphoric effects.3
Clinically, nitrous oxide misuse has been associated with hypoxia, syncope, cardiac arrhythmias, and vitamin B12 depletion leading to myeloneuropathy.4-6 Chronic exposure can result in irreversible neurologic injury, including gait disturbance and sensory loss. Of concern to pharmacists, no standardized manufacturing or purity requirements exist for recreational nitrous oxide products sold at retail, contributing to unpredictable dosing and adverse outcomes.7
Kratom: Opioid Activity Without Oversight
Kratom (Mitragyna speciosa) is marketed as a dietary supplement for pain relief, anxiety, and opioid withdrawal. Its primary alkaloids—mitragynine and 7-hydroxymitragynine—exert activity at μ-opioid receptors, conferring both analgesic and addictive potential.8.9
Although not federally scheduled, kratom has been linked to seizures, hepatotoxicity, hypertension, and opioid-like withdrawal symptoms.10,11 FDA analyses have identified contamination with heavy metals and pathogenic organisms in unregulated products.12 Regulatory approaches vary by state, creating inconsistent consumer protections and increasing the likelihood of misuse.
Delta-8 and Delta-9 THC: Potency and Labeling Concerns
Delta-8 THC and Delta-9 THC products are widely marketed as legal cannabis alternatives in the form of edibles, vape cartridges, and tinctures. Delta-9 THC is the primary psychoactive component of cannabis, and Delta-8 THC is a synthetically derived isomer with similar psychoactive effects.13
FDA and CDC warnings have highlighted concerns regarding inaccurate labeling, excessive THC concentrations, and contamination with residual solvents from chemical synthesis.14,15 Adverse events reported include anxiety, paranoia, impaired cognition, and psychosis—effects that may be amplified in adolescents and young adults.16
Salvia Divinorum: A Legal Hallucinogen
Salvia divinorum, a potent kappa-opioid receptor agonist, remains legal in several US jurisdictions despite its intense psychoactive effects. When smoked or chewed, salvinorin A produces rapid-onset hallucinations, dissociation, and loss of environmental awareness.17
From a safety perspective, Salvia use has been associated with panic reactions, accidental injuries, and prolonged psychological distress.18 Its sale as a novelty or incense product may obscure its clinical risks.
Implications for Pharmacy Practice
The normalization of these substances—amplified by influencer culture and online marketing—has outpaced regulatory oversight. Many do not appear on standard toxicology screens, complicating detection and counseling.19
Pharmacists can play a critical role by:
- Educating patients and caregivers on risks associated with legally marketed substances
- Monitoring emerging substance-use trends
- Encouraging age restrictions and improved labeling standards
- Collaborating with clinicians and public health organizations
Legality does not equate to safety. Increased awareness and pharmacist engagement are essential to addressing the public health risks posed by these widely available products.
