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Alcohol

Depressant

Ethanol · Booze · Beer · Wine

The oldest known psychoactive substance — evidence of intentional fermentation dates to approximately 7000 BCE in China. The highest-harm substance in any multi-criteria analysis (Nutt 2010: 72/100), reflecting both individual and societal damage. Involved in more drug interaction deaths than any other substance because it potentiates nearly every depressant.

Very high harmHighly addictiveVery narrow safety margin

Caffeine

Stimulant

Coffee · Tea · Energy drinks · Pre-workout

Consumed for over a millennium — coffee cultivation traces to 9th-century Ethiopia, tea to ancient China. The world's most widely consumed psychoactive substance, acting as an adenosine receptor antagonist. Physical dependence develops quickly, with withdrawal headaches beginning 12-24 hours after the last dose.

Low harmMildly addictiveModerate safety margin

Nicotine

Stimulant

Cigarettes · Vape · Tobacco · Snus

Tobacco has been used by indigenous peoples of the Americas for thousands of years in ceremonial and medicinal contexts. Acetylcholine receptor agonist and one of the most addictive substances known — approximately 68% of users eventually develop dependence. The harm score of 26 reflects smoked tobacco specifically; nicotine alone (patches, gum, vaping) is far less harmful than combustion.

High harmExtremely addictiveModerate safety margin

Cannabis

Cannabinoid

Marijuana · Weed · THC · Pot

One of the oldest cultivated plants — evidence of use dates to at least 3000 BCE in Central Asia. Acts on the endocannabinoid system (CB1/CB2 receptors), producing relaxation, altered perception, and appetite stimulation. Alcohol increases THC blood levels by approximately 60%, explaining why the combination hits harder than either alone.

Moderate harmLow addiction potentialNo known lethal dose

Cocaine

Stimulant

Coke · Snow · Blow · Crack

Derived from coca leaves, which have been chewed in the Andes for at least 5,000 years; the alkaloid was first isolated in 1860. Blocks dopamine, serotonin, and norepinephrine reuptake. Combined with alcohol, the liver creates cocaethylene — a unique compound more cardiotoxic than either drug alone.

High harmHighly addictiveVery narrow safety margin

MDMA

Empathogen

Ecstasy · Molly · E · X

3,4-Methylenedioxymethamphetamine — first synthesized at Merck in 1912 as a pharmaceutical intermediate; its psychoactive properties went unnoticed until Alexander Shulgin resynthesized it in 1976. Works by reversing serotonin, dopamine, and norepinephrine transporters, and inactivates the liver enzyme (CYP2D6) that clears it, so redosing produces disproportionately higher blood levels. Serotonin depletion after use causes a characteristic low mood 2-4 days later.

Low harmLow addiction potentialVery narrow safety margin

Amphetamine

Stimulant

Speed · Adderall · Dexedrine · Vyvanse

First synthesized in 1887; marketed as Benzedrine inhalers in the 1930s and used extensively by all sides in World War II. Release dopamine and norepinephrine, with extended-release formulations lasting significantly longer than instant-release. Therapeutic doses are well-studied; cardiovascular risk scales with dose and frequency.

Moderate harmModerately addictiveModerate safety margin

Psilocybin Mushrooms

Psychedelic

Shrooms · Magic Mushrooms · Caps

Used ceremonially in Mesoamerica for at least 2,000 years; the active compound was isolated by Albert Hofmann in 1958. Among the safest psychoactives known — no lethal dose has been established in humans. Whole mushrooms are almost never adulterated, and tea preparation produces a faster onset with shorter effects than eating them.

Low harmNo known lethal dose

LSD

Psychedelic

Acid · Lucy · Tabs · Blotter

Lysergic acid diethylamide — first synthesized by Albert Hofmann at Sandoz Laboratories in 1938; its psychoactive properties were discovered accidentally in 1943. Extremely potent — active in microgram doses, far below what's visible to the eye. Rarely adulterated on blotter; NBOMe compounds are the main substitution risk and are bitter-tasting, unlike LSD.

Low harmNo known lethal dose

Ketamine

Dissociative

K · Special K · Ket · Vitamin K

Synthesized in 1962 at Parke-Davis as a safer alternative to PCP for anesthesia. Blocks NMDA receptors, producing a dose-dependent spectrum from mild dissociation to complete K-hole immersion. Now FDA-approved as esketamine (Spravato) for treatment-resistant depression; tolerance builds quickly and chronic heavy use causes bladder damage.

Moderate harmModerately addictiveVery narrow safety margin

Opioids (Heroin)

Opioid

Heroin · Morphine · H · Smack

Heroin was synthesized in 1874 and marketed by Bayer in 1898 as a non-addictive morphine substitute. Mu-opioid receptor agonist that produces profound pain relief and euphoria. In most US markets, samples sold as heroin now contain primarily fentanyl — only ~2% test as expected heroin.

Very high harmHighly addictiveVery narrow safety margin

Methamphetamine

Stimulant

Meth · Crystal · Ice · Tina

First crystallized by Japanese chemist Akira Ogata in 1919; used extensively by Axis and Allied militaries in WWII under brand names like Pervitin. Produces intense dopamine release that is directly neurotoxic at high doses. Street purity is typically high (~88%), meaning the danger is the drug itself, not adulterants.

High harmExtremely addictiveVery narrow safety margin

Benzodiazepines

Benzodiazepine

Benzos · Xanax · Valium · Klonopin

The first benzodiazepine (chlordiazepoxide/Librium) was discovered accidentally by Leo Sternbach in 1955. GABA-A receptor modulators that are relatively safe alone but extremely dangerous combined with opioids, alcohol, or GHB. Physical dependence develops within 2-4 weeks of daily use, and withdrawal can cause seizures.

Moderate harmHighly addictiveVery narrow safety margin

Fentanyl

Opioid

Fent · Blues · Pressed pills · China White

Synthesized in 1960 by Paul Janssen and originally used exclusively in surgical anesthesia. Approximately 50-100x more potent than morphine, with an active dose measured in micrograms. Now detected as a contaminant in cocaine, methamphetamine, pressed pills, and counterfeit prescriptions across most US drug markets.

Very high harmHighly addictiveVery narrow safety margin

Kratom

Opioid

Mitragynine · Ketum · Biak

Derived from the leaves of Mitragyna speciosa, used for centuries in Southeast Asia by laborers and in traditional medicine. Partial mu-opioid agonist with dose-dependent effects — stimulating at low doses, sedating at high doses. Only 5% of kratom-positive overdose deaths had kratom as the sole substance; fatality risk increases when combined with other depressants.

Moderate harmModerately addictive (with regular use)Very narrow safety margin

DXM

Dissociative

Dextromethorphan · Robo · Robotripping · Skittles

Dextromethorphan — developed in the 1950s as a non-addictive replacement for codeine in cough suppressants. Effects are described in four dose-dependent plateaus, from mild stimulation to full dissociation. Many OTC formulations contain acetaminophen, guaifenesin, or antihistamines that are toxic at recreational DXM doses.

Moderate harmLow addiction potentialVery narrow safety margin

GHB

Depressant

G · Liquid Ecstasy · GBL · 1,4-BD

Gamma-hydroxybutyrate — synthesized in 1960 by French researcher Henri Laborit during research on GABA neurotransmission. One of the steepest dose-response curves of any recreational substance — the difference between a recreational dose and a fatal dose can be less than 2x. Combined with any other depressant, individually survivable doses become lethal.

Moderate harmHighly addictiveVery narrow safety margin

Nitrous Oxide

Dissociative

Laughing Gas · N2O · Whippets · Nangs

Discovered by Joseph Priestley in 1772; recreational laughing gas parties were popular in the early 1800s before its medical applications were recognized. The fastest onset and offset of any recreational substance. Triggers endogenous opioid peptide release in the brainstem, which is why it's synergistically dangerous with exogenous opioids.

Low harmLow-moderate (binge pattern)Wide safety margin

Poppers (Alkyl Nitrites)

Inhalant

Amyl Nitrite · Rush · Jungle Juice · Room Odorizer

Amyl nitrite was first synthesized in 1844 and originally used medically for angina; recreational use became widespread in the 1970s. Inhaled alkyl nitrites that cause brief vasodilation, head rush, and smooth muscle relaxation. Combined with PDE5 inhibitors (Viagra/Cialis), both increase cyclic GMP, causing potentially fatal blood pressure collapse — an absolute pharmacological contraindication.

Low harmNot addictiveWide safety margin

Tramadol

Opioid

Ultram · Tramal

Developed in 1962 by the German pharmaceutical company Grünenthal. An atypical opioid that also inhibits serotonin and norepinephrine reuptake, creating interaction risks that pure opioids don't have. Lowers seizure threshold — seizures occur even at prescribed doses — and is uniquely dangerous with other serotonergic drugs due to serotonin syndrome risk.

Moderate harmModerately addictiveVery narrow safety margin

2C-x (2C-B, 2C-E, 2C-I)

Psychedelic

Nexus · Bees

Synthesized by Alexander Shulgin in 1974 and documented in his book PiHKAL. Unusually steep dose-response curve — 2mg more can dramatically change the experience. Combines mild visual effects with tactile and empathogenic warmth at lower doses, shifting to intense psychedelia above 25mg.

Low harmNot addictiveVery narrow safety margin

DMT

Psychedelic

Dimitri · Spirit Molecule · Ayahuasca

N,N-Dimethyltryptamine — found in hundreds of plant species and used for millennia in Amazonian ayahuasca traditions. The most intense psychedelic experience available — complete reality replacement when smoked. Produced endogenously in the human body in trace amounts, though its natural function is unknown.

Low harmNo known lethal dose

Mescaline

Psychedelic

Peyote · San Pedro · Wachuma

Used by indigenous peoples of the Americas for at least 5,700 years, making it one of the oldest known psychedelics. Notably gentle, grounded character compared to LSD or mushrooms, but one of the longest-lasting psychedelics. Active doses are large (200-400mg), and nausea during onset is nearly universal.

Low harmNo known lethal dose

PCP

Dissociative

Angel Dust · Wet · Sherm · Dust

Phencyclidine — developed as a surgical anesthetic in the 1950s and quickly withdrawn due to severe dissociative and psychotic side effects in patients. Unlike ketamine, PCP activates dopamine systems, contributing to both its addiction potential and psychosis risk. Effects are unpredictable and dose-dependent, ranging from euphoria to violent agitation to complete anesthesia.

Moderate harmModerately addictiveVery narrow safety margin

Methylphenidate

Stimulant

Ritalin · Concerta · MPH · R-ball

First synthesized in 1944 by Leandro Panizzon; marketed as Ritalin in 1954, named after his wife Rita. The most widely prescribed stimulant globally. Unlike amphetamine, which forces monoamine release, methylphenidate blocks reuptake of dopamine and norepinephrine — less euphoric, shorter-acting, and generally lower-risk. Combining with alcohol creates ethylphenidate through the same liver pathway that turns cocaine + alcohol into cocaethylene.

Moderate harmLow-moderate at therapeutic dosesModerate safety margin

Synthetic Cathinones

Stimulant

Bath Salts · Eutylone · Methylone · NNDP

Synthetic cathinones are β-keto analogs of amphetamine, structurally derived from cathinone — a natural stimulant in the khat plant. The first wave hit US emergency rooms in 2010-2011 as 'bath salts,' triggering 6,000 poison control calls in 2011 alone. The dominant compound in the supply changes every 1-3 years as each gets banned and chemists tweak the molecule to create an unscheduled replacement. Usually sold as MDMA/ecstasy, not by their actual names — this is a primary reason why roughly 1 in 4 ecstasy samples contains something other than MDMA.

Nitazenes

Opioid

ISO · Pyro · Benzimidazole opioids · Frankenstein opioids

Originally developed by Ciba-Geigy in the 1950s as morphine alternatives but never approved for medical use due to extreme potency and narrow safety margins. Rediscovered by illicit chemists after China's 2019 fentanyl ban. The first modern variant (isotonitazene, 'ISO') appeared in the US Midwest in 2019 and was linked to at least 40 deaths around Chicago and Milwaukee in seven months. A completely different chemical scaffold from both morphine and fentanyl — a benzimidazole core instead of a morphinan or piperidine ring. At least 26 variants identified by early 2025 across Asia, Europe, North America, Oceania, and South America. China banned the class in July 2025, which may shift production elsewhere.

Tusi / Pink Cocaine

Mixture

Tusibi · Tuci · Tucci · Tussi

Originated in Colombia's nightclub scene in the late 2000s as a way to sell 2C-B. When 2C-B supply dried up, dealers kept the name and pink branding but switched to cheaper, locally available ingredients — typically ketamine, MDMA, and caffeine. The 'tusi' name is a phonetic Spanish rendering of '2C,' and 'pink cocaine' is pure marketing — cocaine is almost never present. Tusi is now its own street-market product category with no consistent formula.

Help
Opioid

Tramadol

Ultram · Tramal

Overview

Developed in 1962 by the German pharmaceutical company Grünenthal. An atypical opioid that also inhibits serotonin and norepinephrine reuptake, creating interaction risks that pure opioids don't have. Lowers seizure threshold — seizures occur even at prescribed doses — and is uniquely dangerous with other serotonergic drugs due to serotonin syndrome risk.

Onset & Duration

Oral
🚀 30–60 min 4–6 hr

Dosage

Threshold
25 mg
Light
50–100 mg
Common
100–200 mg
Strong
200–300 mg
Heavy
300+ mg

Chemistry

Cyclohexanol derivativetrans-2-(dimethylaminomethyl)-1-(3-methoxyphenyl)cyclohexanol

Three opioid families, three completely different molecular shapes, one shared receptor target. Tramadol's SNRI activity is why it causes serotonin syndrome with other serotonergic drugs — a risk heroin and fentanyl don't carry.

Cross-family bridge: A third distinct opioid scaffold (not a morphinan, not a piperidine). Also inhibits serotonin and norepinephrine reuptake — a dual mechanism that creates interaction risks pure opioids don't have

Related:OpioidsFentanyl

How It Works In Your Brain

Tramadol is unusual - it's a weak opioid that also acts like an antidepressant. It activates mu-opioid receptors (weakly) while simultaneously blocking serotonin and norepinephrine reuptake. This dual mechanism is why it has both opioid risks (respiratory depression, dependence) and antidepressant risks (seizures, serotonin syndrome).

Mu-opioid receptors (MOR)Primary

ACTION Weakly activates (low-affinity agonist); its metabolite O-desmethyltramadol (M1) is a much stronger agonist

NORMAL ROLE Pain relief and reward

WHAT THAT PRODUCES Moderate pain relief and mild euphoria. Much weaker opioid effect than morphine, but still enough to cause dependence and respiratory depression, especially when combined with other depressants

Serotonin transporter (SERT)Primary

ACTION Blocks reuptake (like an SSRI)

NORMAL ROLE Normally recycles serotonin

WHAT THAT PRODUCES Mild mood elevation and additional pain relief via serotonergic pain pathways. This is why tramadol + other serotonergic drugs = serotonin syndrome risk

Norepinephrine transporter (NET)Secondary

ACTION Blocks reuptake (like an SNRI)

NORMAL ROLE Normally recycles norepinephrine

WHAT THAT PRODUCES Additional pain relief via descending pain inhibition pathways, mild stimulation

Glossary
Agonist

Activates the receptor, mimicking the brain's natural signal

Reuptake Inhibitor

Blocks the cleanup pump that normally removes the neurotransmitter from the synapse, so it stays active longer

Endorphins

Your brain's natural painkillers - chemically similar to opioids. Released during exercise, sex, and injury. Opioid drugs hijack this system.

Serotonin

A mood and perception regulator. Too little is linked to depression; a sudden flood produces euphoria and altered perception. Most psychedelics and MDMA act primarily through this system.

Norepinephrine

The 'alertness and arousal' signal. Closely related to adrenaline. Increases heart rate, blood pressure, and attention. Involved in the physical stimulation from most uppers.

Lethality

From tramadol alone: seizure risk climbs above 400mg (~4-6x a 75-100mg dose). But tramadol also acts on serotonin, so combined with SSRIs, the margin for serotonin syndrome is much smaller — potentially 2x or less. The interaction between tramadol and antidepressants is a common source of emergency visits.

Above 400mg: seizures. With SSRIs or MDMA: potentially fatal serotonin syndrome.

Contraindications

SSRIsDangerous

Serotonin syndrome risk. Both increase serotonin through different mechanisms. Many doctors prescribe both without realizing the risk.

MAOIsDangerous

Serotonin syndrome — potentially fatal. Tramadol acts as an SNRI; MAOIs prevent serotonin breakdown.

GabapentinUnsafe

Both cause respiratory depression and sedation through different mechanisms. Gabapentin reduces CO2 responsiveness in the brainstem; tramadol is a mu-opioid agonist and serotonin reuptake inhibitor. Tramadol also lowers seizure threshold. FDA 2019 warning covers gabapentinoid + CNS depressant combinations broadly.

HIV ARVsUnsafe
WellbutrinDangerous

Both lower seizure threshold. Combined multi-neurotransmitter toxicity risk.

MOUDDangerous

Both are opioid agonists — additive respiratory depression. Methadone's long half-life (24-36 hrs) means tramadol's effects layer on top of sustained opioid baseline. Both prolong QT interval, creating compounded cardiac arrhythmia risk. Tramadol's serotonin reuptake inhibition adds serotonin syndrome risk.

CYP InhibitorsUnsafe

Tramadol is metabolized by CYP2D6 (to active O-desmethyltramadol) and CYP3A4. CYP inhibitors alter the balance between parent drug and active metabolite in unpredictable ways. Seizure risk may increase.

Potency Over Time

Very stable

Stable in tablet form for years

Pharmaceutical tablet with standard stability. SLEP-class longevity expected.

Timeline

Years past printed expiration date under normal storage.

Harm reduction concern

Same as other pharmaceutical opioids: assumption of weakness leading to taking extra. Tramadol's additional serotonergic activity means overdose risk includes seizures, not just respiratory depression.

What slows degradation

Cool, dry, dark, original packaging.

How Your Body Processes It

Half-life5–6 hr (tramadol), 7–9 hr (M1 metabolite)

CYP2D6 converts tramadol to O-desmethyltramadol (M1), which has 200x higher mu-opioid affinity. Poor CYP2D6 metabolizers get less opioid effect; ultrarapid metabolizers get dangerously more.

Back to baseline4–6 hr
Drug testing

Not on standard opioid panels — requires specific tramadol assay. Standard opiate immunoassays do not cross-react with tramadol.

Bloodup to 24 hr
Urine2–4 days

Withdrawal

Severity
Medical danger
Onset: 12–24 hoursPeak: Days 2–5Duration: 5–14 days

Post-acute (PAWS): Weeks to months

Higher danger than standard opioid withdrawal due to seizure risk. Standard opioid management with clonidine alone may NOT prevent tramadol seizures.

Physical

• Standard opioid withdrawal symptoms

• Seizures

Psychological

• Hallucinations (visual, auditory, haptic — 20% of atypical cases)

• Paranoid thoughts

• Paresthesias

• Panic attacks

• Derealization

Unique dual profile: opioid-type AND SNRI-type withdrawal. Seizure risk distinguishes tramadol from all other opioids. 54.4% of tramadol abusers reported at least one seizure over 3 years.

Effects

Mild euphoriaPain reliefWarmthMood lift

Biggest risks

Seizures (dose-dependent)Serotonin syndromeRespiratory depression

Long-term risks

DependenceWithdrawal (seizure risk)Serotonin depletion

Also called

UltramTramal

Source

Synthetic

Every number on this page is sourced. Tap any · marker to see the study, confidence level, and methodology.

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