The Poison Lab

Phenibut is an emerging and unfamiliar drug taking hold in the US that is readily available online and legal to obtain. It acts as a GABA-B agonist and carries risks of dependency and withdrawal. In this episode Ryan interviews phenibut users as well as experts involved in phenibut treatment. They explore the history, current trends, toxicity, and management of phenibut, a novel GABA-B agonist. He is joined by guest Dr. Matthew Stanton PharmD and Dr. Benjamin Weston MD who listen in to an audio documentary that includes clips from Dr. Janessa Graves PhD and Dr. Erica Liebelt MD who wrote a recent report on increasing phenibut exposures, Dr. Dan McCabe MD who is the author of the largest published phenibut case series, and Elliot, a recovered phenibut user who we would like to sincerely thank for sharing his story of use and recovery.

+Update- a systematic review of phenibut withdrawal treatment strategies authored by the poison lab host himeself, Ryan!+

• More on St Anthony's fire
• CDC MWR Study documenting increased poison center exposures (Dr. Graves & Dr. Liebelt)
• Phenibut case series from Dr. McCabe
• All published cases of phenibut withdrawal, reported baclofen regimens, clinical outcomes, multimodal therapies
• THEORETICAL UNTESTED Phenibut withdrawal treatment schema (Not tested, not intended as treatment, intended to stimulate discussion and highlight key considerations in managing withdrawal)

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• Full book reading (6 minutes!)

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In this episode of The Poison Lab, host Ryan Feldman is joined by medical toxicologist Damilola Idowu‑Ellsworth for a fast-moving, case-heavy conversation packed with clinical pearls, listener participation, and classic toxicology weirdness.

The show opens with listener guesses for the previously released mystery case before diving headfirst into a rapid-fire series of Stump the Toxicologist cases—questions pulled straight from the internet and real-world toxicology problem-solving. Along the way, Ryan and Dami cover everything from rodenticides and drug-testing myths to how to clean a benzodiazepine bottle, plus one of the most toxic substances you’ve probably never heard of.

One lucky listener also wins a copy of Poisonous Fungus Amongus, and a shout-out to the newly released second edition featuring photography from expert mycologists.

Skip the listener guesses and jump straight to the mystery toxin: 38:15

Mystery toxin case

The rest of the episode is Dr. Idowu and Ryan discuss the topics below. Looking for timestamps? Join the supporting member feed!

• Looking for time stamps for the rest of the show? Join as a supporting member

(Looking for timestamps? Join the supporting member feed!)

Case #1

• A methemoglobinemia, renal failure inducing enema

Case #2

• Wide-complex dysrhythmia from an over-the-counter topical
• Bonus - Paper from Ryan on the topical toxicity (or lack there of) of this product

Case #3

• Black stools, seizures, high sodium and low potassium after trying to beat a drug test.

Case #4

• GCS 15 and normal vitals… until they’re not — delayed seizures, neurologic collapse, and a toxicologic time bomb.
• Paper from Ryan on this tricky toxic time bomb

• Do GLP-1 agonists release toxins from fat and how might that impact drugged driving laws with THC?
• Why do sedatives make you twitch?
• Not all benzos are Xanax
• What shape is a ketamine crystal

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• Full book reading (6 minutes!)

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• Email: [email protected]

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Hey everybody, you’re listening to The Poison Lab—well, almost.

We’ve got a new episode coming next week, but we’re running a little behind on our usual release schedule because… life happens. That said, if you’re looking for some toxicology content right now, I’ve got you covered.

Recently, I had the chance to appear on two local and state radio shows talking about one of my favorite topics: mushroom poisoning 🍄—and both were an absolute blast.

The first appearance was on Garden Talk, a fun, live call-in show where we covered:

1. Mushroom poisoning basics
2. Listener questions
3. My game GOTTA PICCEM
4. The book Poisonous Fungus Among Us

It was lively, unpredictable, and a great example of how curious people are about mushrooms once you open the door.

After that, I joined a local radio health update to talk specifically about mushroom poisoning from a public-health perspective. It’s always interesting to hear how radio hosts approach such a niche topic—and how quickly it turns into something broadly relevant.

If you’re itching for some Poison Lab content while you wait for the next full episode, these two appearances are a great place to start.

And don’t worry—we’ll be back next week with a full episode and answers to our mystery case.

Thanks, as always, for listening.

Hope to see you there.

— Ryan

Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in the next episode

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In November 2022, hospitals across Australia began seeing patients with sudden rigidity, spasms, seizures—and in some cases cardiac arrest—after drinking homemade poppy seed tea. The source? Food-shelf poppy seeds contaminated with extraordinarily high levels of thebaine, an opioid alkaloid that acts nothing like morphine. In this Outbreak episode, host Ryan Feldman, clinical toxicologist and emergency medicine pharmacist, investigates how pharmaceutical-grade, thebaine-rich poppy seeds were mistakenly repackaged into the food supply—and how poison centers, clinicians, labs, and public health teams traced and contained the threat within days.

You’ll hear firsthand from the experts who responded:

• Dr. Katherine Isoardi, Emergency Physician, Clinical Toxicologist, Medical Director, Queensland Poisons Information Centre
• Dr. Amanda Holford, Clinical Toxicology Fellow & Emergency Physician, Princess Alexandra Hospital
• Dr. Darren Roberts, Medical Director, NSW Poisons Information Centre; Nephrologist; Clinical Pharmacologist

Together, they walk us through the outbreak timeline—from the first ICU cases and puzzling “strych­nine-like” neuroexcitation to the multi-state investigation, product recall, and lessons for future foodborne poisonings.

Looking for timestamps?

A fully timestamped version—so you can jump to any topic—is available to our supporting members.

💡 Key topics:

• Clinical presentation of thebaine toxicity (rigidity, spasms, seizures, metabolic acidosis) and how it differs from classic opioid effects
• Why thebaine behaves like a glycine receptor antagonist (strych­nine-like) rather than a sedating mu agonist
• How early-warning networks (e.g., PRISE in NSW; EDNA in QLD), poison centers, and forensic labs coordinated a rapid response
• Public health trace-back: mislabeled/repacked pharmaceutical poppy seeds entering the food supply; national recalls
• Practical ED management pearls (benzodiazepines, airway/ICU support; recognizing recurrent symptoms) and communication pitfalls during mass poisonings

📍 Resources & Mentions:

• Dr. Isoardi led case series on thebaine-contaminated poppy seeds (Queensland Health, NSW Health)
• Dr. Roberts led kinetics study on thebaine
• Prior Poison Lab Outbreak episode: Markham Aconite Poisoning

🎧 Listen now: www.ThePoisonLab.com

💬 Have thoughts or questions?

Instagram @tox_talk • Twitter @LabPoison • Email [email protected]

Disclaimer: The Poison Lab is for educational purposes only and does not provide medical advice. If you suspect a poisoning, contact your local poison center. In the U.S., call 1-800-222-1222.

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• Full book reading (6 minutes!)

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• Email: [email protected]

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Get your copy here! https://a.co/d/8QUBmQy

Want to hear it with insights from the author?:

 • Poisonous Fungus Among Us | Full Children’...  

Don't have time for the full thing: check the highlights:

 • Poisonous Fungus Amongus Highlights Reel  

Want a clearer picture: Full reading large scale here:

 • Poisonous Fungus Amongus- Children's Book ...  

From the mind of a toxicologist who treats real mushroom poisonings alongside doctors and poison centers comes Poisonous Fungus Amongus—a playful, rhyming adventure into the fascinating world of poisonous mushrooms!

Inside, readers will find a colorful introduction to mushroom anatomy and ecology—learning the parts of a mushroom and discovering helpful hints for safe foraging and identifying dangerous look-alikes. Every species featured in these pages is a real poisonous mushroom, brought to life through vivid illustrations and engaging verse.

This beautifully illustrated book goes beyond the basics, exploring how mushrooms grow, reproduce, and take shape in nature—from tiny spores to sprawling mycelium to the fruiting bodies we find in forests and fields.

Through rhymes and clear explanations, readers learn to recognize essential mushroom features—caps, gills, pores, rings, bulbs (volvas), veils, warts, scales, spore prints, and gill types like free, adnate, and decurrent. Each detail helps distinguish the edible from the toxic—and shows how some features can fool us!

The story encourages safe and curious observation: note each feature, dig gently to look for bulbs, observe nearby trees and seasons, and check for bruising or color changes. Along the way, readers also discover fungi’s hidden ecological roles, from tree-nurturing mycorrhizae to the saprotrophs that recycle the forest floor.

With rhythm, rhyme, and a spark of scientific wonder, Poisonous Fungus Amongus blends accuracy with imagination—inviting kids and adults alike to explore and respect the natural world, while learning that curiosity and caution must always grow together when it comes to mushrooms.

Perfect for young readers, nature lovers, teachers, and families who want to explore the mysterious and magical world of fungi!

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• Full book reading (6 minutes!)

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In this special live episode from the 2025 North American Congress of Clinical Toxicology (NACCT), Ryan takes you inside the conference to hear directly from the researchers themselves. Covering 11 abstracts that span high-stakes management decisions, surprising case reports, and challenges to toxicology dogma, this year’s highlights feature everything from amlodipine overdoses to naturopathic misadventures, metformin-associated blindness, and more. The show kicks off with a foreword from Ryan and Dr. Jon Cole (abstract co-chair for AACT) discussing some of their favorite research from the conference.

If you couldn’t make it to NACCT or just want to catch up on some of the most impactful new research in our field, this episode will give you a front-row seat. Check below for links to the published abstracts, the full list of studies discussed, and timestamps for where you can hear each one.

Link to published abstract manuscript

10:43 #7. Is beta blocker toxicity associated with hypoglycemia?

• Lead author: Dr. Megan Audette, MD

18:17 #237. V-A ECMO as a treatment for vasoplegic shock in amlodipine poisoning: a comparison

• Lead author: Dr. Daniel Tirado, MD

27:59 #247. Blocked but not beaten: ECMO’s role in severe amlodipine toxicity – a poison center case series

• Lead author: Dr. Carlos Saldarriaga, MD

28:18 #26. Amlodipine double-dose therapeutic errors reported to Poison Centers

• Lead author: Johanne Freeman

30:38 #27. Dosing on the edge: unpacking inadvertent amlodipine ingestions reported to a single poison center

• Lead author: Dr. Tiana Patriarca, PharmD

34:03 #292. Intravenous administration of sodium zirconium cyclosilicate resulting in death

• Lead author: Dr. Stephen Thornton, MD

44:16 – #21. Quantitative analysis of amlodipine removal by plasmapheresis

• Guest: Dr. Keahi Horowitz, MD – Acute and Intensive Care Research Award winner

48:33– #23. Relationship between reported ingestion dose and outcome in amlodipine poisoning

• Guest: Dr. Colleen Cowdery, MD

51:37 – #24. Management of severe amlodipine toxicity with high-dose calcium alone

• Guest: Dr. Vincent Ma, MD
• High dose norepinephrine in amlodipine overdose
• Case report of calcium death

56:56– #70. Iatrogenic exposure to long-acting buprenorphine injectable in an opioid-naïve patient

• Guest: Dr. Conor Young, MD

01:00:11 – #182. Left in the dark: a case of blindness in the setting of metformin toxicity

• Guest: Dr. Madison Bombard, MD

01:12:11 – #169. Just because it’s natural doesn’t mean it’s safe: a case of pediatric toxicity from topical and herbal remedies

• Guest: Dr. Aria Darling, MD

01:04:31 – #203. Serotonin syndrome after vaping Moocah

• Guest: Dr. Connor Murphy, MD

01:07:06 – #307. Intravenous ozone autohemotherapy: a retrospective observational case series

• Guest: Nicole McLarty

01:11:25 – #134. Do they really need n-acetylcysteine? Exploratory analysis of outcomes in patients with elevated liver function tests but no detectable acetaminophen

• Guest: Dr. Seth Carroll, PharmD

01:15:33 – #130. Outcomes of acute acetaminophen-poisoned patients treated with and without fomepizole: a Toxic registry study

• Guest: Dr. Jordan Woollum, PharmD

01:21:23 – #295. Evaluation of onset and resolution of complications after chronic methotrexate poisoning

• Guest: Dr. Van Quach, PharmD

01:24:51 – #325. Implications of potassium in salicylate toxicity treated with urinary alkalinization

• Guest: Dr. Andrew Yetka, PharmD

• Stick around to the very end of the episode for a teaser of Stump the Tox and the brand-new game Tox Wavelength, recorded on the train to NACCT. The full episode is available now for supporting members.

Review the show where ever your listening

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The GOTTA PICCEM Poisonous Mushroom Game!

The Poisonus Fungus Amongus Children's Book!

• Full book reading (6 minutes!)

Tox trinkets (Rep the show at home!)

• Email: [email protected]

More Show Resources

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In this special live episode from the 2025 North American Congress of Clinical Toxicology (NACCT), Ryan takes you inside the poster hall to hear directly from the researchers themselves. Covering 11 abstracts that span high-stakes management decisions, surprising case reports, and challenges to toxicology dogma, this year’s highlights feature everything from amlodipine overdoses to naturopathic misadventures, metformin-associated blindness, and more.

If you couldn’t make it to NACCT or just want to catch up on some of the most impactful new research in our field, this episode will give you a front-row seat. Check below for links to the published abstracts, the full list of studies discussed, and timestamps for where you can hear each one.

Link to published abstract manuscript

09:20 - Abstract #7. Is beta blocker toxicity associated with hypoglycemia?

• First author: Dr. Megan Audette

17:00 - Abstract #237. V-A ECMO as a treatment for vasoplegic shock in amlodipine poisoning: a comparison

• First author:Dr. Daniel Tirado

26:50 - Abstract #247. Blocked but not beaten: ECMO’s role in severe amlodipine toxicity – a poison center case series?

• First author: Dr. Carlos Saldarriaga

28:15 Abstract #27. Amlodipine double-dose therapeutic errors reported to Poison Centers

• First author: Carlos Saldarriaga

29:00 Abstract #27. Dosing on the edge: unpacking inadvertent amlodipine ingestions reported to a single poison center

• First author: Dr. Tiana Patriarca

32:38 - 292. Intravenous administration of sodium zirconium cyclosilicate resulting in death

• First author: Dr. Stephen Thornton

40:06 – Abstract #21. Quantitative analysis of amlodipine removal by plasmapheresis

• Guest: Dr. Keahi Horowitz, MD – Acute and Intensive Care Research Award winner

44:00 – Abstract #23. Relationship between reported ingestion dose and outcome in amlodipine poisoning

• Guest: Dr. Colleen Cowdery, MD

47:30 – Abstract #24. Management of severe amlodipine toxicity with high-dose calcium alone

• Guest: Dr. Vincent Ma, MD

53:00 – Abstract #70. Iatrogenic exposure to long-acting buprenorphine injectable in an opioid-naïve patient

• Guest: Dr. Connor Young, MD

55:51 – Abstract #182. Left in the dark: a case of blindness in the setting of metformin toxicity

• Guest: Madison Bompard, MD

57:56 – Abstract #169. Just because it’s natural doesn’t mean it’s safe: a case of pediatric toxicity from topical and herbal remedies

• Guest: Dr. Aria Darling, MD

59:57 – Abstract #203. Serotonin syndrome after vaping "Moocah"

• Guest: Dr. Connor Murphy, DO

1:03:00 – Abstract #307. Intravenous ozone autohemotherapy: a retrospective observational case series

• Guest: Nicole McLarty

1:05:59 – Abstract #134. Do they really need n-acetylcysteine? Exploratory analysis of outcomes in patients with elevated liver function tests but no detectable acetaminophen

• Guest: Dr. Seth Carroll PharmD

1:09:30 – Abstract #130. Outcomes of acute acetaminophen-poisoned patients treated with and without fomepizole: a Toxic registry study

• Guest: Dr. Jordan Woollum, PharmD

1:15:30 – Abstract #295. Evaluation of onset and resolution of complications after chronic methotrexate poisoning

• Guest: Dr. Van Quach, PharmD

1:19:13 – Abstract #325. Implications of potassium in salicylate toxicity treated with urinary alkalinization

• Guest: Dr. Andrew Yetka, PharmD

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In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Joe Kennedy, medical toxicologist at the University of Vermont and consultant for the Northern New England Poison Center. Together they work through real poisoning cases to sharpen toxic differentials, sum up practical resuscitation priorities, and connect first-principles pharmacology to bedside decisions. They also answer listener questions on THAM vs bicarbonate, when to dialyze even with “normal” kidneys, and why rattlesnake antivenom costs so much—plus the real-world logistics of sourcing exotic antivenoms in the U.S.

Dr. Kennedy and Ryan discuss the topics below. Looking for timestamps? Join the subscribed feed!

• Case set #1: Shock with hyperglycemia, big pupils, and probably NOT what you think it is.
• Case set #2: Massive bleeding after gas-station “herbal” products
• Case set #3: Refractory wide-complex rhythms in a teen overdose
• Case set #4: Sudden collapse at a hog farm- (SPOLIER) Recent outbreak of deaths as related to case 4

Want the cases summarized and sent to you so you can come up with your differential before the show? SIGN UP FOR THE NEWS LETTER!

Listener Q&A

• THAM vs bicarbonate (closed vs open buffering; “breathe for bicarb, tinkle for THAM”)
• Why dialyze if the kidneys work? (EXTRIP-style thinking, gradients, and properties)
• Snake antivenom pricing & how zoos help hospitals obtain non-U.S. antivenoms

Call outs from the show

• NACCT Abstracts!
• Clover coagulopathy!
• THAM VS BICARB Electrolytes
• Potato quality video of dialysis from Ryan
• Article on snake antivenom costing >200,000 for one patient
• Article on exotic antivenom procurement
• Case report Ryan published on treating blue Indonesian pit viper

Review the show where ever your listening

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• Ad free episodes
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The GOTTA PICCEM Poisonous Mushroom Game!

The Poisonus Fungus Amongus Children's Book!

• Full book reading (6 minutes!)

Tox trinkets (Rep the show at home!)

• Email: [email protected]

More Show Resources

• Ryan's Medical Games and Resources
• Show Website

GOTTA PICCEM: The Poisonous Mushroom Card Game

👉 Order now right here OR go to www.gottapiccem.com and click "Buy GOTTA PICCEM"

What started as a nerdy teaching tool made to teach mushroom poisoning by folks who treat mushroom poisoning is now a full-fledged card game—equally great for Friday game night and the classroom.

• 58 Poisonous Mushroom Cards
• Full-color pictures, toxin info, clinical syndromes, key anatomy, U.S. + global distribution, and spore print colors.
• 88 Play Cards + 30 Bonus Cards
• Collect mushrooms, play antidotes and modifiers, stack combos, and score big.
• Toxin-Based Scoring
• Point systems reflect real-world toxicity—every round plays differently based on your hand and bonus cards.
• Endless Replayability
• Rule variants at gottapiccem.com keep things fresh.

Dive into the companion blog at www.gottapiccem.com for:

• Deep-dive toxin explainers for each mushroom
• Case reports & real-world clinical notes
• Controversies and mysteries in mushroom poisoning

📖 Start here: gottapiccem.com (Companion Blog → “Learn the Mushrooms”)

👉 Order now right here OR go to www.gottapiccem.com and click "Buy GOTTA PICCEM"

• Multiple box options (pick your fancy)
• Ships direct from our manufacturer in South Korea
• 🌍 Global availability (shipping costs + tariffs may apply)

P.S. We’re exploring U.S. manufacturing to lower costs and expand distribution—timeline TBD—so we made the game available now.

If you grab a copy:

📸 Snap a photo of your first round

✉️ Send it to [email protected] or tag @LabPoison / @tox_talk

Nothing would make Ryan happier than seeing the community play!