Hidden in Plain Sight: Legal Substances Putting Children at Risk

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.

READ MORE: Substance Use Disorder Resource Center

Are you ready to elevate your pharmacy practice? Sign up today for our free Drug Topics newsletter and get the latest drug information, industry trends, and patient care tips straight to your inbox.

REFERENCES

1. National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Accessed January 16, 2026. https://nsduhweb.rti.org/respweb/homepage.cfm

2. Youth Substance Use Trends. Centers for Disease Control and Prevention. November 22, 2024. Accessed January 16, 2026. https://www.cdc.gov/youth-behavior/risk-behaviors/substance-use-among-youth.html

3. van Amsterdam J, Nabben T, van den Brink W. Recreational nitrous oxide use: Prevalence and risks. Regul Toxicol Pharmacol. 2015;73(3):790-796. doi:10.1016/j.yrtph.2015.10.017

5. Thompson AG, Leite MI, Lunn MP, Bennett DL. Whippits, nitrous oxide and the dangers of legal highs. Pract Neurol. 2015;15(3):207-209. doi:10.1136/practneurol-2014-001071

6. Garakani A, Jaffe RJ, Savla D, et al. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature. Am J Addict. 2016;25(5):358-369. doi:10.1111/ajad.12372

7. Vohra V, Matthews H, Stroh-Steiner G. Notes from the Field: Recreational Nitrous Oxide Misuse - Michigan, 2019-2023. MMWR Morb Mortal Wkly Rep. 2025;74(12):210-212. Published 2025 Apr 10. doi:10.15585/mmwr.mm7412a3

8. FDA. FDA Advises Consumers Not to Inhale Nitrous Oxide Product. June 4, 2025. Accessed January 16, 2026. https://www.fda.gov/food/alerts-advisories-safety-information/fda-advises-consumers-not-inhale-nitrous-oxide-products

9. Prozialeck WC. Update on the Pharmacology and Legal Status of Kratom. J Am Osteopath Assoc. 2016;116(12):802-809. doi:10.7556/jaoa.2016.156

10. Kruegel AC, Grundmann O. The medicinal chemistry and neuropharmacology of kratom: A preliminary discussion of a promising medicinal plant and analysis of its potential for abuse. Neuropharmacology. 2018;134(Pt A):108-120. doi:10.1016/j.neuropharm.2017.08.026

11. Olsen EO, O'Donnell J, Mattson CL, Schier JG, Wilson N. Notes from the Field: Unintentional Drug Overdose Deaths with Kratom Detected - 27 States, July 2016-December 2017. MMWR Morb Mortal Wkly Rep. 2019;68(14):326-327. Published 2019 Apr 12. doi:10.15585/mmwr.mm6814a2

12. Li W, Wertheimer A. Narrative Review: The FDA's Perfunctory Approach of Dietary Supplement Regulations Giving Rise to Copious Reports of Adverse Events. Innov Pharm. 2023;14(1):10.24926/iip.v14i1.4989. Published 2023 Oct 10. doi:10.24926/iip.v14i1.4989

13. Laboratory analysis of kratom products for heavy metals. FDA. April 3, 2014. Accessed January 16, 2026. https://www.fda.gov/news-events/public-health-focus/laboratory-analysis-kratom-products-heavy-metals

14. Kruger JS, Kruger DJ. Delta-8-THC: Delta-9-THC's nicer younger sibling?. J Cannabis Res. 2022;4(1):4. Published 2022 Jan 4. doi:10.1186/s42238-021-00115-8

15. 5 Things to know about Delta-8 Tetrahydrocannabinol - Delta-8 THC. FDA. May 4, 2022. Accessed January 16, 2026. https://www.fda.gov/consumers/consumer-updates/5-things-know-about-delta-8-tetrahydrocannabinol-delta-8-thc

16. Increases in availability of cannabis products containing Delta-8 THC and reported cases of adverse events. CDC. September 14, 2021. Accessed January 16, 2026. https://stacks.cdc.gov/view/cdc/109759

17. Volkow ND, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;371(9):879. doi:10.1056/NEJMc1407928

18. Roth BL, Baner K, Westkaemper R, et al. Salvinorin A: a potent naturally occurring nonnitrogenous kappa opioid selective agonist. Proc Natl Acad Sci U S A. 2002;99(18):11934-11939. doi:10.1073/pnas.182234399

19. Babu KM, McCurdy CR, Boyer EW. Opioid receptors and legal highs: Salvia divinorum and Kratom. Clin Toxicol (Phila). 2008;46(2):146-152. doi:10.1080/15563650701241795

20. Levy S, Siqueira LM; Committee on Substance Abuse, et al. Testing for drugs of abuse in children and adolescents. Pediatrics. 2014;133(6):e1798-e1807. doi:10.1542/peds.2014-0865