View source for Anticholinergic

{{Short description|Substance which blocks the action of the acetylcholine (ACh) neurotransmitter}}
{{For|cholinergic blocking drugs|Cholinergic blocking drugs}}
{{distinguish|Anti-cholinesterase}}

'''Anticholinergics''' ('''anticholinergic agents''') are substances that block the action of the [[acetylcholine]] (ACh) [[neurotransmitter]] at [[synapse]]s in the [[central nervous system|central]] and [[peripheral nervous system]].<ref name="Anticholinergic Agents 2012 p.">{{citation|title=Anticholinergic Agents|url=http://www.ncbi.nlm.nih.gov/books/NBK548287/|year=2012|chapter=Anticholinergics|location=Bethesda (MD)|publisher=National Institute of Diabetes and Digestive and Kidney Diseases|pmid=31643610|quote=Anticholinergics have antisecretory activities and decrease nasal and bronchial secretions, salivation, lacrimation, sweating  and gastric acid production, and can be used to decrease secretions in allergic and inflammatory diseases. Anticholinergics relax smooth muscle in the gastrointestinal tract, bladder and lung and can be used for gastrointestinal, urological or respiratory conditions associated with spasm and dysmotility.|access-date=2020-03-23}}</ref><ref>Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2009. Drugs with Anticholinergic Activity. Prescriber's Letter 2011; 18 (12):271233.</ref>

These agents inhibit the [[parasympathetic nervous system]] by selectively blocking the binding of ACh to its receptor in [[nerve cell]]s. The [[nerve fiber]]s of the parasympathetic system are responsible for the involuntary movement of [[Smooth muscle tissue|smooth muscles]] present in the [[gastrointestinal tract]], [[urinary tract]], [[lungs]], [[sweat gland]]s, and many other parts of the body.<ref name="Migirov Datta 2020 p."/>

In broad terms, anticholinergics are divided into two categories in accordance with their specific targets in the central and peripheral nervous system and at the neuromuscular junction:<ref name="Migirov Datta 2020 p.">{{citation | last1=Migirov | first1=A | last2=Datta | first2=AR | title=Physiology, Anticholinergic Reaction | chapter=article-17683 | publisher=StatPearls Publishing | location=Treasure Island (FL) | year=2020 | pmid=31536197 | url=http://www.ncbi.nlm.nih.gov/books/NBK546589/ | access-date=2020-03-24 | others=This book is distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is provided to the Creative Commons license, and any changes made are indicated.}}</ref> [[antimuscarinic]] agents and [[antinicotinic]] agents ([[ganglionic blockers]], [[neuromuscular blockers]]).<ref>{{cite web|title=Urinary Incontinence|url=http://www2.kumc.edu/coa/Education/AMED900/UrinaryIncon.htm|publisher=Landon Center on Aging|author1=Sharee A. Wiggins|author2=Tomas Griebling|url-status=dead|archive-url=https://web.archive.org/web/20110927135227/http://www2.kumc.edu/coa/Education/AMED900/UrinaryIncon.htm|archive-date=2011-09-27|access-date=2011-07-09}}</ref>

The term "anticholinergic" is typically used to refer to antimuscarinics which competitively inhibit the binding of ACh to [[muscarinic acetylcholine receptor]]s; such agents do not antagonize the binding at [[nicotinic acetylcholine receptor]]s at the [[neuromuscular junction]], although the term is sometimes used to refer to agents which do so.<ref name="Migirov Datta 2020 p."/><ref name="UpToDate">{{cite web | title=Anticholinergic poisoning | website=UpToDate | url=https://www.uptodate.com/contents/anticholinergic-poisoning | access-date=2020-03-24 | last1=Su | first1=Mark | last2=Goldman | first2=Matthew | editor1-last=Traub | editor1-first=Stephen J. | editor2-last= Burns |editor2-first= Michele M. |editor3-last=Grayzel | editor3-first=Jonathan}}</ref>

==Medical uses==
Anticholinergic drugs are used to treat a variety of conditions:
* [[Dizziness]] (including [[vertigo]] and [[motion sickness]]-related symptoms)
* [[Extrapyramidal symptoms]], a potential side-effect of antipsychotic medications
* Gastrointestinal disorders (e.g., [[peptic ulcers]], [[diarrhea]], [[Pylorus|pyloro]][[spasm]], [[diverticulitis]], [[ulcerative colitis]], [[nausea]], and [[vomiting]])
* Genitourinary disorders (e.g., [[cystitis]], [[urethritis]], and [[prostatitis]])
* [[Insomnia]], although usually only on a short-term basis
* Respiratory disorders (e.g., [[asthma]], [[Bronchitis#Chronic bronchitis|chronic bronchitis]], and [[chronic obstructive pulmonary disease]] [COPD])
* [[Sinus bradycardia]] due to a hypersensitive [[vagus nerve]]
* [[Organophosphate]] based [[nerve agent]] [[Organophosphate poisoning|poisoning]], such as [[VX (nerve agent)|VX]], [[sarin]], [[Tabun (nerve agent)|tabun]], and [[soman]] (atropine is favoured in conjunction with an oxime, usually [[pralidoxime]])<ref>{{Cite web|title=NERVE AGENTS|url=https://fas.org/nuke/guide/usa/doctrine/army/mmcch/NervAgnt.htm#MEDICAL%20MANAGEMENT|access-date=2020-07-27|website=fas.org}}</ref><ref>{{Cite journal|last1=Nair|first1=V. Priya|last2=Hunter|first2=Jennifer M.|date=2004-10-01|title=Anticholinesterases and anticholinergic drugs|url=https://academic.oup.com/bjaed/article/4/5/164/291028|journal=Continuing Education in Anaesthesia, Critical Care & Pain|language=en|volume=4|issue=5|pages=164–168|doi=10.1093/bjaceaccp/mkh045|issn=1743-1816|doi-access=free}}</ref>

Anticholinergics generally have ''[[antisialagogue]]'' effects (decreasing saliva production), and most produce some level of sedation, both being advantageous in surgical procedures.<ref>Page 592 in: {{cite book |author1=Cahalan, Michael D. |author2=Barash, Paul G. |author3=Cullen, Bruce F. |author4=Stoelting, Robert K. |title=Clinical Anesthesia |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2009 |isbn=978-0-7817-8763-5 }}</ref><ref>{{cite book|url=https://books.google.com/books?id=-YI9P2DLe9UC|title=Clinical Anesthesia|access-date=8 December 2014|url-status=live|archive-url=https://web.archive.org/web/20170220091947/https://books.google.com/books?id=-YI9P2DLe9UC|archive-date=20 February 2017|isbn=9780781787635|last1=Barash|first1=Paul G.|year=2009|publisher=Lippincott Williams & Wilkins }}</ref>

Until the beginning of the 20th century, anticholinergic drugs were widely used to treat psychiatric disorders.<ref>Bangen, Hans: ''Geschichte der medikamentösen Therapie der Schizophrenie''. Berlin 1992, {{ISBN|3-927408-82-4}}</ref>

==Physiological effects==
Effects of anticholinergic drugs include:

* [[Delirium]] (often with [[hallucination]]s and [[delusion]]s indistinguishable from reality)
*Ocular symptoms (from [[eye drop]]s): [[mydriasis]], [[pupil dilation]], and [[acute angle-closure glaucoma]] in those with shallow [[anterior chamber]]<ref name="DailyMed 2017">{{cite web | title=ATROPINE- atropine sulfate solution/ drops | website=DailyMed | date=2017-11-20 | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f7b40bf1-3063-4849-a5a0-0ac5d0d1e72a | access-date=2020-03-28}}</ref><ref name="DailyMed 2019 Alcon">{{cite web | title=MYDRIACYL- tropicamide solution/ drops | website=DailyMed | date=2019-12-13 | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=57165763-29dc-4812-b840-a8a5086416f3 | access-date=2020-03-28}}</ref><ref name="DailyMed 2019 Mydriasis">{{cite web | title=MYDRIACYL- tropicamide solution/ drops | website=DailyMed | date=2019-12-13 | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0d4f4a2e-eb00-4c65-b3fa-baf5738d468d | access-date=2020-03-28}}</ref>
*[[Anhidrosis]], dry mouth, dry skin
* [[Fever]]
* [[Constipation]]
* [[Tachycardia]]
* [[Urinary retention]]
*[[Cutaneous]] [[vasodilation]]<ref name="Migirov Datta 2020 p."/>

Clinically the most significant feature is [[delirium]], particularly in the elderly, who are most likely to be affected by the [[toxidrome]].<ref name="Migirov Datta 2020 p."/>

==Side effects==
Long-term use may increase the risk of both cognitive and physical decline.<ref name=Fox2014>{{cite journal |last1=Fox |first1=C |last2=Smith |first2=T |last3=Maidment |first3=I |last4=Chan |first4=WY |last5=Bua |first5=N |last6=Myint |first6=PK |last7=Boustani |first7=M |last8=Kwok |first8=CS |last9=Glover |first9=M |last10=Koopmans|first10=I|last11=Campbell|first11=N|title=Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review |journal=Age and Ageing |date=September 2014 |volume=43 |issue=5|pages=604–15|pmid=25038833|doi=10.1093/ageing/afu096|doi-access=free }}</ref><ref>{{cite journal |last1=Andre |first1=L |last2=Gallini |first2=A |last3=Montastruc |first3=F |last4=Montastruc |first4=JL |last5=Piau |first5=A |last6=Lapeyre-Mestre |first6=M |last7=Gardette |first7=V |title=Association between anticholinergic (atropinic) drug exposure and cognitive function in longitudinal studies among individuals over 50 years old: a systematic review. |journal=European Journal of Clinical Pharmacology |date=29 August 2019 |volume=75 |issue=12 |pages=1631–1644 |doi=10.1007/s00228-019-02744-8 |pmid=31468067|s2cid=201675824 }}</ref> It is unclear whether they affect the risk of death generally.<ref name=Fox2014/> However, in older adults they do appear to increase the risk of death.<ref>{{cite journal |last1=Ruxton|first1=K|last2=Woodman|first2=RJ|last3=Mangoni|first3=AA|title=Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: A systematic review and meta-analysis.|journal=British Journal of Clinical Pharmacology|date=2 March 2015 |pmid=25735839|doi=10.1111/bcp.12617|volume=80|issue=2|pages=209–20|pmc=4541969}}</ref>

Possible effects of anticholinergics include:

{{div col}}
* [[Ataxia|Poor coordination]]
* [[Dementia]]<ref name=Falk2018>{{cite journal |last1=Falk |first1=N |last2=Cole |first2=A |last3=Meredith |first3=TJ |title=Evaluation of Suspected Dementia. |journal=American Family Physician |date=15 March 2018 |volume=97 |issue=6 |pages=398–405 |pmid=29671539}}</ref><ref>{{cite journal | vauthors = Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R, Yu O, Crane PK, Larson EB | display-authors = 6 | title = Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study | journal = JAMA Internal Medicine | volume = 175 | issue = 3 | pages = 401–407 | date = March 2015 | pmid = 25621434 | pmc = 4358759 | doi = 10.1001/jamainternmed.2014.7663 | author5-link = Rebecca Hubbard }}</ref>
* Decreased mucus production in the nose and [[throat]]; consequent dry, sore throat
* [[Xerostomia|Dry mouth]] with possible acceleration of [[dental caries]]
* Cessation of [[perspiration|sweating]]; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin
* Increased [[body temperature]]
* [[mydriasis|Pupil dilation]]; consequent sensitivity to bright light ([[photophobia]])
* Loss of accommodation (loss of focusing ability, blurred vision – [[cycloplegia]])
* [[diplopia|Double vision]]
* [[tachycardia|Increased heart rate]]
* Tendency to be easily startled
* [[Urinary retention]]
* [[Urinary incontinence]] while sleeping
* Diminished bowel movement, sometimes [[ileus]] (decreases motility via the [[vagus nerve]])
* Increased [[intraocular pressure]]; dangerous for people with narrow-angle [[glaucoma]]
{{div col end}}

Possible effects in the [[central nervous system]] resemble those associated with [[delirium]], and may include:

{{div col}}
* Confusion
* Disorientation
* Agitation
* [[Euphoria]] or [[dysphoria]]
* Respiratory depression
* Memory problems<ref name="Talan">{{Cite journal|last=Talan|first=Jamie|title=Common Drugs May Cause Cognitive Problems|journal=Neurology Now|date=July–August 2008|volume=4|issue=4|pages=10–11|url=https://www.brainandlife.org/articles/common-drugs-may-cause-cognitive-problems/ |archive-url=https://web.archive.org/web/20190626181238/https://www.brainandlife.org/articles/common-drugs-may-cause-cognitive-problems/ |url-status=dead |archive-date=2019-06-26 |access-date=26 June 2019 |doi=10.1097/01.NNN.0000333835.93556.d1}}</ref>
* Inability to concentrate
* Wandering thoughts; inability to sustain a [[train of thought]]
* Incoherent speech
* Irritability
* Mental confusion (brain fog)
* Wakeful [[myoclonic jerk]]ing
* Unusual sensitivity to sudden sounds
* Illogical thinking
* [[Photophobia]]
* Visual disturbances {{Citation needed|date=January 2019}}
** Periodic flashes of light
** Periodic changes in visual field
**[[Visual snow]]
** Restricted or "tunnel vision"
* Visual, auditory, or other sensory [[hallucination]]s
** Warping or waving of surfaces and edges
** Textured surfaces
** "Dancing" lines; "spiders", insects; [[form constants]]
** Lifelike objects indistinguishable from reality
** Phantom smoking 
** Hallucinated presence of people not actually there (e.g. [[shadow people]])
* Rarely: seizures, coma, and death
* [[Orthostatic hypotension]] (severe drop in systolic blood pressure when standing up suddenly) and significantly increased risk of falls in the elderly population<ref>{{cite web|url=http://lifeline.theonlinelearningcenter.com/SCOframe.aspx|archive-url=https://archive.today/20120712173900/http://lifeline.theonlinelearningcenter.com/SCOframe.aspx|url-status=dead|archive-date=12 July 2012|title=Lifeline Learning Center|publisher=Lifeline.theonlinelearningcenter.com|access-date=8 December 2014}}</ref>
{{div col end}}

Older patients are at a higher risk of experiencing CNS side effects.{{Citation needed|date=December 2023}} The link possible between anticholinergic medication use and cognitive decline/dementia has been noted in weaker observational studies.<ref name=":0" /> Although there is no strong evidence from randomized controlled trials to suggest that these medications should be avoided, clinical guidelines suggest that a consideration be made to decrease the use of these medications if safe to do so and the use of these medications be carefully considered to reduce any possible adverse effects including cognitive decline.<ref name=":0">{{Cite journal |last1=Taylor-Rowan |first1=Martin |last2=Alharthi |first2=Ahmed A. |last3=Noel-Storr |first3=Anna H. |last4=Myint |first4=Phyo K. |last5=Stewart |first5=Carrie |last6=McCleery |first6=Jenny |last7=Quinn |first7=Terry J. |date=2023-12-08 |title=Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=12 |pages=CD015405 |doi=10.1002/14651858.CD015405.pub2 |issn=1469-493X |pmc=10704558 |pmid=38063254|pmc-embargo-date=December 8, 2024 }}</ref>  

===Toxicity===
An acute anticholinergic syndrome is reversible and subsides once all of the causative agents have been excreted. Reversible [[acetylcholinesterase inhibitor]] agents such as [[physostigmine]] can be used as an antidote in life-threatening cases. Wider use is discouraged due to the significant side effects related to cholinergic excess including seizures, muscle weakness, bradycardia, bronchoconstriction, lacrimation, salivation, bronchorrhea, vomiting, and diarrhea. Even in documented cases of anticholinergic toxicity, seizures have been reported after the rapid administration of physostigmine. Asystole has occurred after physostigmine administration for tricyclic antidepressant overdose, so a conduction delay (QRS > 0.10 second) or suggestion of tricyclic antidepressant ingestion is generally considered a contraindication to physostigmine administration.<ref>Rosen, Peter, John A. Marx, Robert S. Hockberger, and Ron M. Walls. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Mosby Elsevier, 2014.</ref>

==Pharmacology==
Anticholinergics are classified according to the receptors that are affected:
* ''[[Antimuscarinic]]'' agents operate on the [[muscarinic acetylcholine receptor]]s. The majority of anticholinergic drugs are antimuscarinics.
* ''[[Antinicotinic]]'' agents operate on the [[nicotinic acetylcholine receptor]]s. The majority of these are non-depolarising [[skeletal muscle]] relaxants for surgical use that are structurally related to [[curare]]. Several are depolarizing agents.

==Examples==
Examples of common anticholinergics:

{{div col|colwidth=20em}}
* '''Antimuscarinic agents'''
** [[Antipsychotics]] ([[clozapine]], [[quetiapine]])<ref name=TI113>{{cite web |title=[113] How well do you know your anticholinergic (antimuscarinic) drugs? {{!}} Therapeutics Initiative |url=https://www.ti.ubc.ca/2018/09/10/113-anticholinergic-antimuscarinic-drugs/ |website=Therapeutics Initiative |access-date=20 September 2018 |date=10 September 2018}}</ref>
** [[Atropine]]
** [[Benztropine]]
** [[Biperiden]]
** [[Chlorpheniramine]]
** Certain [[SSRIs]] ([[Paroxetine]])<ref name=TI113/>
** [[Dicyclomine]] ([[Dicycloverine]])
** [[Dimenhydrinate]]<ref name=TI113/> 
** [[Diphenhydramine]]<ref name=TI113/>
** [[Doxepin]]
** [[Doxylamine]] 
** [[Flavoxate]]
** [[Glycopyrronium|Glycopyrronium/-late]] 
** [[Hyoscyamine]]
** [[Ipratropium]]
** [[Orphenadrine]] 
** [[Oxitropium bromide|Oxitropium]]
** [[Oxybutynin]]<ref name=TI113/>
** [[Promethazine]]
** [[Propantheline bromide]] 
** [[Hyoscine hydrobromide|Scopolamine]]
** [[Solifenacin]]
** [[Tolterodine]]
** [[Tiotropium]] 
** [[Tricyclic antidepressant#List of TCAs|Tricyclic antidepressants]]
** [[Trihexyphenidyl]]
** [[Tropicamide]]<ref name="autogenerated1"/>
** [[Umeclidinium]] 
* '''Antinicotinic agents'''
** [[Bupropion]] – Ganglion blocker<ref name="pmid24484978">{{cite book |vauthors=Carroll FI, Blough BE, Mascarella SW, Navarro HA, Lukas RJ, Damaj MI |chapter=Bupropion and Bupropion Analogs as Treatments for CNS Disorders |title=Emerging Targets & Therapeutics in the Treatment of Psychostimulant Abuse |volume=69 |pages=177–216 |year=2014 |pmid=24484978 |doi=10.1016/B978-0-12-420118-7.00005-6 |series=Advances in Pharmacology |isbn=9780124201187 }}</ref><ref name="Dwoskin2014">{{cite book | author = Dwoskin, Linda P. | title = Emerging Targets & Therapeutics in the Treatment of Psychostimulant Abuse | url = https://books.google.com/books?id=b3UpAgAAQBAJ&pg=PA177 | date = 29 January 2014 | publisher = Elsevier Science | isbn = 978-0-12-420177-4 | pages = 177–216 | url-status = live | archive-url = https://web.archive.org/web/20170320155042/https://books.google.com/books?id=b3UpAgAAQBAJ&pg=PA177 | archive-date = 20 March 2017 }}</ref><ref name="TasmanKay2011">{{cite book | author1 = Tasman, Allan | author2 = Kay, Jerald | author3 = Lieberman, Jeffrey A. | author4 = First, Michael B. | author5 = Maj, Mario | title = Psychiatry | url = https://books.google.com/books?id=vVG7zz7eaxcC&pg=RA9-PT2900 | date = 11 October 2011 | publisher = John Wiley & Sons | isbn = 978-1-119-96540-4 | url-status = live | archive-url = https://web.archive.org/web/20170320140656/https://books.google.com/books?id=vVG7zz7eaxcC&pg=RA9-PT2900 | archive-date = 20 March 2017 }}</ref>
** [[Dextromethorphan]] - Cough suppressant and ganglion blocker<ref name="pmid15356218">{{cite journal |doi=10.1124/jpet.104.075093 |pmid=15356218 |title=Effect of Dextrometorphan and Dextrorphan on Nicotine and Neuronal Nicotinic Receptors: In Vitro and in Vivo Selectivity |journal=Journal of Pharmacology and Experimental Therapeutics |volume=312 |issue=2 |pages=780–5 |year=2004 |last1=Damaj |first1=M. I. |last2=Flood |first2=P |last3=Ho |first3=K. K. |last4=May |first4=E. L. |last5=Martin |first5=B. R. |s2cid=149958 }}</ref><ref name="pmid16563374">{{cite journal |doi=10.1016/j.ejphar.2006.02.034 |pmid=16563374 |title=Effects of dextrorotatory morphinans on α3β4 nicotinic acetylcholine receptors expressed in Xenopus oocytes |journal=European Journal of Pharmacology |volume=536 |issue=1–2 |pages=85–92 |year=2006 |last1=Lee |first1=Jun-Ho |last2=Shin |first2=Eun-Joo |last3=Jeong |first3=Sang Min |last4=Kim |first4=Jong-Hoon |last5=Lee |first5=Byung-Hwan |last6=Yoon |first6=In-Soo |last7=Lee |first7=Joon-Hee |last8=Choi |first8=Sun-Hye |last9=Lee |first9=Sang-Mok |last10=Lee |first10=Phil Ho |last11=Kim |first11=Hyoung-Chun |last12=Nah |first12=Seung-Yeol }}</ref><ref name="pmid10869398">{{cite journal |pmid=10869398 |url=http://jpet.aspetjournals.org/cgi/pmidlookup?view=long&pmid=10869398 |year=2000 |last1=Hernandez |first1=S. C. |title=Dextromethorphan and Its Metabolite Dextrorphan Block α3β4 Neuronal Nicotinic Receptors |journal=The Journal of Pharmacology and Experimental Therapeutics |volume=293 |issue=3 |pages=962–7 |last2=Bertolino |first2=M |last3=Xiao |first3=Y |last4=Pringle |first4=K. E. |last5=Caruso |first5=F. S. |last6=Kellar |first6=K. J. }}</ref>
** [[Doxacurium]] – Nondepolarizing skeletal muscular relaxant
** [[Hexamethonium]] – Ganglion blocker
** [[Mecamylamine]] – Ganglion blocker and occasional [[smoking cessation]] aid<ref>{{cite journal|last=Shytle|first=RD|author2=Penny, E |author3=Silver, AA |author4=Goldman, J |author5= Sanberg, PR |title=Mecamylamine (Inversine): an old antihypertensive with new research directions |journal=Journal of Human Hypertension|date=Jul 2002|volume=16|issue=7|pages=453–7|pmid=12080428 |doi=10.1038/sj.jhh.1001416|doi-access=free}}</ref> 
** [[Tubocurarine]] - Nondepolarizing skeletal muscular relaxant
{{div col end}}

===Antidotes===
[[Physostigmine]] is one of only a few drugs that can be used as an antidote for anticholinergic poisoning. [[Nicotine]] also counteracts anticholinergics by activating [[nicotinic acetylcholine receptors]]. [[Caffeine]] (although an [[adenosine]] [[receptor antagonist]]) can counteract the anticholinergic symptoms by reducing sedation and increasing acetylcholine activity, thereby causing alertness and arousal.

==Psychoactive uses==
When a significant amount of an anticholinergic is taken into the body, a [[toxidrome#Anticholinergic|toxic reaction]] known as acute anticholinergic syndrome may result. This may happen accidentally or intentionally as a consequence of either [[recreational drug use|recreational]] or [[entheogen]]ic drug use, though many users find the side effects to be exceedingly unpleasant and not worth the recreational effects they experience. In the context of recreational use, anticholinergics are often called [[deliriants]].<ref name="autogenerated1">{{Cite journal | doi = 10.1016/j.genhosppsych.2013.04.013| pmid = 23706777| title = Drops of madness? Recreational misuse of tropicamide collyrium; early warning alerts from Russia and Italy| journal = General Hospital Psychiatry| volume = 35| issue = 5| pages = 571–3| year = 2013| last1 = Bersani | first1 = F. S. | last2 = Corazza | first2 = O. | last3 = Simonato | first3 = P. | last4 = Mylokosta | first4 = A. | last5 = Levari | first5 = E. | last6 = Lovaste | first6 = R. | last7 = Schifano | first7 = F. }}</ref>

==Plant sources==
The most common plants containing anticholinergic [[alkaloids]] (including [[atropine]], [[Hyoscine hydrobromide|scopolamine]], and [[hyoscyamine]] among others) are:
*''[[Atropa belladonna]]'' (deadly nightshade)
*''[[Brugmansia]]'' species 
*''[[Datura]]'' species
*''[[Garrya]]'' species
*''[[Hyoscyamus niger]]'' (henbane)
*''[[Mandragora officinarum]]'' (mandrake)

==Use as a deterrent==
Several narcotic and [[opiate]]-containing drug preparations, such as those containing  [[hydrocodone]] and [[codeine]] are combined with an anticholinergic agent to deter intentional misuse.<ref name=dailymed>{{cite web|url=http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id=5209&type=display|title=NIH DailyMed – Hydromet Syrup|publisher=Dailymed.nlm.nih.gov|access-date=2008-08-17|url-status=live|archive-url=https://web.archive.org/web/20110523224811/http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id=5209&type=display|archive-date=2011-05-23}}</ref> Examples include [[hydrocodone/homatropine]] (Tussigon, Hydromet, Hycodan), [[diphenoxylate/atropine]] (Lomotil), and [[hydrocodone polistirex/chlorpheniramine polistirex]] (Tussionex Pennkinetic, TussiCaps). However, it is noted that opioid/antihistamine combinations are used clinically for their synergistic effect in the management of pain and maintenance of dissociative [[anesthesia]] (sedation) in such preparations as [[meperidine]]/[[promethazine]] (Mepergan) and [[dipipanone]]/[[cyclizine]] (Diconal), which act as strong anticholinergic agents.<ref name=springer>{{cite journal|title=Characterizing the subjective, psychomotor, and physiological effects of a hydrocodone combination product (Hycodan) in non-drug-abusing volunteers|doi=10.1007/s00213-002-1245-5|pmid=12404072|volume=165|issue=2|journal=Psychopharmacology|pages=146–156|year = 2003|last1 = Zacny|first1 = James P.|s2cid=7835794}}</ref>

==References==
{{Reflist}}

{{Pharmacomodulation}}
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[[Category:Anticholinergics| ]]
[[Category:Medical mnemonics]]