- Sharp increase in reported exposures in 2011.
- Considered “legal highs” available in small packages and billed as “not for consumption” to avoid regulation.
- Added to Schedule I agents list by DEA in October 2011.
- More common cathinones officially banned by President Obama in July 2012, along with other designer chemicals.
- Serious medical effects or death observed in approximately 16% of cases.
- Amphetamine analogs
- Naturally occurring beta-ketone amphetamine found in leaves of Catha edulis plant, or khat
butylone, dimethylcathinone, ethcathinone, ethylone, fluoromethcathinone, mephedrone, methedrone, methylone, pyrovalerone, methylenedioxypyrovalerone (MDPV)
- Categories of items sold: Bath salts, plant food, jewelry cleaner, phone screen cleaner, ladybug attractant.
- Product names: Ivory Wave, Blizzard, Vanilla Sky, Bloom, Scarface, White Lightning/Rush, Bliss, Cloud 9, Red Dove, Zoom, Night Lights.
Pharmacology and Physiologic Effects
- Studies limited regarding mechanism, but thought to be similar to other amphetamines.
- Alpha, beta adrenergic stimulation – HTN, hyperacuity, tachycardia, mydriasis, diaphoresis
- Dopamine, serotonin, norepinephrine release and reuptake inhibition – psychotic, hallucinogenic properties
- Lipophilic – easily crosses blood-brain barrier
- Effects peak approximately 1 hour after ingestion
- Half-life varies 3-24 hours
Methods of Ingestion
- Ingestion of pill/tablet/capsule
- “Bombing” – powder wrapped in cigarette paper and swallowed
- “Keying” – dipping key into powder and insufflating, 5-8 keys per gram
- Less commonly, rectal, gingival, inhalation, IM, IV
- Khat leaves are often chewed in Africa
- What is it like to get high with bath salts?
- Similar to cocaine, but prolonged effect and more satisfying
- Approximately 20% have adverse reaction
- >80% will have co-ingestion or co-abuse with other recreational drugs, so DO NOT ASSUME PATIENT IS ONLY TAKING BATH SALTS
- Most common symptom of overdose is agitation, can range from mild aggression to psychosis
- Vitals – hypertension, hyperthermia, and tachycardia
- Cardio – not directly proarrhythmic, often causes chest pain
- CNS – agitation, hallucinations, paranoia, self-inflicted injuries, violence against others, seizures
- Musculoskeletal – similar to other methamphetamines – myoclonus, tremors – risk of rhabdomyolysis
- Renal, electrolyte – case reports of ATN, hyponatremia (thought to be similar to ecstasy)
- Heme – Case reports of death due to DIC in those ingesting bath salts
- CO-INGESTION, as noted above. Be on the lookout for signs of other intoxication.
- Other causes of sympathomimetic intoxication, in particular
- Cocaine, amphetamines, pseudoephedrine, phenlpropanolamine, theophylline, caffeine
- Bath salts are unique in class of sympathomimetics in that the DURATION IS LONGER and is associated with PSYCHOSIS that can last for days to weeks.
- Hallucinogen intoxication
- Hallucinogens do not typically cause hypertension and tachycardia like cathinones and amphetamines.
- Anticholinergic intoxication
- Similar features to cathinone intoxication include agitation, tachycardia, and HTN.
- Anticholinergics tend not to have diaphoresis.
- Cessation/withdrawal from other drugs of abuse can be similar to cathinone intoxication.
- Medical problems: thyroid, pheochromocytoma, heat stroke, psychiatric conditions
- No testing available to specifically diagnose intoxication with bath salts. Cathinone intoxication is a CLINICAL DIAGNOSIS.
- Workup is similar to other tox workup
- Labs: Accucheck, APAP, ASA, CMP (metabolized by liver, also evaluate hyponatremia)
- Consider CK if there is concern for rhabdo
- Consider coags to assess for DIC
- Focused on controlling agitation and keeping staff and patient safe.
- Management is very similar to other sympathomimetics.
- Consider avoiding ketamine for RSI due to dissociative effects.
- Only consider gastric decontamination if recent ingestion of large amount of drug, such as a body-stuffer.
- Controlling agitation
- Large doses of benzos may be needed.
- Haloperidol and antipsychotics may lower seizure threshold and prolong QT, therefore are not recommended.
- As with other sympathomimetic intoxications, beta blockers are not recommended due to risk of unopposed alpha stimulation.
- Nitroprusside and phentolamine are appropriate for addressing HTN.
- Be aggressive with control of hyperthermia, sedate and paralyze if necessary.
- Dispo – admission for persistent psychosis, electrolyte abnormalities, or rhabdo
- Withdrawal – self-reported in 0.7-22% of users
- Older individuals tend to be at higher risk for medical complications.
Recap Basics, Pearls
- Cathinone intoxication = sympathomimetic intoxication + psychomotor agitation + hallucinations.
- Be aware that patients are likely abusing multiple recreational drugs when cathinones are involved.
- Diagnosis is clinical. No test is available currently. Workup is standard tox workup.
- Treatment is geared towards control of agitation and management of medical complications such as HTN, rhabdomyolysis, and hyponatremia.
- Three key cathinones have been outlawed, however, new formulations can be found that avoid regulation.
- More investigation needed regarding designer drugs such as cathinones and synthetic marijuanas.
- The toxicology of bath salts: a review of synthetic cathinones.
- Psychoactive “bath salts”: not so soothing.
- Bath salts and synthetic cathinones: An emerging designer drug phenomenon.
- A 9-state analysis of designer stimulant, “bath salt,” hospital visits reported to poison control centers.
- Compartment syndrome after “bath salts” use: a case series.
- “Bath salts” and “plant food” products: the experience of one regional US poison center.
- Two cases of disseminated intravascular coagulation due to “bath salts” resulting in fatalities, with laboratory confirmation.
Discussion Questions/Future Exploration
- Are designer cathinones not on Schedule I list still available for purchase?
- Has cathinone use remained popular, given extensive media coverage of strange cases reportedly involving bath salts?
- How often do cathinone ingestion diagnoses get missed, given lack of specific testing and high rates of co-ingestion?
- Do patients who tend to abuse cathinones tend to abuse other designer drugs, or tend to abuse more traditional recreational drugs?