Bath Salts

Introduction

Classification: Cathinone

Background

  • 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.

Chemical Classification

  • Amphetamine analogs
  • Naturally occurring beta-ketone amphetamine found in leaves of Catha edulis plant, or khat

Chemical Names

butylone, dimethylcathinone, ethcathinone, ethylone, fluoromethcathinone, mephedrone, methedrone, methylone, pyrovalerone, methylenedioxypyrovalerone (MDPV)

Street Names

  • 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
  • Insufflation
  • “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

Clinical Features

  • 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

Differential Diagnosis

  • 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

Diagnosis

  • 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
  • EKG

Management

  • 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.

What’s New

  • 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.

Further Reading

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?
Edited by Alex Koyfman

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