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

• 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?