Bath Salts

Bath Salts – Another Wave in Drugs of Abuse s

In orgIn part of our ongoing effort to provide updated information to Kaiser Physicians, we wanted to cover the topic of "Bath Salts" in some detail. This topic was covered on NPR this morning () and other public media these past few weeks. Bath salts are generic term now used by the public to represent a variety of chemical stimulants. Theses products are not necessarily new but their ease of access is. They have been seen throughout Europe for several years, where we obtained most of our current knowledge. Bath Salts may contain a variety of drugs. Most commonly, bath salts contain 4-methylmethcathinone (methedrone), 3,4-methylenedioxypyrovalerone (MDPV), synthetic cathinones, and other synthetic cathinone derivatives. Some of the other synthetic cathinones/derivatives include www.npr.org

• N,N-dimethylcathinone
• Ethcathinone
• Bk-PMMA (Methedrone)
• 4-Fluoromethcathinone (Flephedrone)
• 3-Fluoromethcathinone
• bk-MDMA (Methylone)
• bk-MDEA (Ethylone)
• bk-MBDB (Butylone)

Essentially, these are all stimulants related to amphetamines. Cathinone has been around for centuries as a naturally occurring stimulant present in the Khat plant. It is widely used in the Middle East. Its effects and structure are similar to those of ephedrine and amphetamine. These bath salts are compounds that have been presented to the public ahead of legislature to ban them. They are sold in convenience stores and truck stops and widely dispersed over the internet. There are a wide variety of "street" or over-the-counter names for bath salts including 4-MMC, Bubbles, Meow, and M-Cat, Miaow Miaow, growth stimulator, pond scum remover, pH optimizer, odorizer, white powder, vanilla sky, ivory wave, white rush, plant food, and White China. There are likely additional names that will surface in the upcoming weeks to months and the government seeks ways to ban the sales of the drugs. Florida and Louisiana recently banned sale at convenience stores and truck stops.

These compounds are typically white powders or yellowish liquids at ambient temperature. The powder is readily soluble in water and can be dissolved for oral/rectal use or for injection. The drugs have also been found as capsules containing powder and as tablets pressed from powder. There is limited data on the metabolism of mephedrone and other cathinone derivatives. There is no data available to be able to determine how long either mephedrone or its metabolites remain detectable, nor on their stability in biological specimens.

 Mephedrone is reported to be used in single doses of between 5–250 mg, although due to short-lived effects the total doses used per session may be greater, possibly between 0.5–2 g. Onset of desired effects is typically seen within 15–45 minutes of oral ingestion and a few minutes after nasal insufflation. Users report that the desired effects last approximately 2–3 hours and therefore that they may consume multiple doses during a session to prolong the duration of the desired effects.
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Adverse effects reported by users in European monitoring include sweating, headaches, tachycardia, palpitations, nausea, chest pain, bruxism, agitation/aggression and paranoia. In addition, nasal insufflation of mephedrone is reported to be associated with significant nasal irritation and pain which has led to some users switching to oral use of mephedrone.1

In cases seen in the United States in emergency departments, these patients look very similar to the methamphetamine cases seen 10-15 years ago. Patients are agitated, paranoid, and often aggressive. Patients are sympathomimetic with dilated pupils, diaphoresis, tachycardia, and hypertension. Treatment should start with the liberal use of benzodiazepines and likely a high-potency antipsychotic in severe cases. Early aggressive therapy is paramount to the management of these patients. Minimizing sensory stimuli with low doses of benzodiazepines in combination with low doses of antipsychotic agents has been a useful approach to amphetamine-induced psychosis. Seizures are a potential concern as well, which also supports the use of benzodiazepines in the early management. Patients may require passive/active cooling measures for hyperthermia.

Patients are not likely to have a positive amphetamine immunoassay on routine urine drugs of abuse screen. Woods, et al recently described a case series from the United Kingdom of 15 patients who presented to the emergency department following self-reported mephedrone use. The significant clinical features included agitation in 53.3%, tachycardia in 40%, systolic hypertension in 20%, and seizures in 20%. Twenty per cent required treatment with benzodiazepines, predominantly for management of agitation.2

Patients with signs of mild amphetamine intoxication may be monitored in the ED; patients with moderate or severe intoxication should be admitted. Decisions regarding disposition to intensive care settings depend on the degree of acidosis, rhabdomyolysis, and other end-organ injuries. Once the acute symptoms of amphetamine poisoning have abated, treating physicians should consider referring patients for drug treatment or psychiatric care.3

1. Risk assessment report of a new psychoactive substance: 4-methylmethcathinone (mephedrone). European Monitoring Centre for Drugs and Drug Addiction, UK Advisory Council on the Misuse of Drugs, 2010, 1-16.
2. Wood DM, Greene SL, Dargan PI. Clinical pattern of toxicity associated with the novel synthetic cathinone mephedrone.Emerg Med J. 2010 Jun 26. [Epub ahead of print].
3. Hernon C, Boyer E. Amphetamine Derivatives. www.toxed.com.

Editorial Update: 2010-05-10. KPNC Regional Toxicology Service
916-328-0417
kpssctoxicology.org