Bath Salts: An 'Ivory Wave' Epidemic?

Sarah T. Melton, PharmD

Disclosures

August 26, 2011

Question:

What are "bath salts?" How are they abused and what are the potential consequences of abuse?

Response from Sarah T. Melton, PharmD
Director of Addiction Outreach; Associate Professor of Pharmacy Practice, Appalachian College of Pharmacy, Oakwood, Virginia; Clinical Pharmacist, C-Health, PC, Lebanon, Virginia

The "bath salts" in question have no legitimate use for bathing; the name is slang for a group of designer drugs that contain 3,4-methylenedioxypyrovalerone (MDPV) or 4-methylmethcathinone (mephedrone).[1] Emergency department (ED) visits and calls to poison control centers in 2011 have skyrocketed due to ingestion of "bath salts." In the United States, over 4000 calls to poison control centers were made regarding exposure to "bath salts" as of July 31, 2011, and about 1500 ED visits due to exposure were reported in the first quarter of 2011.[2]

With names including "Ivory Wave," "White Lightning," and "Vanilla Sky,"[2] these designer drugs are sold as tablets, capsules, or powder in sealed envelopes and can be bought by consumers of any age in many states. They are often sold at tobacco stores, gas stations, and head shops (ie, specialty shops that sell drug paraphernalia and "legal high" products) and are widely available on the Internet.[2,3]

The packets usually are marked "not for human consumption" or are marked as plant food in order to avoid government regulation. The powder can be smoked, snorted, injected, administered rectally, and wrapped in pieces of paper and ingested or "bombed."[3] These chemicals cannot be detected by routine drug screening, making the substances attractive for misuse.[4]

Both MDPV and mephedrone are stimulants.[1] Mephedrone has amphetamine- or cocaine-like effects related to the alkaloid cathinone which is derived from the active ingredient of the Khat plant. The clinical effects of synthetic cathinones begin within 20 minutes of oral ingestion and last from 2 to 4 hours. If snorted, the effects begin within minutes and the peak occurs in less than 30 minutes.[5]

Effects may include intense stimulation, alertness, euphoria, elevated mood, and a pleasurable "rush." Users may describe feelings of closeness, sociability, and moderate sexual arousal. Other physical symptoms are typical of stimulants and include tremor, shortness of breath, and loss of appetite.[3,5,6] Changes in body temperature regulation accompanied by hot flashes and sweating (characterized by a strong body odor) are common as are nose and throat bleeds with burns and ulcerations caused from snorting the "bath salts."[5]

Effects on the cardiovascular system include tachycardia, hypertension, peripheral vasoconstriction, and chest pain. Psychiatric effects at higher doses can include anxiety, agitation, hallucinations, paranoia, and erratic behavior.[5]Depression has been associated with mephedrone use as have reports of successful suicide attempts during use.[5,7] Withdrawal symptoms are not typically reported, but users often describe strong cravings for the drug.[3]

Although few data exist in the United States characterizing demographics of users of "bath salts," a large survey was done in the United Kingdom of ever-users of mephedrone (N = 2700). This survey found that the mean age of users was 25 years and the group consisted of experienced polydrug users. Mephedrone was the sixth most common drug used in the previous month after alcohol (97%), tobacco (72%), cannabis (54.4%), ecstasy (53.1.%), and cocaine (47.4%). Over 40% reported ever having used mephedrone, 38.7% reported use in the previous 12 months, and over 33.2% reported use in the previous month.[3]

A majority of users perceived mephedrone to have a better high than cocaine regardless of route of administration. Those snorting mephedrone reported using larger amounts more often and rated the drug as more addictive than those taking the drug orally. The authors attribute the rapid emergence of mephedrone in the drug-using population to the phenomenon of Web-based information sharing and the availability of easy and relatively inexpensive access to mephedrone.[3]

The Morbidity and Mortality Weekly Report recently published a public health investigation of ED cases resulting from use of "bath salts."[1] A total of 35 patients were identified at Michigan EDs during the time period of November 13, 2010 to March 31, 2011. Of these patients, 17 patients were hospitalized and 1 died. Nearly half had a history of mental illness and 16 of 17 with known drug test results also tested positive for other drugs.

Management of mephedrone or MDPV toxicity is considered to be empirical as treatment guidelines have not been published. Treatment is usually symptomatic and supportive. Agitation caused by mephedrone is often managed by benzodiazepines.[5,6] Antipsychotics have been used as secondary agents when sedation with benzodiazepines was ineffective.[1] Patients with underlying cardiac, neurologic, or psychiatric conditions may be at highest risk for toxicity.[5]

Many countries in Europe have acted to ban or control MDPV and mephedrone distribution; in December 2010 the Council of the European Union banned mephedrone across Europe. Over the past year, states across the United States have enacted legislation to ban substances found in "bath salts." New York Senator Charles Schumer has proposed a bill requesting that "bath salts" be added to a list of federally controlled substances.

Healthcare providers should consider mephedrone, MDPV, or other "legal high" stimulant use in patients who present with symptoms suggestive of a sympathomimetic overdose in the absence of any other information. Furthermore, healthcare providers should be informed about this class of substances and work cooperatively with local law enforcement, poison control centers, EDs, parents, and teachers to identify sources of the agents, prevent use of these drugs, and reduce harm associated with these "legal highs."

Dr. Melton acknowledges the research assistance of Christa Kendrick and Trang Nguyen, Doctor of Pharmacy Candidates at the Appalachian College of Pharmacy.

Editor's note: On September 7, 2011, the DEA announced that it is using its emergency scheduling authority to make psychoactive "bath salts" (PABS) a controlled substance.

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