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Synthetic Cathinones: Signs, Symptoms, and Treatment

Synthetic Cathinones: Signs, Symptoms, and Treatment

bath salts overdoseWhat are the latest reports on Bath Salts?

Substances previously unknown to most psychiatrists, synthetic cathinones (SCs)—commonly referred to as bath salts—have catapulted to the front line of substance abuse in the last 2 years. In 2010, there were 302 Poison Control calls related to the SC 3,4-methylenedioxypyrovalerone (MDPV). For the first 11 months of 2011, this number increased to 5625.1

SCs are sold online, in “head shops,” and in convenience stores. These substances have been marketed as bath salts, plant food, and other seemingly benign compounds in order to be sold over the counter and avoid FDA regulations. Most packages include the warning, “not for human consumption.”

Naturally occurring cathinones are derived from the khat plant (Catha edulis). Active ingredients in SCs include MDPV; 4-methylmethcathinone (mephedrone); and 3,4-methylenedioxy-N-methylcathinone (methylone) The structure is similar to amphetamines. The Table lists some aliases of bath salts.

Sometimes viewed as “legal cocaine,” the over-the-counter status of SCs gives the illusion that they are safe. These substances produce sought-after effects (eg, euphoria, elevated mood, increased alertness, aphrodisiac). The most common method of ingestion is injection, followed by snorting and oral ingestion, but they are also taken rectally. Typical dosages range from 3 mg to 20 mg, with peak absorption within 1.5 hours.2 Effects can last for 3 to 4 hours, followed by a crash period of 2 to 4 hours. With mephedrone, effects may last over 24 hours.3

Common physical signs of use and intoxication include
•Tachycardia
•Hypertension
•Hyperthermia
•Diaphoresis
•Seizures
•Tremors
•Motor automatisms
•Mydriasis
•Paranoia
•Irritability
•Anxiety
•Psychosis

Bath salt use can mimic other medical problems when it results in seizures, hyperthermia, or cardiovascular issues. Concurrent use of serotonergic drugs and SCs may increase the risk of serotonergic syndrome. Kidney damage from rhabdomyolysis, ischemia, and hypoperfusion has also been reported.4

An investigation of 35 emergency department patients who used bath salts in Michigan from November 2010 to March 2011 noted diffuse organ system involvement.5 This report found 91% of patients had neurologic involvement, 77% cardiovascular involvement, and 49% psychological involvement. Liver failure developed in one patient 12 days after initial presentation. In addition to reports of hyperthermia and multiorgan failure, deaths have occurred. One death was a result of acute intoxication. Another reported death by suicide was thought to be from the direct psychological effect of MDPV.6

Legal regulation of SCs is difficult because each compound, as opposed to the class, must be individually banned. The Drug Enforcement Agency (DEA), and not the FDA, regulates the products because they are “not intended for consumption.” On October 21, 2011, the DEA exercised its emergency scheduling authority to ban the 3 most common SCs: mephedrone, MDPV, and methylone.

In July 2012, President Barack Obama signed into law a federal ban of 31 synthetic substances, 10 of which were bath salts.7 This law also inhibited the sale of synthetic drugs and placed mephedrone and MDPV on the FDA list of substances that cannot be sold for any reason. As a result of this action, these 3 compounds became Schedule I substances, making possession illegal.

The challenge continues as new synthetic compounds emerge, including alpha-pyrrolidinovalerophenone (alpha-PVP) and pentedrone, among others. Many of these substances are first seen in Europe before they appear in the US.

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