Bath Salts (Review)

Bath Salts Hit Bangor, or why you should care about 3,4-methylenedioxypyrovalerone (MDPV) and 4-methylmethcathinone (mephedrone)

Published June 30, 2011 | By Dr. Busko

The really important points:

Introduction: Two canthinone analog stimulants, 3,4-methylenedioxypyrovalerone (MDPV) and 4-methylmethcathinone (mephedrone) began appearing in the United States at the end of the first decade of 2000. Imported as “Bath Salts” or “Plant Food” and labeled “Not For Human Consumption,” these stimulants have recently become prevalent in Maine, particularly in Bangor and the Lewiston-Auburn area. This has resulted in a maor upswing in EMS calls and Emergency Department visits as well as crimes associated with the use of stimulants including, allegedly, a homicide.

Medical Implications: Mephedrone probably acts as a general monoamine releaser / reuptake inhibitor and MDPV probably acts as a specific norepinephrine-dopamine reuptake inhibitor. These stimulants are associated with psychosis, erratic behavior, hallucinations, and violent behaviors. Physical findings can include hypertension, tachycardia, headaches, peripheral vasoconstriction, diaphoresis, and hyperthermia. Altogether these signs and symptoms are consistent with a syndrome called “excited” or “agitated” delirium.

EMS Treatment: The goal is to control the patient as quickly as possible. Try to avoid prolonged physical excitation as much as possible and instead focus on rapidly controlling the patient physically followed by immediate chemical restraint with a benzodiazepine. Work closely with law enforcement and medical control.

The complicated points:

Bath Salts and Plant Food: Come on, really?

People are always looking for new ways to get high. Generally speaking, drugs can be considered stimulants or depressants. Although the psychological effects may be different based on the individual or the context in which they are used, the physiological effects are what determine whether a drug is a stimulant (revs your metabolism up) or a depressant (slows your metabolism down).

In the past few years, two synthetic drugs have become increasing popular in the United States, 3,4-methylenedioxypyrovalerone (MDPV) and 4-methylmethcathinone (mephedrone). Mephedorne was first synthesized in 1929 but was lost to everyone except the academics until 2003 when it was reintroduced in the designer drug circles. MDPV was first synthesized in 1969 along with other drugs for chronic fatigue and appetite suppression. It never got FDA approval and fell out of general knowledge until 2004 when it was reintroduced as a designer drug. Both drugs are analogs of cathinone, the active agent in khat, an organic stimulant found in East Africa.

These and similar drugs were popular in the UK, Israel, Europe, Australia, and New Zealand but over time became illegal. In 2008 the US Department of Justice chemists were given a substance sample to analyze seized from an intoxicated individual. This ended up being MDPV. Since then, there has been increasing use of these drugs in the US. A CDC report in early 2011 discussed a case series of “bath salts” abuse from Michigan and the popular media began reporting the use of these drugs. In Maine, Bangor has become the most impacted area, with the Lewiston-Auburn area also being impacted. As of mid-June, three had been no significant report of use in Portland.

In other countries, these drugs were sold as exactly what they were (and by their street names) until they were made illegal. So why are the sold as “Bath Salts” and “Plant Food” in the US? The Federal Analog Act, part of the Comprehensive Drug Abuse Prevention and Control Act of 1970, makes it illegal to produce, possesses, consume and sell substances considered “analogs” of banned drugs to prevent chemists from making small modifications to banned drugs to produce “legal” drugs. However, the Federal Analog Act only applies if the substances are intended for “human consumption.” Therefore, although mephedrone and MDPV will neither make a plant grow better or make your bath more bubbly, labeling them as “bath salts” or “plant food” sidesteps the Federal Analog Act, which is why each state must individually make the drugs illegal if they wish to ban their use.

So what do these drugs do? Both are stimulants that probably increase the levels of the excitatory monoamine neurotransmitters although the exact mechanism is unknown. The intended effects of these drugs include euphoria, stimulation (mental, physical, and sexual), elevated mood, decreased hostility, and improved mental acuity.

There are also a number of unintended physical and psychiatric effects. These include tachycardia, hypertension, psychosis, hallucinations, erratic behavior, difficulty breathing, paranoia, depression, headaches, agitation, peripheral vasoconstriction, adrenergic effects, palpitations, hyperthermia, skin flushing and a sense of being “on fire.” The mechanisms of these effects are also unclear but are probably related to increased levels of the excitatory monoamine neurotransmitters throughout the body.

These drugs have been used in large numbers in other countries for years. While there are some reports of adverse effects, there are not reports of the very high levels of major side effects requiring emergency department evaluation that are being seen in the Bangor area. Why, then are we seeing so many of these patients? While the real reason may never be known, there are a number of possible causes. First, there may be so many users in Bangor that statistically we are right where we should be in ED visits, although that would suggest that almost half of the population of the greater Bangor area is using these drugs. Another possible explanation is that, because Mainers typically abuse sedative drugs such as opiates and benzodiazepines, they are relatively naive to the effects of stimulants and so are coming to the emergency department for “normal” unintended effects. Yet another possibility is that the versions of these drugs in Bangor are contaminated, more potent, or cut with other drugs. Regardless of the cause, however, users are presenting to local emergency departments in high numbers with toxicity from mephedrone and MDPV.

What are the major negative effects we are seeing? The most significant are the issues with altered mental status, whether it’s the unresponsive patient or the psychotic patient. These patients are dangerous to themselves and providers because they are not aware of their actions and environment. The problem with the psychosis in particular is that it can be persistent for days; there is a case report of a patient with psychosis from bath salts who was intubated, sedated, and ventilated for 12 days and when the patient was awakened, the psychosis continued. Again, these cases are unusual but represent a real danger to patients and providers.

These patients, at their worst, are experiencing the syndrome known as “agitated delirium” or “excited delirium” (with apologies to those whose legal systems don’t allow you to use the term “agitated delirium”). The delirium is defined by the acute changes in mental status with confusion and abnormal behavior. The excited or agitated behavior is the positive or stimulated state. Typical findings in agitated delirium include confusion, violence, lack of response to pain, violent and lashing out behaviors associated with the physiologic changes of hyperthermia, tachycardia, sweating, and hypertension. These patients have an acute medical emergency and require immediate sedation and stabilization.

The treatment of these patients starts with making the environment safe to prevent self injury or injury of others. The ultimate goal is chemical restraint with benzodiazipines (e.g. Versed®). However, to administer those drugs these patients will need to by physically controlled. If you have been appropriately trained and have sufficient numbers of individuals to perform a restraint, do so. However, as much as possible, you need to involve law enforcement to assist in physical control, particularly if you are not trained to do these restraints. Use of an electrical immobilization device (i.e. Taser ®) or physical control devices may facilitate safe and rapid physical control. Keep in mind that physical restraint alone is not adequate, so you must plan to perform immediate intramuscular chemical restraint. In Maine, this will be achieved with IM Versed ®. Contact medical control as these patients may require multiple and large doses of benzodiazipines.

In summary, although mephedrone and MDPV have been available on the designer drug market since 2003 and 2004 respectively, they are becoming more common in the US over the last few years and are much more common in the greater Bangor area in the last 6 months. These drugs are stimulants and users expect an experience of euphoria, stimulation, positive well-being, and sharpened mental acuity. Unfortunately, these users may also experience psychosis, depression, obtundation, hyperthermia, tachycardia, hypertension, coma, seizures, agitated delirium, and other adverse effects. Management focuses on making the patient safe, rapidly controlling the patient’s behavior, sedating the patient, and rapidly transferring the patient to definitive care. Make sure that you protect your own safety as well. And don’t take baths from someone you don’t know.

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