II. Mechanism

  1. Synthetic designer drug (Illicit Drug)
  2. Methylenedioxypyrovalerone (MDPV) is most common active ingredient in Psychoactive Bath Salts
    1. Analog to key psychoactive component in Khat Plant (Catha edulis) extract, a phenylethylamine
    2. Khat leaves are chewed by users in Middle East, South Asia and Africa for their stimulant effects
  3. MDPV is related to pyrovalerone and alpha-pyrrolidinophenones
    1. Inhibits Norepinephrine, Serotonin and Dopamine reuptake, resulting in increased neurotransmitter levels
      1. Results in Sympathomimetic and Hallucinogenic effects
    2. CNS stimulant with same active core component (phenethylamine pharmacore) as Amphetamines and MDMA
    3. Appear to have worst characteristics of LSD, PCP, MDMA, Cocaine and Methamphetamine
    4. CNS effects are 10 fold greater than with Cocaine
    5. Introduced in 2007 (Russia and UK) and appeared in U.S. by 2011
  4. Routes
    1. Intranasal
    2. Orally (salts dissolved in liquid)
  5. Addictive potential
    1. Tolerance, withdrawal and craving with long term use
    2. Mephedrone may have highest risk of dependence (related to Dopaminergic effects)
  6. Marketing claims
    1. Typically labeled as "not for human consumption"
    2. Stimulant (cheap substitute for other stimulants)
    3. Alertness enhancer
    4. Aphrodesiac
  7. Street Names
    1. Ivory Wave
    2. Vanilla Sky
    3. White Lightning
    4. Scarface
    5. Energy-1
    6. Plant Fertilizer or plant food
    7. Legal Cocaine
    8. Jewelry cleaner
    9. Lunar Waves
    10. Bloom
    11. Cloud Nine
    12. Flakka
  8. Formulations (>30 different chemical compounds)
    1. Methylone, Mephedrone and MDPV are banned in U.S.
    2. Alpha-Pyrrolidinopentiophenone (Alpha-PVP, Flakka, gravel) appeared on market in 2015
    3. Sold as white or brown powder in pill or capsule at $20-35 per gram
  9. Delivery
    1. Has been used intranasally, orally, IV/IM and PR, but typically not smoked due to lability
    2. Have been dissolved in beverages or vaporized
    3. Bombing (swallowing powder wrapped in Cigarette paper)
    4. Keying (nasal insufflation of powder from key surface)

III. Pharmacokinetics

  1. Lowest effective dose: 3-5 mg intranasally, per-Rectum or intravenous
  2. Average dose 5-20 mg
  3. Onset and duration
    1. Insufflation effect onset at 10-20 minutes (duration 1-2 hours)
    2. Oral effect onset at 15-45 minutes (peaks at 1.5 hours, duration 2-4 hours)
    3. Intravenous effect onset at 10-15 minutes (duration 30 minutes)
  4. Course
    1. Agent wears off with "harsh crash"
    2. Entire course from intake may last 8 hours

IV. Symptoms: Desired Effects

  1. Increased energy
  2. Increased Libido
  3. Euphoria

V. Adverse Effects: Excited Delirium

  1. Sympathetic stimulation
    1. Tachycardia
    2. Hypertension
    3. Hyperthermia
    4. Seizures
    5. Arrhythmias
    6. Vasoconstriction
    7. Mydriasis
    8. Diaphoresis
    9. Palpitations
  2. Neuropsychiatric effects (including Altered Level of Consciousness, Agitated Delirium, acute Psychosis)
    1. Anxiety
    2. Severe Panic Attack
    3. Agitation (66% of patients)
    4. Paranoia
    5. Hallucinations
    6. Acute Psychosis (paranoia, auditory and Visual Hallucinations)
    7. Violent Behavior or aggressive behavior
    8. Self-destructive behavior or self-mutilation
    9. Insomnia
    10. Anorexia
    11. Depressed mood
  3. Miscellaneous effects
    1. Headache
    2. Nausea or Vomiting

VI. Labs

  1. No current lab tests detect Psychoactive Bath Salts
  2. Bath salts (as with Ketamine) may cause a False Positive for Phencyclidine (PCP) on Urine Drug Screening

VII. Precautions

  1. Addictive
  2. Deaths have occurred
  3. Polysubstance Overdose with bath salts may occur
    1. Coingestion occurs in 94% of cases (often with Cocaine)
    2. May confuse the presentation

VIII. Management

  1. See Agitated Delirium
  2. ICU monitoring
  3. Intravenous Fluids
    1. Prevent Rhabdomyolysis
  4. Cooling measures
    1. Indicated for hyperthermia
  5. Physical Restraints may be needed for initial management
    1. Avoid prolonged use (see Agitated Delirium) and requires 1:1 observation
  6. Benzodiazepines IV indications
    1. Sedation for Agitation, Psychosis
    2. Seizure managament
    3. Hypertension or Tachycardia
  7. Supportive care
  8. Precautions
    1. Avoid Beta Blockers (risk of unopposed Alpha Adrenergic Receptor stimulation)

IX. Complications

  1. Overdose is a significant risk with packages containing as much as 500 mg
  2. Cerebrovascular Accident
  3. Hyponatremia (and cerebral edema) due to water Intoxication and Vasopressin release
  4. Respiratory distress
  5. Rhabdomyolysis (higher risk than other stimulants)
  6. Acute Kidney Injury
  7. Arrhythmias, Myocardial Infarction or cardiovascular collapse
  8. Hyperthermia (>104.9 F or 40.5 C is associated with 50% mortality)
  9. Deaths have been reported

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