II. Mechanism
- Synthetic designer drug (Illicit Drug)
- Methylenedioxypyrovalerone (MDPV) is most common active ingredient in Psychoactive Bath Salts
- Analog to key psychoactive component in Khat Plant (Catha edulis) extract, a phenylethylamine
- Khat leaves are chewed by users in Middle East, South Asia and East Africa for their stimulant effects
- MDPV is related to pyrovalerone and alpha-pyrrolidinophenones
- MDPV (3,4-Methylenedioxypyrovalerone) has strong adrenergic effects similar to Cocaine (but 10 fold potency)
- Inhibits Norepinephrine, Serotonin and Dopamine reuptake, resulting in increased neurotransmitter levels
- Results in Sympathomimetic and Hallucinogenic effects
- Earliest agents (Methylone, Mephedrone) were Monoamine Oxidase Inhibitors
- CNS stimulant with same active core component (phenethylamine pharmacore) as Amphetamines and MDMA
- Synthetic Cathinones contain Ketone moiety (carbonyl group) that differentiates them from Amphetamines
- Mescaline (Peyote Cactus extract) is also a Substituted Phenylethylamine
- Bupropion is similar in structure as phenylethylamine derivatives and MDPV
- Bupropion has been abused via insufflation and injection
- Bupropion abuse may result in Seizures, QTc Prolongation, and difficult to treat Arrhythmias
- Appear to have worst characteristics of LSD, PCP, MDMA, Cocaine and Methamphetamine
- CNS effects are 10 fold greater with MDPV than with Cocaine
- Introduced in 2007 (Russia and UK) and appeared in U.S. by 2011
- Routes
- Intranasal
- Orally (salts dissolved in liquid)
- Addictive potential
- Tolerance, withdrawal and craving with long term use
- Mephedrone may have highest risk of dependence (related to Dopaminergic effects)
- Marketing claims
- Typically labeled as "not for human consumption" as bath salts or plant food
- Stimulant (cheap substitute for other stimulants)
- Alertness enhancer
- Aphrodesiac
- Street Names
- Ivory Wave
- Vanilla Sky
- White Lightning
- Scarface
- Energy-1
- Plant Fertilizer or plant food
- Legal Cocaine
- Jewelry cleaner
- Lunar Waves
- Bloom
- Cloud Nine
- Flakka
- Meow Meow
- Formulations (>30 different chemical compounds, and at least 6 new agents introduced in 2019 alone)
- Sold as white or brown powder in pill or capsule at $20-35 per gram
- Earliest Synthetic Cathinones (Methylone, Mephedrone and MDPV) are banned in U.S.
- Alpha-Pyrrolidinopentiophenone (Alpha-PVP, Flakka, gravel) appeared on market in 2015
- Eutylone (bk-EBDB) and N-ethylpentylone, released in 2014 and more commonly found agents in 2021
- Delivery
- Has been used intranasally, orally, IV/IM and PR, but typically not smoked due to lability
- Have been dissolved in beverages or vaporized
- Bombing (Swallowing powder wrapped in Cigarette paper)
- Keying (nasal insufflation of powder from key surface)
III. Pharmacokinetics
- Lowest effective dose: 3-5 mg intranasally, per-Rectum or intravenous
- Average dose 5-20 mg
- Onset and duration
- Insufflation effect onset at 10-20 minutes (duration 1-2 hours)
- Oral effect onset at 15-45 minutes (peaks at 1.5 hours, duration 2-4 hours)
- Intravenous effect onset at 10-15 minutes (duration 30 minutes)
- Course
- Agent wears off with "harsh crash"
- Entire course from intake may last 8 hours
IV. Symptoms: Desired Effects
- Increased energy
- Increased Libido
- Euphoria
V. Adverse Effects: Excited Delirium
- Sympathetic stimulation
- Tachycardia
- Hypertension
- Hyperthermia
- Seizures
- Arrhythmias
- Vasoconstriction
- Mydriasis
- Diaphoresis
- Palpitations
- Neuropsychiatric effects (including Altered Level of Consciousness, Agitated Delirium, acute Psychosis)
- Anxiety
- Severe Panic Attack
- Agitation (66% of patients)
- Paranoia
- Hallucinations
- Acute Psychosis (paranoia, auditory and Visual Hallucinations)
- Violent Behavior or aggressive behavior
- Self-destructive behavior or self-mutilation
- Insomnia
- Anorexia
- Depressed mood
- Miscellaneous effects
VI. Labs
- Obtain labs per Unknown Ingestion evaluation
- Creatinine Kinase (for Rhabdomyolysis)
- No current lab tests detect Psychoactive Bath Salts
- Bath salts (as with Ketamine) may cause a False Positive for Phencyclidine (PCP) on Urine Drug Screening
VII. Diagnostics
-
Electrocardiogram (EKG)
- QTc Prolongation may occur (esp. with abused Bupropion)
- QRS Widening (suggests mixed ingestion)
VIII. Precautions
- Addictive
- Deaths have occurred
- Polysubstance Overdose with bath salts may occur
- Coingestion occurs in 94% of cases (often with Cocaine)
- May confuse the presentation
- Contaminated products have resulted in severe adverse effects
- Methcathinone contamination with manganese (2008, Europe) resulted in refractory Parkinsonism
IX. Management
- See Unknown Ingestion
- See Agitated Delirium
- ICU monitoring
-
Intravenous Fluids
- Prevent Rhabdomyolysis
-
Evaporative Cooling measures
- Indicated for hyperthermia
-
Physical Restraints may be needed for initial management
- However rapidly institute Agitated Delirium management
- Avoid prolonged Physical Restraints (see Agitated Delirium) and requires 1:1 observation
-
Benzodiazepines IV indications
- Sedation for Agitation, Psychosis
- Seizure managament
- Hypertension or Tachycardia
-
Seizures
- First-Line: Benzodiazepines
- Avoid Sodium channel blocking agents (e.g. Phenytoin), but other antiepileptic agents may be used
-
Atypical Antipsychotics
- Start with liberal use of Benzodiazepines
- Antipsychotics may be used as second line agents, but avoid in QTc Prolongation or QRS Widening
- Supportive care
- Manage hemodynamic instability
-
Electrocardiogram abnormalities
- QRS Widening
- Sodium Bicarbonate ampules until QRS narrows again
- QTc Prolongation
- Magnesium 2 g IV
- QRS Widening
- Precautions
- Avoid Beta Blockers (risk of unopposed Alpha Adrenergic Receptor stimulation)
- Disposition
- Minor Intoxication without serious findings and Clinical Sobriety may be reasonable for discharge
- However, effects vary widely and with potential for serious complications
- Consider hospital observation or admission for significant Intoxication
X. Complications
- Overdose is a significant risk with packages containing as much as 500 mg
- Cerebrovascular Accident
- Hyponatremia (and cerebral edema) due to water Intoxication and Vasopressin release
- Respiratory distress
- Rhabdomyolysis (higher risk than other stimulants)
- Serotonin Syndrome (examine for Clonus)
- Acute Psychosis
- Acute Kidney Injury
- Arrhythmias, Myocardial Infarction or cardiovascular collapse
- Hyperthermia (>104.9 F or 40.5 C is associated with 50% mortality)
- Deaths have been reported
XI. Resources
- U.S. DEA Site
XII. References
- Haynes, Meadors and Yuan (2016) Crit Dec Emerg Med 30(2): 3-9
- Rosenbaum (2012) J Med Toxicol 8(1): 15–32
- Trautmann (2021) Crit Dec Emerg Med 35(3): 15-20
- Baumann (2013) Neuropsychopharmacology 38(4): 552-62 [PubMed]
- Klega (2018) Am Fam Physician 98(2): 85-92 [PubMed]
- Khullar (2014) J Gen Intern Med 29(8):1200-4 +PMID:24553958 [PubMed]
- Ross (2011) N Engl J Med 365(10): 967-8 [PubMed]
