Synthetic Cathinones: Signs, Symptoms, and Treatment

What 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.

Although not revealed via routine drug screens, SCs are detectable by mass spectroscopy. This lab test should be obtained on patients with symptoms of ingestion, as well as chemistry panels to test for renal function and liver function. Because of the cardiac effects and the propensity to cause a myocardial infarction, an ECG should also be obtained.⁵

Treatment of cathinone use is symptomatic. The mainstay of acute intoxication treatment is benzodiazepines. The administration of lorazepam allows for a more careful titration of dose based on symptoms compared with a longer acting benzodiazepine. Psychotic symptoms can persist after autonomic symptoms have abated and may necessitate antipsychotic medication and psychiatric hospitalization. Antipsychotics may lower the seizure threshold. Psychosis usually resolves within 4 days, but there are reports of psychosis lasting for weeks.⁸

There have been several reports of violence and suicide after SC ingestion.^6,9 All individuals with known or suspected SC use should have thorough violence and suicide risk assessments. When evaluating for violence risk, physicians should look for the presence of delusions, specifically persecutory delusions. A history of violence and of mental illness increases the risk of violence in an intoxicated individual.

The suicide risk assessment should focus not only on thoughts of the patient but also on intent. Attention should be placed on actions taken during the time of intoxication. One should not assume that suicide risk is completely tied to SC intoxication; risk should also be assessed outside of intoxication. Once brought to the attention of the healthcare provider, the intoxicated individual should be monitored until no longer symptomatic, even if this requires hospitalization.

Conclusion
SCs are marketed under several different names and product classes. Symptoms of intoxication mimic those of cocaine and amphetamines. Intoxication can involve most organ systems. Some symptoms of use are serious, and death has been reported. Treatment is symptomatic and should include suicide and violence risk assessments. The 3 most common compounds have been made illegal-but new synthetic compounds are already appearing and are likely to come to light for the psychiatric practitioner.

Table. Bath salt aliases^1,10

MDPV

Mephedrone

Methylone

Naphyrone

Wildcat

Ivory Coast
Ivory Wave
Magic PV
PeeVee Purple Wave
Super Coke
Vanilla Sky

Blow
Bubbles
MCAT
Meow Meow
Meph
Plant Feeder
Poor Man’s Meth
White Magic

Snow

Energy1
NRG-1
O-2482