Applied Evidence

How to recognize a patient who’s high on “bath salts”

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Forget about a routine drug screen; it won’t help. Here’s how these patients will present and how best to care for them.




Include cathinone use in the differential diagnosis for any patient exhibiting paranoid psychotic behavior or hallucinatory delirium. C

Keep in mind that cathinone effects can mimic the “excited delirium” attributed to cocaine, methamphetamine, PCP, and Ecstasy. C

Consider using benzodiazepines to control agitation, or low-dose antipsychotics to treat hallucinations. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

A 31-year-old construction worker with a history of intermittent cocaine use was brought to the emergency department (ED) by the police. He was handcuffed and appeared confused and frightened. The patient’s wife had phoned the police after he began running through a field in pursuit of perceived invaders of their home. The wife reported that a few hours earlier, the patient had begun to hallucinate and had become very fearful after getting high.

His heart rate was 126, blood pressure 136/96 mm Hg, and temperature 99.6°F. During the initial exam, the patient became agitated, attempted to assault a nurse, and tried to leave the ED before being subdued. A urine screen for drugs was negative for cocaine. His creatine phosphokinase was 850 U/L, creatinine 2.32 mg/dL, and blood urea nitrogen 27 mg/dL.

The health care team learned that the drug he’d been snorting earlier that day—and the day before—was “bath salts.”

This patient was one of the 30 that we’ve seen at our university hospital over the past year.

Since early 2010, EDs, psychiatric facilities, and poison control centers have seen a surge in the number of patients abusing novel synthetic stimulants—cathinones—that had once been sold in convenience stores and tobacco shops and often labeled innocuously as “bath salts” or “plant food.” Sales have largely gone underground, sold by those trafficking in methamphetamine and cocaine. These products are also available for online purchase and may be sold under such provocative names as “Cloud Nine” or “Rave.”1 In 2010, poison control centers received 304 calls related to the use of these substances; in 2011, the number was 6138.2

Cathinone: An emerging recreational drug

For centuries the peoples of East Africa and the Arabian Peninsula have used the leaves of the indigenous khat plant (Catha edulis) for its amphetamine-like properties.3 Its active ingredient, cathinone, is a central nervous system stimulant that inhibits dopamine reuptake.4 In 2005, extracts from the plant were imported to Israel as “Hagigat” and promoted as a stimulant or aphrodisiac. These products were banned by the Israeli government in 2008 following documented cases of cardiovascular and neurologic sequelae.5

The growing problem of synthetic cathinone analogs in the United States. In 2008, synthetic analogs of cathinone were first identified in an analysis of drugs seized in the United States from individuals suffering psychological reactions to their use.1 Two such substances, 4-methylmethcathinone (mephedrone) and 3,4-methylenedioxypyrovalerone (MDPV), have since circulated worldwide, publicized by information on the Internet. Although the packets sold as “bath salts” clearly state that the contents are not for human consumption, Web sites promote the chemicals as “legal highs.”6

While these substances were being banned in many Western European countries, their use rapidly increased throughout the United States and elsewhere, often as an alternative to cocaine. Increases in the number of reports to poison control centers throughout the United States provide evidence of the increasing use of these drugs, despite legislation outlawing possession and sale in many states.7 In September 2011, the US Drug Enforcement Agency, using its emergency scheduling authority, made possession and sale of MDPV and mephedrone illegal throughout the United States.8

Who’s using bath salts? A review of calls to 2 poison control centers involving 236 patients over a 7-month period ending in February 2011 suggests that users of cathinones are primarily male (78%) and young (modal age 26).7 Many users of cathinones do not regularly use other drugs recreationally, and they believe the open sale of these substances implies low risk.7 However, one reported series from a hospital in Michigan indicated that 69% of users presenting to the ED had acknowledged past use of illicit drugs.9

What the drugs look like. Mephedrone and MDPV are supplied as white powders packaged in small packets of 500 mg and sell for about $25. Most users take the drug by nasal insufflation, although there is an alarming trend toward intravenous use.7 The intended effects in using these stimulants are improved attention and energy, as well as euphoria. Doses of about 25 mg produce these effects in most individuals and last for 2 to 3 hours, leading some users to compulsively re-dose to maintain the effects.

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