Applied Evidence

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

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Use of bath salts leads to paranoid delusions, violent behavior

Both mephedrone and MDPV are strong inhibitors of dopamine reuptake in areas of the brain regulating reward and motivation.10,11 With prolonged exposure, the resultant stimulant effect of dopamine in reward centers of the brain moves a user from recreational pleasure seeking to addictive use just to maintain normal function.12 This transition occurs in a matter of days or weeks in some individuals, and we have seen multiple readmissions for paranoid psychotic reactions shortly after discharge from hospitalization.

Multiple serious complications of use have been described. The mainstream media have reported bizarre suicides and some homicides.13,14 Our clinic has reported on a unique hallucinatory delirium after use of MDPV, resulting in paranoid delusions and violent behavior in response to vivid hallucinations.15 Other patients suffer prolonged anxiety and panic reactions or depressive symptoms with suicidal ideation.16

Cardiovascular and other sequelae
About half of patients presenting to hospital EDs have cardiovascular complications such as tachycardia, chest pain, and hypertension from the sympathomimetic effects of these agents.9,16 There have also been reports of rhabdomyolysis and renal failure requiring intensive medical treatment.7,9,16

Taken together, mental status changes and physiologic reactions are similar to the “excited delirium” attributed to cocaine, methamphetamine, phencyclidine (PCP), and methylenedioxymethamphetamine (Ecstasy), all drugs that act on central monoamines.1720 There have also been reports of death after the use of these drugs.21

Cathinones do not show up on routine drug screens
A routine urine screen for synthetic cathinones is not available, although a specific test arranged through commercial laboratories is available for cases when use is suspected. According to a written communication from A. Macher, MD, in 2011 (manuscript in preparation), urine drug screens for PCP using the immunoassay method may yield a false-positive result in the presence of MDPV. Simply asking patients whether they’ve been using these products often elicits an honest answer.

Treatment is largely supportive

Management guidance based on clinical trials is lacking. Cardiovascular complications require usual treatment.9,16 Serious psychiatric reactions may necessitate hospitalization to assure patient safety, particularly with evidence suggesting the potential to act on paranoid delusions or suicidal ideation. Benzodiazepines may be needed to control agitation, and low-dose antipsychotics, such as risperidone 1 mg, can aid in treating hallucinations.9,15

The hallucinatory psychosis seen with these substances is best characterized as a toxic delirium.15 Aggressive use of antipsychotic agents is not advised, given the risk of treatment-related morbidity in patients with a history of repeated stimulant use.22 Many patients presenting with acute delirium may require restraints. These procedures should be used with caution to minimize muscle tissue damage; patients should be monitored frequently for hyperthermia, dehydration, and rhabdomyolysis.16

Nothing is known about the long-term effects of these drugs, although substances with similar actions are associated with long-term cognitive and memory deficits after repeated use.4

CORRESPONDENCE Thomas M. Penders, MD, LFAPA, Department of Psychiatry, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834;

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