Alarming new stimulant: Bath salts labeled “not for human consumption”

Update 09/21/2011: DEA Moves to Make 'Bath Salts' Illegal as Overdoses Rise

What are these “bath salts”?

The abuse of psychoactive “bath salts” (PABS) has become commonplace, and patients with PABS overdoses are presenting to emergency departments with increasing frequency. The main ingredient of the synthetic designer drugs in these bath salts, which are not related to any hygiene product, is methylenedioxypyrovalerone (MDPV).

What is the clinical presentation?

From the NYTimes: "Doctors could not believe what he was seeing this spring in the emergency room: people arriving so agitated, violent and psychotic that a small army of medical workers was needed to hold them down.

They had taken new stimulant drugs that people are calling “bath salts,” and sometimes even large doses of sedatives failed to quiet them. Director of Poison Center. “If you gave me a list of drugs that I wouldn’t want to touch, this would be at the top.”

Bath salts contain man-made chemicals like mephedrone and methylenedioxypyrovalerone, or MDPV, also known as substituted cathinones. Both drugs are related to khat, an organic stimulant found in Arab and East African countries that is illegal in the United States." These products are easily obtained over the Internet under such names as Ivory Wave or Vanilla Sky.

What to do when evaluating and treating a patient intoxicated with psychoactive “bath salts” (PABS)?

Clinicians need to be aware of several issues (source: NEJM):

- severity and potential lethality from overdoses often require admission to the intensive care unit (ICU)

- routine drug screens do not detect PABS

- PABS can be cut with other psychoactive substances, which can confound the clinical presentation

- patients may need physical restraints and high doses of sedatives to prevent self-harm or harm to others.

Treatment is largely supportive, with IV benzodiazepines (for sedation or to control seizures) and IV fluids, particularly if there is rhabdomyolysis

References:

An Alarming New Stimulant, Sold Legally in Many States. NYTimes.
“Bath Salts” Intoxication. NEJM.
Bath Salt Drug Abuse - INFOGRAPHIC goo.gl/JrI6V

Comments from Google+:

Nancy Onyett, FNP-C: UDS cannot screen for this yet it has severe effects on CV/neuro system acting like cocaine. People are snorting it smoking it, a few cases of injection with death. Also, "Spice" herb is being used in rampant amounts Dominion Labs is who I use for UDS which picks up metabolites of Spice. DEA has it listed as a Class I controlled substance. No listing for bath salts yet but there needs to be. Police have an ampule that can check bath salts vs. cocaine. It is a rapid check on the street. Any physician nurse practitioner working in FP needs to be aware of Spice and bath salts. Unfortunately, there is not a metabolite designated yet to pick up on UDS , soon to be if DEA classifies the drug. Also, for those that don't know

Spice is flavored but looks just like Marijuana. Police have an ampule to differentiate the two on street.

Ian Miller: Interested from an emergency department nurse perspective on how you manage these highly agitated patients (refractory to sedation) that are also potentially very unwell. Do you have a specialized treatment area within the ED, do you just use lots of manpower to restrain?

A very difficult management situation with respect to patient and staff safety.

Joan Justice: Are people doing this "for fun"? What is fun about this? I read today that doctors have to put some of these patients under anesthesia because they cannot restrain or calm them. What a drain on resources, and again, what is the benefit for the user here?