Bath Salts Use Rising
Bath Salts: The New Synthetic Drug
Bath salts are presenting an increased public health risk in the United States, as toxicity and mortality reports are rising, along with calls to poison control centers. Packages with whimsical-sounding labels such as White Ice, Ivory Wave, Ocean Snow, and Vanilla Sky look to hide the dangerous substances within, which are not really meant to be used as bath products.1 In fact, the contents are a white/tan crystalline powder, commonly administered by snorting or oral ingestion, although reports of rectal suppositories and intramuscular or intravenous injections have also been reported. The powder, contains either mephedrone or MDPV, which are both derivatives of cathinone, a compound isolated from the East African plant Catha edulis and are structurally similar to amphetamines.1 Common names for Mephedrone are plant food, MCAT, 4-MMC, meow meow, meph, and drone, while MDPV is commonly referred to as MTV, MDPK, magic, and super coke.1 A movement to ban these substances is growing in the United States and Europe; however, emergency physicians now need to be knowledgeable about bath salt use and how to treat its toxicity.1
Effects of Bath Salts
Studies have shown that both mephedrone and MDPV possess stimulant properties. Users of the substances report that they experienced a euphoric high that lasted between two and four hours, followed by a downer effect lasting several hours after.1 Doses range from 5 to 10 mg for MDPV and 100 to 500 mg for mephedrone., Other effects felt after taking the drugs: empathic mood, sexual stimulation, greater mental focus, and increased energy.2 A study of 1,506 past mephedrone users revealed that the drug the participants most closely related mephedrone to was ecstasy.1
There have also been significant complications reported due to use of bath salts, such as seizure activity, severe agitation, myocarditis, chest pain, and even death. A 36-year-old male in the Netherlands became agitated and enraged after taking both bath salts and cocaine, when he lost consciousness and died. A 29-year-old male in the United States was found dead at a nightclub, and toxicology screening showed mephedrone and no other substance in his bloodstream.6
Use of bath salts continues to increase in the United States.1 Nationally, 302 calls regarding bath salt toxicity were made to poison control centers in 2012; however, by October 2011, the number had risen to 5,226. These calls represent only a percentage of bath salt users. Therefore, on September 7, 2011, the US Drug Enforcement Agency (DEA) stated that they would exercise their emergency scheduling authority and temporarily labeled MDPV and mephedrone as schedule I substances for 12 months. At that time, 33 states also took independent measures to control the use of bath salts.8 However, some believe that scheduling bath salts would have little effect on the control of the substances, as the shift from legal to illegal could result in increased risk of users due to illegal manufacturing and reliance on street dealers. As they stated, bath salt use continues to rise.1
Treating Bath Salts Intoxication is Difficult
While making specific recommendations to emergency physicians regarding the treatment of patients under the influence of bath salts can be difficult, there are certain steps that can be taken to assure toxicity is under control.1 A specific antidote for bath salts does not exist and few laboratories even have the ability to screen urine for the substances, never mind the screenings meeting emergency department timelines.1 Also, while the typical symptoms of bath salt toxicity are altered mentation, agitation, tachycardia, hypertension, and hyperthermia, as well as others, these symptoms are common of other disease states also, making it difficult to diagnose.1 Serotonin syndrome, neuroleptic malignant syndrome, anticholinergic and sympathomimetic toxidromes, drug withdrawal syndrome, and exposure to older hallucinogens all share the same symptoms as bath salt toxicity.1
Treatment of bath salt toxicity is limited; therefore, monitoring and therapeutic interventions are more widely used.1 As starting points, peripheral intravenous access and cardiac monitoring are important, as well as obtaining full vital signs including temperature, repeating every 30 minutes until stable.1 Electrocardiograms and chest radiographs should be taken if the patient shows signs of tachycardia, chest pain, or shortness of breath.1 While specific cardiac markers in the evaluation of patients under the influence of bath salts have not been clarified, monitoring for cardiac damage is important.1 A basic metabolic panel should be taken for all patients in order to check for hyponatremia and metabolic acidosis.1 Also, a complete blood count should be completed. For patients showing signs of agitation, benzodiazepines may be administered as a first-line therapy.1 Fluid-management and temperature control may also aid in controlling such. Seizures should be treated with benzodiazepines, barbiturates, and/or propofol.1 For those evolving to epilepticus status, advanced airway management should be used.1
While there is limited information about bath salts, its growing popularity has led to case reports, media releases, and poison control center data that is helping to build upon the literature. This will be especially helpful to emergency department physicians as the number of individuals experiencing toxicity is growing and treatments and interventions are limited.
 Olives, T.D.; Orozco, B.S.; and Stellpflug, S.J. (2012, February). Bath Salts: The Ivory Wave of Trouble. Western Journal of Emergency Medicine 13(1): 58-62.
 Schifano F, Albanese A, Fergus S, et al. Mephedrone (4-methylmethcathinone; ‘meow meow’): chemical, pharmacological and clinical issues. Psychopharmacology (Berl) 2011;214:593–602.
 Drugnet Europe. Mephedrone ban across the EU: news from the European Monitoring Centre for Drugs and Drug Addiction, January–March 2011. European Monitoring Centre for Drugs and Drug Addiction Web site. Available at: http://www.emcdda.europa.eu/publications/drugnet/online/2011/73/article2. Accessed 1 June 2012.
 Erowid. MDPV effects. Available at: http://www.erowid.org/chemicals/mdpv/mdpv_effects.shtml. Accessed June 1, 2012.
 Erowid. 4-Methylmethcathinone (mephedrone, 4-MMC) the basics. Available at: http://www.erowid.org/chemicals/4_methylmethcathinone/4_methylmethcathinone_basics.shtml. Accessed June 1, 2012.
 Wood DM, Davies S, Greene SL, et al. Case series of individuals with analytically confirmed acute mephedrone toxicity. Clin Toxicol (Phila) 2010;48:924–927.
 Lusthof KJ, Oosting R, Maes A, et al. A case of extreme agitation and death after the use of mephedrone in The Netherlands. Forensic Sci Int. 2011;206:e93–e95.
 Wehrman J. U.S. poison centers raise alarm about toxic substance marketed as bath salts; states begin taking action. American Association of Poison Control Centers Web site; Available at: http://www.aapcc.org/dnn/Portals/0/prrel/april20bathsalts.pdf. Accessed June 1, 2012.
 United States Drug Enforcement Administration. DEA moves to emergency control synthetic stimulants [press release] Available at: http://www.justice.gov/dea/pubs/pressrel/pr090711.html. Accessed June 1, 2012.
 McElrath K, O’Niell C. Experiences with mephedrone pre- and post-legislative controls: perceptions of safety and sources of supply. Int J Drug Policy. 2011;22:120–127. Bath Salts.