Bath Salts: stronger than dirt

A new "Ivory Wave" of synthetic drugs

PumpIt!, Ivory Wave, and Bath Salts are just a few of the label names of synthetic drugs that are causing intoxication similar to Ecstasy and methamphetamine. These synthetics are often sold in convenience stores, on line, and in your neighborhood may also be labeled as an enhanced plant food...some printed with the warning "not for human consumption". Few, it seems, are heeding that warning as the Centers for Disease Control (CDC) and National Institute of Health (NIH) are calling attention to the growing numbers of emergency department visits, hospital intensive care admissions, and deaths linked to use of Bath Salts. As a example to their popularity, YouTube hosts hundreds of videos on this topic.

Not unlike other drugs, these materials are being swallowed, snorted, smoked, injected or otherwise consumed by a growing population that crosses age, economic, and social barriers. 

From K2Incenseonline.com

What's in this stuff? 

Common chemical ingredients include:

• Cathinone - a monoamine alkaloid that is similar to ephedrine and amphetamine. Cathinone  has toxic side effects of anorexia, anxiety, irritability, insomnia, hallucinations and panic attacks. This chemical is also known as Khat and is found in plant food.
• Mephedrone  - a substance known to produce methamphetamine-like reactions in rats.

Patient presentation

Bath Salts, PumpIt! and similar drugs have been compared to a combination of Ecstacy, cocaine and methamphetamine.  According to both CDC and NIH consumption of these and similar products results in symptoms resembling stimulant overdose. Since these drugs often lack an immediate effect, users  frequently increase their intake resulting in overdose situations with neurological and cardiovascular dysfunction including acute myocardial infarction (AMI). Rhabdomylysis has also been reported.

The major psychiatric componant associated with these materials is a psychosis that can last for days. psychotic symptoms may include:

• loss of contact with reality
• false beliefs 
• hallucinations/delusions
• disorganized thinking and speech 

Patients testing positive for Bath Salt use often test positive for other substances. Be on the lookout for indications and side effects of polypharmaceutical overdose!

If all that's not good enough, intramuscular injection of Bath Salts is linked to aggressive cellulitis and necrotizing fasciitis or flesh eating soft tissue infections. For more on the link between cellulitis/necrotizing Fasciitis see this report from Z6Mag

Its like methamphetamine, cocaine, and Ecstasy...not exactly. 

Image from Z6Mag

• Like meth, Bath Salts cause a spike in dopamine levels causing users develop a craving quickly.  "Dopamine burnout" is a factor in the abuse potential.
• Like Ecstasy, there is an increase in serotonin. With continued use, an eventual inability to react to serotonin develops and is related to increased use and binging. 
• Like both meth and Ecstasy chronic use increases the risk of personality disorders and AMI

PumpIt! has an added twist. This product contains Methylhexanamine, a chemical created in 1944 as a nasal decongestant/vasoconstrictor. Side effects/toxic effects are similar to caffeine and stimulant overdose and include the discussion above with the added increased risk of hyperpyrexia due to a strong thermogenic properties.

Treatment
Treatment is mainly supportive and based on symptoms. Sedation, benzodiazapine, and anti psychotics may be used (refer to local standards). Because of the risk of polypharmacy use, treatment and recognition may be difficult.

Scope
As reported in Morbidity and Mortality Weekly Report (MMWR), May 2011, and in numerous other publications, the scope and severity of this situation is increasing. According to the MMWR report, in a sampling of 35 patients who reported to a Michagan emergency department had the following findings:

• symptoms similar to stimulant intoxication
• 32 patients had neurological symptoms
• 27 patients had cardiovascular symptoms
• many tested positive for other drugs
• Hospital admits were to the ICU, medical floors, and psychiatry 

Operational Considerations
There is an increased risk of multiple patients becoming intoxicated with these substance when used in groups. There may be risk for multi patient events. Be on the lookout for commonalities in patient complaints and presentations.

Further Information
The following links were helpful:
Centers for Disease Control and Prevention (CDC) www.cdc.gov
Morbidity and Mortality Weekly Report http://www.cdc.gov/mmwr/
National Institute of Health (NIH) http://www.nih.gov/
YouTube > search keywords: Bath Salt, Spice, K2, Ivory Wave, PumpIt! Power Drug