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Riding high on Cloud 9.

INTRODUCTION

Designer drugs are substances that have been modified or altered from parent compounds in order to evade control of the Drug Enforcement Agency. (1, 2) Many of these drugs are intially legal to use and are openly sold with warning labels stating "not for human consumption." (3) Synthetic derivatives of cathinones, a pharmacologically active alkaloid that is extracted from the leaves of the khat plant, namely 3,4-methylenedioxypyrovalerone (MDPV) and mephedrone (4-methylmethcathinone), are among the newest wave of designer drugs. (4) These drugs are frequently referred to as "bath salts."

Mephedrone was first synthesized in 1929 by Saem de Burnaga Sanchez. (5) However, it was not until 2004 in Israel that synthetic cathinones became widely abused. (6) In 2007, bath salts appeared on the market in Europe and arrived on the US market in 2010. (7-9) Bath salts were initially reported to the Louisiana Poison Control Center in September of 2010, and reports rose significantly over the following months. (10) The Louisiana Poison Control Center received 110 phone calls concerning bath salts in December 2010, representing 61% of calls received by all Poison Control Centers in the United States in regards to bath salts. More than 90% of calls were placed by hospital emergency departments.

Many countries have enacted legislation to control synthetic stimulants, as have many states in the United States. On January 6, 2011, Louisiana banned six chemical compounds that are found in designer drugs, including: mephedrone, MDPV, methylone, methedrone, flephedrone, 3-flouromethcathinone (3-FMC). (7) On October 21, 2011, the United States Drug Enforcement Adminstration enacted its emergency scheduling authority to control three synthetic stimulants (mephedrone; 3,4, methylenedioxypyrovalerone; and methylone) for at least one year pending further research. (11) This action makes the unauthorized sale and possession of these substances illegal in the United States.

Synthetic cathinones are commonly sold under pseudonyms, including bath salts, plant food, research chemical, Miaow, Meow Meow, 4-MMC, MMC, (12) Cloud 9, and Ivory Wave (Table 1). (7) Prior to recent legislation, bath salts were sold in head shops, gas stations, and convenience stores. A majority of users surveyed reported snorting the drug; however, individuals also abuse mephedrone and MDPV through oral, intravenous, intramuscular, and rectal routes of administration. (6,8,12-14)

Individuals that have a history of substance abuse report that the effects of bath salts are most simliar to the effects of 3,4 methylenedioxymethamphetamine (MDMA) and cocaine. (12-13) Pleasurable effects reported are euphoria, energy, excessive talking, time-distortion, visual hallucinations, and increased sex drive. (8,12) Negative effects reported include headache, excessive sweating, palpitations, nausea, cold/blue fingers, as well as anxiety and panic. (12,13)

Mephedrone has been linked to multiple deaths around the world, with several case reports from Western Europe. (15-19) Common adverse effects of mephedrone can be divided into cardiac, neurologic, psychologic, and other (Table 2). The objective of this paper is to present data from 10 patients who admitted to acute bath salt use and presented to our inner city hospital emergency department with acute psychosis, which required detention by a physician's emergency certificate (PEC).

METHODS

Retrospective data was collected from 10 cases that were detained in the emergency department by involuntary commitment following psychiatric symptoms after bath salt intoxication. To be included in the paper, patients had to have reported use of bath salts within 24 hours of emergency department admission. Charts were reviewed for demographic, physiological, and psychiatric data.

RESULTS

For a summary of the results, see Table 3. The average age of the patients was 34 years (20-54), with 80% being male. Only 3 of the 10 patients had previous inpatient psychiatric admissions. Agitation (n = 8) and paranoia (n = 7) were the most common presenting symptoms. Other serious manifestations included suicidal ideation (n = 3), visual hallucinations (n = 3), violence (n = 2), anxiety (n = 1), and depression (n = 1). The bath salts were reported to have been snorted, smoked, or used intravenously by this group of patients.

There was a sympathomimetic effect in most of the patients, as reflected in their blood pressures and heart rates. The average presenting pulse was 103 (72-123), with the average discharge pulse being 85.3 (72-98). The average admit blood pressure was 145/80 (125-162/59-103), with the average discharge BP 127/75 (114-156/60-86).

Urine drug screen results were positive in all patients, with opiates or tetrahydrocannabinol (THC; n = 6) being the most common drugs encountered, followed by cocaine (n = 3), benzodiazepines (n = 3), and amphetamines (n = 3). Neither mephedrone nor MDVP were part of our routine urine drug screen.

Ninety percent of the patients were discharged home by a psychiatrist and did not require inpatient psychiatric admission. The length of stay ranged from six hours to four days, with half (n = 5) of the patients being discharged home by a psychiatrist within 24 hours. Only one patient, who had comorbid substance abuse and depression, as well as a significant history of suicide attempts, was sent to an inpatient unit. The most common Axis I discharge diagnosis was Substance Induced Psychosis (n = 7). Other Axis I diagnoses at the time of discharge included Polysubstance Abuse (n = 2), Substance Abuse (n = 1), and Depression (n = 1). Five of the 10 patients had no previous mental health contact.

DISCUSSION

Most of our patients exhibited mild sympathomimetic effects that were short-lived. With the exception of one patient, all tachycardia resolved within several hours. Nine of the 10 patients had an absolute decrease in systolic blood pressure at the time of discharge. In general, the patients in this study initially exhibited significant psychiatric effects of bath salts. The finding of individuals with no previous mental health history is in accord with the findings of Spiller et al., who noted significant psychiatric symptoms following intoxication with bath salts, despite no history of such symptoms in those same patients when they abused other stimulants. (20) The majority of our patients had resolution of their psychosis within 48 hours. Previous case reports note that psychiatric symptoms typically resolve within two to five days, suggesting that symptoms subsided relatively quickly in our group. (21-23)

Another interesting finding in our cases is that the average age was 34. Previous European studies have described mephedrone use as a "youth phenomenon, in particular of 15-24 years old," and research on the drug in Europe has primarily targeted schools, colleges, and universities. (8,24) The average reported ages of users in Europe are 25 to 26 years old. (12,13) In contrast, literature from the United States indicates that the average age of mephedrone users may be higher, estimated at 28 and 29 years old, with ranges from 16-64. (20,25)

Despite being older, the patients in our study were not well informed. These patients reported that they tried bath salts because they were legal, affordable, and offered euphoria. However, they had no knowledge about the substance itself, including its chemical composition, potential effects, and the risks involved.

CONCLUSION

Bath salts are stimulant drugs that produce sympathomimetic and psychological effects. The psychological effects sometimes require involuntary detainment. With the exploding popularity of these drugs, a strain on the mental health system is quite possible, particularly if the psychotic intoxications require inpatient psychiatric beds. Our cases suggest that despite being severe, these psychiatric symptoms subside fairly quickly, and inpatient psychiatric hospitalization might be avoided with a minimally prolonged observation period in the emergency department. Future research should examine time frames for acute bath salt-induced psychosis.

REFERENCES

(1). Buchanan JF, Brown CR. 'Designer drugs'. A problem in clinical toxicology. Medical toxicology and adverse drug experience. 1988;3(1):1.

(2). Jerrard D. " Designer drugs"--a current perspective. The Journal of Emergency Medicine. 1990;8(6):733.

(3). Newcombe R. The Use of Mephedrone (M-cat, Meow) in Middlesbrough. Lifeline Publications and Research. 2009. http:// www.lifeline.org.uk/feature.php?idnum=76.

(4). Wood DM, Davies S, Puchnarewicz M, et al. Recreational use of Mephedrone (4-methylmethcathinone, 4-MMC) with associated sympathomimetic toxicity. Journal of Medical Toxicology. 2010;6(3):327-330.

(5). Sedefov R, Gallegos A. EMCDDA Risk Assessments: Report on the Risk Assessment of Mephedrone in the Framework of the Council Decision on New Psychoactive Substances. No.: ISBN 978-92-9168-457-1. 2011:195.

(6). Schifano F, Albanese A, Fergus S, et al. Mephedrone (4-methylmethcathinone; 'meow meow'): chemical, pharmacological and clinical issues. Psychopharmacology. 2011;214(3):593-602.

(7). Myers T. Louisiana Bans Drugs Used in "Bath Salts" Criminal Activity: Thoughts on a Life of Crime from NOLA Criminal Law. January 6, 2011. http://nolacriminallaw.com/blog/2011/01/06/ louisiana-bans-drugs-used-in-bath-salts/. Accessed January 12, 2011.

(8). Vardakou I, Pistos C, Spiliopoulou C. Drugs for youth via Internet and the example of mephedrone. Toxicology Letters. 2011;201(3):191-195.

(9). Winstock AR, Marsden J, Mitcheson L. What should be done about mephedrone? BMJ. January 1, 2010 2010;340.

(10). Ryan M. Director of the Louisiana Poison Control Center. Initial Reports of Bath Salts to the Louisiana Poison Control Center ed. Baton Rouge October 22, 2011.

(11). Chemicals Used in "Bath Salts" Now Under Federal Control and Regulation United States Drug Enforcement Administration. October 21, 2011. http://www.justice.gov/dea/pubs/pressrel/ pr102111.html.

(12). Winstock A, Mitcheson LR, Deluca P, Davey Z, Corazza O, Schifano F. Mephedrone, new kid for the chop? Addiction. 2010;106:154-161.

(13). Carhart-Harris RL, King LA, Nutt DJ. A web-based survey on mephedrone. Drug and Alcohol Dependence. 2011;118(1):19-22.

(14). Zawilska J. " Legal Highs"-New Players in the Old Drama. Current drug abuse reviews. 2011;4:122-130.

(15). Consideration of Cathinones. Advisory Council on the Misuse of Drugs (ACMD). 2010. http://www.homeoffice.gov.uk/ publications/alcohol-drugs/drugs/acmd1/acmd-cathinodesreport-2010. Accessed January 25, 2011.

(16.) Dyer C. Mephedrone is an amphetamine "by another name," drug adviser tells MPs. BMJ. January 1, 2010 2010;340.

(17.) Johnson A. A collapse in integrity of scientific advice in the UK. The Lancet. 2010;375(9723):1319.

(18). Morris K. UK places generic ban on mephedrone drug family. The Lancet. 2010;375(9723):1333-1334.

(19). Lusthof KJ, Oosting R, Maes A, Verschraagen M, Dijkhuizen A, Sprong AGA. A case of extreme agitation and death after the use of mephedrone in The Netherlands. Forensic Science International. 2011;206(1-3):e93-e95.

(20). Spiller HA, Ryan ML, Weston RG, Jansen J. Clinical experience with and analytical confirmation of "bath salts" and "legal highs"(synthetic cathinones) in the United States. Clinical Toxicology. 2011;49(6):499-505.

(21). Penders TM, Gestring R. Hallucinatory delirium following use of MDPV: "Bath Salts". General Hospital Psychiatry. 2011;33(5):525-526.

(22). Striebel JM, Pierre JM. Acute psychotic sequelae of" bath salts". Schizophrenia research. 2011.

(23). Antonowicz JL, Metzger AK, Ramanujam SL. Paranoid psychosis induced by consumption of methylenedioxypyrovalerone: two cases. General Hospital Psychiatry. 2011.

(24). Dargan P, Wood D. Novel and emerging recreational drugs. Toxicology Letters. 2010;196:S16-S16.

(25). Emergency Department Visits After Use of a Drug Sold as "Bath Salts"--Michigan, November 13, 2010--March 31, 2011. Morbidity and Mortality Weekly Report (MMWR). 2011;60(19):624-627. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a6. htm. Accessed October 5, 2011.

Terrell Caffery, MD; Mandi Musso, MA; Robert Manausa, MD; Jamie Everett, LMSW; John Perret, MD

Dr. Caffery is an Emergency Medicine Ultrasound Director with the Louisiana State University Health Sciences Center's Department of Emergency Medicine in Baton Rouge. Working with him there is Ms. Musso; Dr. Manausa, an Emergency Medicine Resident; Ms. Everett, a Licensed Master of Social Work; and Dr. Perret, Emergency Medicine Research Director.
Table 1: Street names for bath salts (1)

Bath Salts
Cloud 9
Ivory Wave
White Lightning
Ocean
Charge Plus
Scarface
Hurricane Charlie
White Dove
Red Dove

Table 2: Adverse Effects of Bath Salts

Cardiac Symptoms

Cardiovascular collapse
Chest pain
Hypertension
Hypokalemia
Myocardial infarction
Palpitations
Tachycardia

Neurological

Blurred Vision
Cerebal Edema
Confusion
Drowsiness
Headache
Mydriasis
Myoclonus
Seizure/Tremor
Stroke

Psychiatric

Anxiety/Panic
Aggressive/Violent behavior
Agitation
Anorexia
Catatonia
Delirium
Depression
Insomnia
Paranoia
Psychosis/Hallucinations/Delusions
Self-mutilation
Suicidal ideation

Other

Arrhythmias
Cold/Blue fingers
CPK elevations
Excessive sweating
Hyperthermia
Nausea
Respiratory distress
Vasoconstriction

Table 3: Summary of Results

Patient   Age   Gender   Prior PEC   Prior
                                     Inpatient
                                     Psychiatric
                                     History

1         32    Male     Yes         Yes
2         31    Female   No          No
3         33    Male     No          No
4         54    Male     No          No
5         38    Male     No          No
6         25    Male     Yes         Yes
                                     (substance abuse)
7         32    Male     No          No
8         41    Male     No          No
9         35    Female   Yes         Yes
10        20    Male     No          No

Patient   UDS Result      Length     Disposition   Psychiatric
                                                   Diagnosis

1         THC, Opiates    2 days     Inpatient     Polysubstance
                                     treatment     abuse,
                                                   depression
2         Cocaine, BZD,   6 hours    Discharged    Substance
          Opiates, THC                             induced
                                                   mental
                                                   disorder
3         Cocaine, BZD,   6 hours    Discharged    Substance
          Opiates, THC,                            abuse
          Amphetamines
4         THC, Opiates    1 day      Discharged    Polysubstance
                                                   induced
                                                   psychosis
5         Cocaine         2 days     Discharged    Substance
                                                   induced
                                                   psychosis
6         THC, Opiates    4 days     Discharged    Polysubstance
                                                   abuse
7         Opiates         1 day      Discharged    Substance
                                                   induced
                                                   psychosis
8         Amphetamines    1.5 days   Discharged    Amphetamine
                                                   induced
                                                   psychosis
9         BZD,            2 days     Discharged    Substance
          Amphetamines                             induced
                                                   psychosis
10        THC             10.5       Discharged    Drug induced
                          hours                    psychosis

BZD--Benzodiazepines, THC--Tetrahydrocannabinol, UDS--Urine Drug
Services

* Length of stay is highly dependent upon time of day psychiatrist
makes rounds in the mental health emergency room extension.
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Author:Caffery, Terrell; Musso, Mandi; Manausa, Robert; Everett, Jamie; Perret, John
Publication:The Journal of the Louisiana State Medical Society
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2012
Words:2188
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