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Emergency Medicine News:
doi: 10.1097/01.EEM.0000395423.09894.34
Toxicology Rounds

Toxicology Rounds: Giving New Meaning to ‘Bed, Bath, and Beyond’

Gussow, Leon MD

Free Access

Packaged as a “soothing bath salt,” the polyonomous Ivory Wave is sold in convenience stores and smoke shops under a variety of trade names such as Vanilla Sky, Cloud 9, and Hurricane Charlie. The packages do not completely list the products' ingredients, but usually carry the warning: “Not for human consumption.” And, as the Daily Mail (UK) has reported, instructions for use can seem vaguely more appropriate for a drug than for an external bath supplement: “Start with [adding] a very tiny amount to your bath to see your body's tolerance. … Once you get used to the strong effect of Ivory Wave in your bath, you can use more to reach the complete relaxation you want.”

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Ivory Wave is, in fact, the latest “legal” designer drug to hit streets and emergency departments in the United States. It became available toward the end of 2010 after K2 (“synthetic marijuana”) was banned. Before that, it had been sold in the United Kingdom, where it was associated with the deaths of at least two users.

Although some users smoke or ingest Ivory Wave, the usual route of abuse is snorting. Effects come on rapidly, and can last for days. A physician in Britain who treated a dozen young people brought to hospital after using Ivory Wave told the BBC: “I have never seen anything like it. It was really awful. All have had a very fast heart rate so we have been monitoring them in the critical care unit for about 12 hours. The drugs are getting out of their system, but it is taking two to three days for the agitation and psychosis to wear off.”

What is Ivory Wave? Some news stories have identified its active ingredient as 2-DPMP, a drug related to methylphenidate (Ritalin) that was investigated in the 1950s as a treatment for narcolepsy and attention deficit hyperactivity disorder (ADHD). Most chemical analyses of Ivory Wave, including one by the St. Louis Medical Examiner's Office, however, have found methylenedioxypyrovalerone (MDPV).

MDPV is still legal in many areas, although it was banned in Louisiana early in 2011, and is considered a controlled substance in several Scandinavian countries. It is sold under a variety of trade names (See table.) Unfortunately, there is scant medical information describing the effects of MDPV; a recent PubMed search identified exactly zero clinical articles on the topic.

Turning to Wikipedia, surprisingly often the best and most reliable source of information about new street drugs, we learn that MDPV is a pure stimulant with effects similar to cocaine and amphetamine. Often called the “poor man's meth,” it is derived from pyrovalerone, a drug similar to Ritalin that was studied as a possible anorectic agent and treatment for chronic fatigue.

Signs and symptoms of MDPV exposure are mostly sympathomimetic. MDPV inhibits reuptake of dopamine and norepinephrine without having much effect on serotonin levels. Major clinical manifestations reported in patients who used Ivory Wave and other such products include hypertension, tachycardia, agitation, panic attacks, paranoid delusions, and suicidal ideation. Psychoactive effects can last for several days. Despite the lack of activity on serotonin pathways, hallucinations have been reported in these patients. A number of deaths have been associated with MDPV use, often from suicide or trauma. It is, of course, important to realize that Ivory Wave and other bath salts are not standardized or regulated products, so without specific confirmatory tests (which are virtually never done), it is impossible to know for certain which chemical or chemicals a patient has taken.

Keeping up with the ever-changing array of “legal” highs available over-the-counter and through the Internet is becoming a major challenge for emergency practitioners and poison specialists. Toxicology was once easy, at least when it came to drugs of abuse. When I started in emergency medicine — let's say it was a number of years ago, and leave it at that — we knew a good deal about the substances our clients were taking on the street. They had been around for decades, if not longer, and for the most part they had been subject to intense scientific investigations.

Cocaine? It had been used medicinally since the late 1800s, both for its analgesic and its psychoactive properties. There were hundreds of scientific publications describing its metabolism, effects, and overdose. Although nuances of treatment have changed somewhat in recent years, there was little about cocaine that we did not know.

Heroin? The opium poppy was cultivated for millennia, and prescribed by ancient physicians as a sedative and pain killer. Early in the 20th century, heroin was sold as a cough suppressant. Its pharmacology and toxicology were thoroughly understood.

Phencyclidine? PCP had been around since 1926, and was at one time patented for development as a surgical anesthetic under the trade name Sernyl. Because of unfortunate side effects such as delirium and hallucinations, it was eventually taken off the market. By that time, however, it had been well studied.

But the 21st century has ushered in a grave new world in which potent, previously unknown street drugs are being synthesized and marketed with increasing frequency. Many of these chemicals are manufactured overseas and sold over the Internet, often labeled as innocuous products such as “plant food” or “pond cleaner.” Users know that the not-for-human-consumption warning is a legal fig leaf. When these products appear, they are often so new that legislatures and regulatory bodies have not yet gotten around to banning them. When one of these drugs is outlawed, a new, related but chemically distinct and therefore legal substance takes it place. This means emergency physicians must struggle to keep up with a constantly changing situation, and treat based on clinical presentation rather than precise knowledge of specific drugs involved. It also means that patients who use these drugs are playing a toxicological version of Russian roulette.

Comments about this article? Write to EMN at emn@lww.com.

Dr. Gussow is a volu...
Dr. Gussow is a volu...
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