Lovato, Luis M. MD
Dr. Lovato is an associate professor at the David Geffen School of Medicine at UCLA, the director of medical informatics for emergency medicine at Olive View-UCLA Medical Center, and the chair of the Emergency Medicine Best Practices Committee for the Los Angeles County Department of Health Services.
About the time “Breaking Bad” was first becoming a television phenomenon, underground chemists in undisclosed laboratories were already modifying natural substrates to jumpstart the next drug craze. Synthetic stimulants are a varied group of designer chemicals collectively known as bath salts. These agents contain derivatives of cathinone, an amphetamine analogue naturally found in the leaves of the Catha edulis plant (Khat, Bushman's Tea). People in northeast Africa and the Arabian Peninsula historically chewed Khat for its euphoric effects. (JAMA 2012;308:2445.)
Fueled by the demand for bath salts, increased Khat cultivation has led to a resurgence of this ancient practice in many countries. Americans prefer snorting, ingesting, or injecting bath salts to achieve their high, although intramuscular, rectal, and gingival use have all been reported. (J Med Toxicol 2012;8:33.)
Synthetic stimulants are surreptitiously marketed using deceptive labels designed to avoid regulation. The Federal Analog Act outlawed substances in 1986 that are “substantially similar” to already regulated compounds, but this law only applies to substances intended for human consumption. The designer stimulant industry initially skirted regulation by labeling products as “not intended for human consumption” and openly marketing them for alternate, widely variable, and misleading purposes such as plant fertilizer, stain remover, insect repellent, jewelry cleaner, aroma therapy, and of course, a bathing additive.
The earliest bath salts contained cathinone derivatives such as methylenedioxypyrovalerone (MDPV) and mephedrone, substances that have now been banned specifically by their chemical names. Clandestine labs, however, are perpetually engineering new compounds by making small molecular alterations that retain the euphoric effects but evade policing until they are clearly identified, named, and legislatively added to federally monitored watch lists.
These agents' popularity is bolstered by how relatively inexpensive they are. A bag of three hits sells for as little as $15. (JAMA 2012;308:2445.) Casual users also are attracted to the relative safety of “legal-high” purchasing from established brick-and-mortar retailers rather than sketchy dealings at 3 a.m. in dark backstreet alleys. Urine drug testing is always improving, but even the latest immunoassay-based screens are unlikely to detect the most recently engineered bath salt derivatives. Any “plant food” purchased at your neighborhood head shop today is unlikely to be detected by your physician, arresting deputy, or probation officer.
Unfortunately, considering their lineage, even innocuously christened bath salts like “Lady Bubbles” are still potentially deadly sympathomimetics that share the cardiovascular hazards of their old-fashioned cousins (cocaine, amphetamines). Bath salts also exhibit a relatively greater tendency to incite psychosis and aggression. (Ann Emerg Med 2012;60:103.)
A 9-State Analysis of Designer Stimulant, “Bath Salt,” Hospital Visits Reported to Poison Control Centers
Warrick BJ, Hill M, et al
Ann Emerg Med
This retrospective review of data was collected from nine Midwest poison control centers over a one-year period ending November 2011. Cases uploaded into a regional data collection system were searched by toxicologists looking for bath salt-related poisonings. Patients were excluded if not seen by a health provider, such as poison center calls directly from the public. Subjects also were excluded if a detailed case review concluded that reported symptoms were unlikely related to designer stimulants.
A total of 1633 cases were included, and subjects were predominantly male (68%) and between 18 and 46 (83%). Notable clinical findings included agitation (62%) and hallucination (33%) along with symptoms typical of sympathomimetic syndrome (tachycardia, hypertension, mydriasis). Chest pain was reported in only seven percent of patients, and the primary route of entry was inhalation (44%), followed by ingestion (24%) and injection (11%). Nine deaths were mostly attributed to direct drug effects, but a self-inflicted gunshot wound secondary to drug-induced paranoia was also reported. Co-ingestions were uncommon, found in only 26 percent of cases, which led the authors to speculate that subjects intentionally avoided illegal co-ingestants in pursuit of a “legal” high. The most commonly reported treatment was sedation, with either benzodiazepines (59%) or antipsychotics (15%). Nine percent of patients receiving sedation also required intubation.
This study has several limitations worth mentioning. First, by design, identified cases relied on generating a call to the poison center (reporting bias). Mild cases of bath salt toxicity or those assumed to have come from another sympathomimetic agent may not have been identified or included in this report. Similarly, instances prompting poison center consultation were more likely a subset of patients suffering more severe symptoms, potentially overestimating outcome severity. Finally, calls to the poison center might change over time because of factors like drug availability, use patterns, evolving legislation, enforcement efforts, and increased physician comfort managing bath salt toxicity without assistance.
Despite these limitations, this study provides valuable insight into the scope of the bath salt problem, the epidemiology of bath salt users, and the symptoms patients are most likely to exhibit.
Bath salts are synthetic stimulants meticulously designed and fabricated for open distribution, offering users an easily accessible, low-cost, “legal” high. They have reassuring names like “Ivory Fresh” and an established presence in more traditional venues, even though pharmacological evidence indicates they may be more potent than amphetamines. (Neuropharmacology 2013;71:130.) Designer stimulants have the personality and the addiction potential to become the illicit sympathomimetics of choice. Perhaps a television drama based on the bath salt industry will soon fill the void “Breaking Bad” left. Certainly with prime time exposure, “Vanilla Sky” would have no limits.