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Emergency Medicine News:
doi: 10.1097/01.EEM.0000441270.71425.1b
Screened & Examined

Screened & Examined: This is Your Brain on … Bath Salts and Krokodil

Ballard, Dustin MD

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Dr. Ballard is an associate emergency physician at Kaiser-Permanente in San Rafael, CA, and the chair of the CREST ED Research Network. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet's Yaw (IUniverse, 2007). Dr. Ballard writes a biweekly-medical column for the Marin Independent Journal, which he posts on his blog: http://incisionanddrainage.blogspot.com/.

Eggs sizzling and popping in a frying pan. Those of us old enough to remember 1980s television can easily recall the tagline: “This is your brain on drugs.”

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The frying-brain public education campaign is one of the most memorable visuals of our nation's long-running cultural and political battle against illicit drug use. It's also been parodied many times over, including recently by the A&E show Breaking Bad, itself a five-season indictment of methamphetamine abuse. “This is your brain,” says meth cook Jesse Pinkman as he fries an egg, and then, adding another egg, “This is your brain on drugs.”

Regardless of your opinion on recreational drug use, it's undeniable that there is some truth to these images. Obviously, no one would use them if drugs didn't do a darn thing to the brain. But where the fried egg image and some other public service announcements fall down is in differentiating drug use. Different drugs are just that: different. Some sizzle brain neurons faster than others. Take two examples, nasty new drugs that I hope you're lucky enough to not have seen in your ED: bath salts and krokodil.

Krokodil is a recent and truly awful import from Russia, a homemade opiate comprised of codeine, gasoline, and paint thinner. The concoction provides a short, heroin-like high when injected while simultaneously destroying brain and other tissues and turning the skin scaly green like a crocodile's. Sepsis, gangrene, and brain damage are common among users. The average life span for krokodil users in Russia is two to three years, according to a Time magazine investigation. Nasty. Fortunately, only a handful of cases of Krokodil complications have been reported in the United States so far, none in my home county.

Sadly, the same cannot be said for bath salts, which are synthetic stimulants containing substances called cathinones with specific names like 3,4-methylenedioxypyrovalerone (MDPV). That may sound like alphanumeric soup, but catchier street names (Ivory Wave, OceanBurst, or TranQuility), poor regulations, and disingenuous marketing (yes, these drugs are marketed as salts for your bath) have helped to propagate a burgeoning epidemic.

I imagine that whether you were aware of it or not, you have likely encountered some ED patients tripping on TranQuility. Bath salt use has exploded over the past decade, spreading from Japan to Finland to the U.K. and to the United States. The expanding popularity of the drugs is beyond me. Inhaled, ingested, or injected, bath salts cause a prolonged, unpleasant, and psychotic high, frequently causing severe aggression, hallucinations, and death. Take this example, from the National Poison Data System published in Clinical Toxicology. (2011;49[10]:910.)

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“Amphetamines (synthetic stimulants) inhalation/nasal: undoubtedly responsible [for death]. Scenario: A 26-y/o male found attempting to enter a stranger ’s home after using bath salts; he was delirious and eating dirt… [This] combative and confused patient, shortly after ED arrival, had seizures and cardiac arrest.”

The patient did poorly, despite aggressive treatment, developing massive swelling on the brain and pneumonia. Ultimately, three days into treatment, he succumbed, with the autopsy showing (among other findings) “Diffuse cerebral and cerebellar acute hypoxic changes, consequences of ‘Excited Delirium Syndrome’ associated with MDPV.”

Sadly, this scary case is no isolated incident. I tallied 32 deaths in the 2011 National Poison Data System report that were likely the result of bath salt ingestion, and there certainly were more among the 169 fatalities listed under “Miscellaneous Stimulants and Street Drugs.”

Another study of 2011 poison control center data from nine Midwestern states compiled by Warrick and colleagues and focused specifically on bath salt abuse in a group of 1,633 patients found that 16 percent had a fatal or life-threatening medical complication. (Ann Emerg Med 2013;62[3]:244.) This does not include the 62 percent of patients who suffered agitation, the 26 percent who hallucinated, or the 20 percent who became confused. If those data don't concern you, consider that 103 (6%) of these patients were teenagers, and all five fatalities were people in their 20s or 30s.

The problem of bath salt use remains incompletely tracked. The exact chemical composition of the drugs is in constant flux (this is intentional; chemists strive to stay a step ahead of the law), and diagnosis and testing procedures remain spotty. Nationwide, we do not have any firm statistics on the scope of bath salt abuse, but it certainly is growing, and we can only hope it does not grow and fester like krokodil in the skin.

© 2013 by Lippincott Williams & Wilkins

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