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‘Bath salts’ stimulants prompt state bans

Because the drugs are so new, many hospitals, health officials and law enforcement agencies are still learning how to respond

By Carolyne Krupa
American Medical News

WASHINGTON — At least eight states have outlawed synthetic chemicals commonly found in the party drugs, which can cause extreme paranoia, hallucinations and violent behavior.

Physicians nationwide are facing a new form of synthetic drug that is driving users to emergency departments and drug addiction programs with violent, psychotic behavior and a range of other symptoms.

The powerful stimulants, known as “bath salts,” are sold legally in much of the United States and typically include a variety of chemical compounds, including derivatives of cathinone, piperidine, pyrovalerone and tryptamine, said emergency physician Zane Horowitz, MD, medical director of the Oregon Poison Center.

Because the drugs are so new, many hospitals, health officials and law enforcement agencies are still learning how to respond.

“The people who are using these substances are really playing Russian roulette in terms of what they are taking,” said Dr. Horowitz, an associate professor of emergency medicine at Oregon Health & Science University School of Medicine. “No one knows what most of these are. The people who make them are not professional chemists. They’re literally just experimenting on our teenagers.”

The dangerous behaviors the drugs provoke have led the United Kingdom, Australia, Canada and Israel to ban the chemicals methylenedioxypyrovalerone (MDPV) and mephedrone, commonly found in bath salts stimulants.

In the United States, at least eight states, including Florida, Louisiana, Mississippi and North Dakota, have outlawed the drugs, and many other states are considering similar action. Several counties, cities and local municipalities also have banned the products.

Mississippi State Rep. Lester Carpenter has seen the effects of the drugs firsthand as a paramedic. Similar to phencyclidine (PCP) in the 1970s, bath salts are used as a party drug by teenagers and young adults, he said.

The drugs cause users to become paranoid and experience auditory or visual hallucinations. Carpenter said he has seen patients engaged in normal conversation suddenly swat at imagined objects in the air and grow extremely paranoid.

“It makes people not know what they’re doing. They’re in a different state of mind,” he said.

Carpenter introduced legislation that was signed into law March 20 banning bath salts in Mississippi. “It was just causing a lot of trouble in the state,” he said.

Despite action by some states, bath salts are readily available over the Internet and in convenience stores, smoke shops and other retail businesses in states where they remain legal, said Diane M. Machen, a criminalist with the Washoe County Sheriff’s Office in Nevada.

The stimulants come in powder form, similar to salt, that people smoke, swallow, inject or drink mixed in liquids, she said.

The number of bath salt cases reported to poison control centers nationwide increased from 302 in 2010 to 1,491 in 2011 as of April 5, with most reports coming from hospital emergency departments, according to the National Poison Data System. But those figures give only a partial picture of the drugs’ use.

“Although we lack sufficient data to understand exactly how prevalent the use of these stimulants are, we know they pose a serious threat to the health and well-being of young people and anyone who may use them,” Gil Kerlikowske, director of National Drug Control Policy, said in a statement.

Looking for symptoms
Louisiana psychiatrist Jose F. Artecona, MD, said he has encountered patients with no history of mental illness who became psychotic and violent after using bath salts. “It’s a very powerful drug,” he said.

Severe side effects of the drugs can last for several days and often get worse with time, said Mark Ryan, PharmD, director of the Louisiana Poison Center in Shreveport, La.

Bath salts have been associated with violent behavior and suicides, including the March 9 nonfatal stabbing of a priest in Scranton, Pa., and the March 13 slaying of a Rutgers University student.

In many cases, doctors found that benzodiazepines didn’t calm patients and instead used antipsychotics.

“Some of these people were heavily sedated, and when they tried to wean them off of the sedation, the psychosis reappeared,” Ryan said.

Inside and outside the emergency department, physicians can look for symptoms such as dilated pupils, rapid speech, agitation, lack of sleep, and increased heart rate and blood pressure, said Dr. Artecona, assistant professor of psychiatry at Tulane University School of Medicine in New Orleans.

If physicians suspect patients are using bath salts or other drugs, they should discuss it with them, said Gaya Dowling, PhD, acting chief of the National Institute on Drug Abuse’s science policy branch. Ideally, physicians should incorporate a couple of questions to screen patients for drug abuse on every visit, she said.

“There is a natural stigma around drug abuse and addiction, and I think a lot of physicians feel uncomfortable talking about it with patients because of that stigma,” she said. “The physician is really an ideal person to intervene to prevent escalation.”

Dr. Horowitz recommends that patients suspected of using bath salts be evaluated by a mental health professional, because the drug often causes suicidal tendencies.

“A moving target”
Bath salts are sold under dozens of names, including Ivory Wave, Hurricane Charlie, Ocean Snow, Red Dove and Vanilla Sky. They are labeled “not for human consumption” to get around federal drug laws and may be marketed as a variety of products, including bath crystals, plant food, incense and insect repellant, Ryan said.

In Louisiana alone, the drug has been sold under at least 31 names. The state saw its first case of bath salts use in September 2010, but by December the number of cases had grown to 110. “As it progressed, it got our attention very quickly,” Ryan said.

On Jan. 6, the state banned six substances found in bath salts.

At the federal level, the Combating Dangerous Synthetic Stimulants Act was introduced in Congress on Feb. 17 by Sen. Charles Schumer (D, N.Y.) to classify MDPV and mephedrone as controlled substances. On March 29, Sen. Bob Casey (D, Pa.) also urged the Drug Enforcement Administration to temporarily ban the chemicals.

“A series of recent crimes and violent attacks by individuals using bath salts have shown that these drugs pose an imminent threat to public safety,” Casey wrote in a letter to DEA Administrator Michele Leonhart.

But even if those chemicals are banned, party-drug makers soon will find other compounds to sell to people looking for their next high, said Petros Levounis, MD, director of the Addiction Institute of New York and chief of addiction psychiatry at St. Luke’s-Roosevelt Hospital in New York City.

“It is somewhat of a moving target,” Dr. Levounis said. “Bath salts are not just one compound, but a whole family of compounds, so even if you outlaw one compound or five or 10, there will be others.”

Dr. Horowitz said at least six other synthetic chemicals are already being sold that aren’t associated with bath salts.

“You’re seeing a lot of these new drugs come into the market that are one step ahead of the FDA,” Dr. Artecona said. “There are a lot of new synthetic drugs that are being created that haven’t been researched and have the potential to do a lot of damage. That is a larger issue that I think we will be dealing with for some time.”

“Bath salts” use climbing
Use of new synthetic stimulants known as bath salts is rising nationwide, despite efforts in several states and municipalities to ban chemicals commonly found in the drugs. Poison control centers nationwide have received reports of use since the drugs first surfaced in 2010.
Month Reports
July 2010 3
August 2010 13
September 2010 20
October 2010 20
November 2010 64
December 2010 182
January 2011 299
February 2011 484
March 2011 628
Total 1713

Source: National Poison Data System, American Assn. of Poison Control Centers

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