Gerald Scott Winder, MD; Bradley Stilger, MD; Colleen Ehrnstrom, PhD; and Avinash Hosanagar, MD
Dr. Winder is a psychosomatic medicine fellow, and Dr. Stilger is a psychiatry resident, and Dr. Hosanagar is on the faculty and a psychiatrist all at the University of Michigan Department of Psychiatry in Ann Arbor, Michigan. Dr. Hosanagar is a psychiatrist and Dr. Ehrnstrom was a clinical psychologist at the VA Ann Arbor Health Care System and at the University of Michigan Department of Psychiatry and now is a clinical psychologist at the Eastern Colorado Health Care System in Aurora, Colorado.
Mr. H is a 28-year-old Iraq War veteran with a history of posttraumatic stress disorder (PTSD), alcohol abuse, and opioid dependence who presented for inpatient psychiatric admission after making suicidal statements to his wife in the context of 2 weeks of “bath salts” use. A family member initially introduced him to the drug. His first drug purchase had been 1 gram ($30) at a local movie rental store.
After discharge from the hospital, Mr. H began purchasing increasing amounts online with a credit card. Although he initially had been insufflating and inhaling the substance, he later began injecting it (dissolving it in tap water and loading it through a cotton filter in a syringe). The patient admitted to finding the drug significantly more addictive than any others he had used, and his use resulted in leaving his job and abandoning his family.
Severe cravings and depression were present between episodes of use. He spent $40,000 over 6 months of use. Insomnia lasted for several days, his appearance changed dramatically (including persistent skin infections), and he became paranoid, believing that everyone around him was an undercover police officer. He remained on medications for persistent anxiety. His daily drug cravings continued, although he remained uncertain about the actual ingredients of bath salts.
Cathinone is a naturally occurring stimulant from the khat plant (Catha edulis), which grows indigenously in Egypt and on the Arabian Peninsula. The recreational and religious use of this plant has occurred for thousands of years, though it is not without risk: The chewing of the leaves containing natural cathinones has been associated with esophagitis, gastritis, oral keratosis, myocardial infarction, dilated cardiomyopathy, hypertension, cerebral ischemia, thromboembolism, diabetes, sexual dysfunction, duodenal ulcer, and hepatitis.33,34
The stimulants known colloquially as bath salts are synthetic cathinones, which have become more widely available within the past 10 years: first in the Middle East, then Europe, and now in the U.S.5,9,10,14,19,25,35-41,44 Although the current rise in use has occurred in the past few years, the first documented abuse of synthetic cathinones in the U.S. dates to the early 1990s in Michigan.42
Bath salts is the most common of the many names used to denote synthetic cathinones. The compounds have no utility when used as such but often are marketed as research chemicals, plant fertilizer, or shoe polish. It is this deliberate counterfeit of household product names that allows many distributors to avoid classifying the compounds according to the true, intended use. More appealing brand names may also be used to entice the user (Table 1).25
Synthetic cathinones owe their popularity to similarities with cocaine and methamphetamine. They are sympathomimetic with synaptic increases of monoamines after use: Surges in norepinephrine and dopamine account for the stimulant qualities, and serotonergic changes mediate distinct psychoactive effects (Table 2).40 Users are interested in the drugs for many of the same reasons that other recreational stimulants have appeal: euphoria, energy, empathy, heightened sexuality, sociability, and an overall intensification of senses. Synthetic cathinones have become preferred to cocaine for some users.43
The drugs can be used via oral and anal routes. Using methods known as “bombing” or “keystering,” users deliver boluses of the powder wrapped in cigarette paper, which they swallow or insert into the rectum. Insufflation and IV injection are also common methods of administration with a quicker onset of action expected.40 The prices of the drugs range from $25 to $50 per 500-mg packet (though the cost is increasing with more regulation). Users typically use 500 mg to 2 g in one session.
The 2 most commonly abused synthetic cathinones are mephedrone and MDPV (methylenedioxypyrovalerone). There is some regional variability about which ingredient is present; mephedrone tends to be more prevalent in Europe, whereas MDPV is noted to be more common in the U.S.10,44
When ordering a laboratory test to evaluate for the presence of these drugs, a specific request should be given to the technicians to look for signals of MDPV (most common metabolite is dimethylenyl-methyl-MDPV), mephedrone (4-methylmethcathinone), 3-bromomethcathinone (3-BMC), or 3-fluoromethcathinone (fluphedrone).45-48 The study testing (both in VA and civilian settings) for Mr. H was done by a commercial laboratory several states away where patented techniques can screen for more than 30 compounds via LC-MS. The laboratory offered bath salts panels for urine, serum/plasma, and blood samples.
Synthetic cathinones are dangerous, and as the body of medical literature continues to expand, reports of significant morbidity and death related to their use are appearing. The harmful effects of recreational synthetic cathinone use has been documented across the globe in the form of serotonin syndrome, intoxication delirium, hyperthermia and multi-organ failure, myocarditis, hypo-osmotic hyponatremia with encephalopathy, agitation, psychosis, and death after cardiac arrest.5,12,38,39,49-53 Published treatment methods are largely supportive with the available literature, suggesting that benzodiazepines, antipsychotics (both typical and atypical), restraints to maintain safety, and IV fluids may be indicated.5,9,50
