The mechanisms underlying MDPV-induced delirium have not been definitively identified. Given the similarities in mechanism of action between MDPV and cocaine, causes for delirium related to MDPV are similarly presumed to be multifactorial. The course of delirium associated with MDPV intoxication is self-limited and requires supportive measures.8,9
Suspect MDPV abuse in patients who present with signs or symptoms of stimulant intoxication but have a negative toxicology screen for cocaine and other psychostimulants. MDPV is not detected on routine toxicology assessments; however, it can be identified through laboratories with gas chromatography/mass spectroscopy capabilities. However, the time needed to obtain the results may exceed the clinical course of the patient’s delirium. One of the limitations in Ms. K’s case was the lack of gas chromatography/mass spectroscopy to confirm MDPV ingestion. Ms. K’s roommate could not locate any unused brown powder within their apartment to bring in for laboratory investigations. Recently, screening assessments for MDPV have become commercially available (see Related Resources).
Table 3
Overview of MDPV features
| Chemical name | 3,4-methylenedioxypyrovalerone |
| Popular names | MDPV, PV, PeeVee, Super coke, Magic |
| Sources | Sold as “bath salts” by Internet sources, “head shops,” and gas stations |
| Mode of use | Oral, snorting, smoking, rectal insertion, intravenous |
| Acute effects | Increased energy, perception of heightened alertness/attention, aphrodisiac properties, increased sociability |
| Adverse psychological effects | Anxiety (panic attacks), irritability, agitation, confusion, suicidal ideations, visual distortions |
| Adverse physical effects | Insomnia/overstimulation, bruxism, muscle twitching, pupil dilation/blurred vision, anorexia, headache, nausea/vomiting, hyperthermia, irregular heart beat, tachycardia, dyspnea, fatigue |
| Effects of protracted use | Dysphoria, depression, anhedonia |
| LD50 | Unknown |
| LD50: lethal dose; MDPV: methylenedioxypyrovalerone Source: Reference 8 | |
OUTCOME: Referral to treatment
Dialysis is discontinued within 1 day of hospitalization. Ms. K’s peripheral arterial perfusion improves, as does her thermoregulatory status. Her mental status improvements coincide with improvements in her physical and metabolic status.
Ms. K is able to sustain attention when speaking with interviewers. She is aware of her surroundings and is no longer distracted by extraneous stimuli. Her speech is articulate and her thoughts are linear. There is no evidence of any residual thought disorganization, delusions, or hallucinations.
Initially, Ms. K is reluctant to acknowledge her substance use, but eventually, she concedes to acquiring a stimulant from an Internet source and abusing it in undetermined amounts. She had no experience with using MDPV and did not know how to avoid ingesting dangerous amounts. We educate Ms. K about the dangers she faced during this hospitalization and the potential life-threatening outcomes. She is amenable to pursuing outpatient substance abuse treatment. Her roommate is enlisted to facilitate her follow-up with this treatment.
The authors’ observations
Managing MDPV toxicity presents a diagnostic dilemma for medical personnel and psychiatrists when evaluating and managing acute delirium. MDPV ingestion may go unrecognized in clinical settings because toxicology assessments for it are not readily available and patients’ historical information may be unreliable.
Because of the seriousness of sequelae associated with MDPV use, state and federal agencies have intervened. Until recently, bath salts did not have a controlled substance designation. In October 2011, the US Drug Enforcement Administration (DEA) ruled to make MDPV a controlled substance for 1 year, with the possibility of a 6-month extension.13 Although this ruling is temporary, it makes possession, sale, or distribution of these chemicals, or the products that contain them, illegal in the United States. In the interim, the DEA and the US Department of Health and Human Services will determine whether MDPV should remain a controlled substance.
- American Screening Corp. (MDPV screening). www.americanscreeningcorp.com.
- U.S. Drug Enforcement Administration. 3, 4-Methylenedioxypyrovalerone (MDPV). www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf.
- Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones [published online ahead of print November 23, 2011]. J Med Toxicol. doi: 10.1007/s13181-011-0193-z.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.