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7/24/2014 Objectives • Discuss the epidemiology of bath salt poisonings • Review toxicological facets Bath Salts, Coming To Your Town… • Identify current marketed street identities • Expose symptomatologies • Discuss current therapeutic modalties Expect the Unexpected…. 1 7/24/2014 “The Tennessee Bureau of Investigation said Rogers is a truck driver. They believe he picked Nelms in Knoxville, killed her, then dumped her body”. “The medical examiner's preliminary autopsy revealed that Nelms died of multiple blunt force trauma and stab wounds” Bath Salts – As Intended… Epsom Salt The Most Studied Bath Salt • The earliest systematic exposition of the different kinds of salts, its uses, and the methods of its extraction was published in China around 2700 years BC. • Bath salts provide a variety of benefits to a bather. Salts change the osmotic balance of the water so that less water is absorbed by the skin via osmosis. This reduces the "pruning" or "wrinkling" effect of prolonged exposure of skin to fresh water. • Hippocrates encouraged his fellow healers to make use of salt water to heal various ailments by immersing their patients in sea water. The ancient Greeks continued this, and in 1753 English author and physician Dr. Charles Russel published "The Uses of Sea Water • Some bath salts such as phosphates have a detergent action which softens calloused skin and aids in exfoliation. • High concentrations of salts increase the density of the water and increase buoyancy which makes the body feel lighter in the bath. Very high concentrations of salts in water are used in flotation therapy. 2 7/24/2014 Bath Salts… The “New” Bath Salts… • Appearance • Free base form (possibly) • Dirty or tan (copper colored) powder • “Pure” form • White powder • Possibly the HCl salt form • Odorless • Resembles baby powder or flour Bath Salts… Bath Salts - What Are They??? • Drugs that contains 3,4-methylenedioxypyrovalerone (MDPV) and may be combined with mephedrone • Mephedrone • Derivative of methcathinone • Stimulant derived from the Khat plant • MDPV • Belongs to a class of compounds referred to as beta ketones sold as “research chemicals” • Highly potent pyrovalerone analogue • Developed in the 1960’s and was used to treat fatigue and lethargy and used as an anorectic • Now a Schedule V controlled substance • Abuse and Dependence “Synthetic drugs that contain a variety of stimulant and hallucinogenic compounds” • Availability: • Convenience stores, discount stores, tobacco outlets, gas stations, pawnshops, tattoo parlors, truck stops, smoke shops and internet • Sold in 50mg – 500mg packets • Price: • $25 - $50 per 50mg packet • Dose: • 5mg-20mg • Redosing is common • Up to 200mg has been reported 3 7/24/2014 Products that may be currently marketed as “Bath Salts”… • • • • • • • • Arctic Blast Cloud 9 Disco Bath Salt Hurricane Charlie Ivory Wave Lunar Wave Mamba Snow Leopard • • • • • • • • Tranquility Vanilla Sky Zoom White Rush Ocean Burst Sky Blitz Premium Sextacy UP Powder Symptomatologies… (can be variable) • Agitation • Paranoia • Choreoathetoid movements • Psychosis • Hallucinations • Hypertension • Hyperthermia • Rhabdomyolysis • Renal Failure • Tachycardia http://www.youtube.com/watch?v=CjrxXpgjp4I&feature=related Bath Salts: Mechanisms of Introduction • Inhalation • Most common • Orally • Capsules • “Bombing” – wrap it up in cigarette papers and swallow • Smoking • Rectally • Mix with water • IV What effects will it have of my patient? • MOAI • Inhibits the reuptake of dopamine and norepinephrine • No effect on serotonin levels • ADME (Absorption, Distribution, Metabolism, and Excretion) • Peak affect occurs around 90 minutes • “Come down” occurs around hour 2.5 • Lasts approximately 1 hour • Patient stories state otherwise • Many patients report adverse effects lasting for days • Panic attacks and prolonged anxiety may occur at higher doses and with regular use • Non-oral forms • May peak earlier • May be shorter acting 4 7/24/2014 Yet more… • Clinical effects Therapeutic Modalities • High dose benzodiazepines to control agitation • Dose dependent • Lower doses - methylphenidate like effects (psychostimulant) • Higher doses – cocaine and amphetamine like effects • Patient experience states > dose, > +/- effects • Desired effects • • • • • • Stimulant Increased energy Sociability Euphoria Increased concentration Aphrodisiac effects Toxicology Testing • Active measures to keep cool if the patient becomes hyperthermic – Sedation, cooling blankets, cool IV fluids, ice packs, and ultimately chemical paralysis with sedation • Aggressive fluid resuscitation due to (1) increased losses, and (2) potential for rhabdomyolysis • Consultation with a Medical Toxicologist Collect a Red Top Vacutainer • There are NO standard drug screens that can detect the presence of the numerous synthetic drugs that comprise “bath salts” • NMS Labs based out of Willow Grove, PA is staying current with the availability of trends and can test for all compounds found in the “bath salts” product. • Testing is optional but can help differentiate between psychotic break and drug effect, as well as helping correlate symptoms with a specific compound. 5 7/24/2014 The Legal Perspective • Legal status • Currently no federal laws against its use • States independently are passing emergency bills to ban both MDPV and mephedrone MDPV • North Carolina Mephedrone • March 16th a bill classifying MDPV and mephedrone as a schedule 1 controlled substance was ratified and passed • June 1st the law will go into effect In Summary • Morbidity and mortality rates are hastily increasing secondary to these toxic compounds! • Unexplained bizarre behavior or movements should raise your index of suspicion that bath salts are onboard. 6 7/24/2014 Poison Control Center THANK YOU!!!! 1-800-222-1222 Works Cited • Carolinas Poison Center: Laboratory testing for “Bath Salts” or “Plant Food” • K2 and Bath Salts Talk: author - Nicole Abolins, Pharm.D. • http://www.austincc.edu/mlt/phb_tubes • http://www.buffalonycriminaldefenselawyer.com/2011/01/calgon-take-me-awaybath-salts-used-as-fake-cocaine.shtml • • http://en.wikipedia.org/wiki/Bath_salts http://www.google.com/imgres?imgurl=http://cdn.blogs.sheknows.com/thewire.s heknows.com/2011/05/bathsalts.jpg&imgrefurl=http://thewire.sheknows.com/20 11/05/23/bath-salts-a-dangerous-newdrug/&h=510&w=550&sz=134&tbnid=kw2JJrgvnA8_CM:&tbnh=95&tbnw=102&pr ev=/search%3Fq%3Dpicture%2Bof%2Bbath%2Bsalts%26tbm%3Disch%26tbo%3Du &zoom=1&q=picture+of+bath+salts&docid=b-Y_kdb3AzuEuM&sa=X&ei=99UTtH0KIHy0gH0wej5Bw&ved=0CF8Q9QEwEQ 7