Is Your Patient High on “Bath Salts” ? by Mark M

Is your patient high on “bath salts” ? By Mark M. McGraw, BSN, RN, CCRN, CEN, CTRN

THESE BATH SALTS have nothing to do with bathing. Instead, they’re new designer drugs with a name that sounds deceptively harmless. This new synthetic stimulant, which until recently had been marketed as a legal novelty 2.0 item in convenience stores, in “head shops” (where drug paraphernalia and ANCC legal products that produce a “high” are sold) and on the Internet, may be CONTACT HOURS labeled “bath salts,” “plant food,” or “insect repellant.”1 They include a promi- nent warning: “not for human consumption.”2 In stark contrast to its labeling, this easily obtained alternative to ecstasy, cocaine, and amphetamines is actu- ally intended for human consumption. (See Defining “bath salts.”) Samples of bath salts seized from different regions vary greatly even when they have the same label and have been developed by the same producers.3 In October 2011, the Drug Enforcement Administration made it illegal (except as authorized by law) to possess or sell the chemicals in bath salts or products containing them in the United States for at least 1 year while further 4 studies are done to weigh whether they should be permanently banned. Bath HOTO P salts had already joined the ranks of MDMA (3,4-methylenedioxymetham- TOCK S I phetamine), the active ingredient in ecstasy, psilocybin (4-phosphoryloxy- / N,N-dimethyltryptamine) obtained from certain types of mushrooms, LSD ILOSJOKIC

(D-lysergic acid diethylamide), and mescaline (the active ingredient in peyote) M

26 l Nursing2012 l January www.Nursing2012.com

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. as a U.S. Drug Enforcement Admin- sites offered bath salts for purchase. istration Schedule I substance.5 A By March 2010, 70 sites offered it, Schedule I compound is a chemical and new sites were being created with a high potential for abuse and every few weeks.10 no safe approved medical use.6 Little scientific evidence or infor- This article will explain the dan- mation is available about these prod- gerous effects of bath salts and ap- ucts due to their recent emergence. propriate nursing interventions to According to the American Associa- help promote safe, competent care to tion of Poison Control Centers, in patients who’ve been using them. 2009 U.S. poison control centers First, consider the extreme behavior received no calls reporting the inges- that’s indicative of bath salt use. tion of bath salts. In 2010, they received 303 calls. But as of July 31, Unearthing the facts 2011, they’d received more than Graphic media reports demonstrate 4,100 calls about the ingestion of the extreme danger that people who bath salts in the United States.11 are high on bath salts present to The increased availability has themselves and others. (See Startling Bath salts, a Schedule I contributed to more users coming cases from the popular media.) Even compound, have a high to the ED for treatment. The use of without provocation, these people potential for abuse and no these designer drugs has become an often lash out or injure themselves safe approved medical use. increasing cause of concern for many without warning. These accounts parents, healthcare workers, and also emphasize the need for legisla- government officials. tion, public education, and information for healthcare workers and first cathinone mephedrone has increased Understanding the responders. as rates of ecstasy use have declined.8 pharmacology Bath salts’ popularity skyrocketed This is partially attributed to the in- Bath salts are manufactured differ- with members of the club scene in stability of the ecstasy market and ently in each region of the world as Europe. A survey in 2010 of over unavailability of MDMA.9 the producers develop their own rec- 2,000 clubbers reported over 40% Because bath salts, a new product, ipes. The pharmacologic effects de- had used some form of bath salts, hadn’t yet been banned by formal pend on the substance’s purity, con- and more than 30% had used them legislation, it became more widely centration, and filler compounds.12,13 within the last month.7 The use of available. In December 2009, about The limited information about bath bath salts containing the synthetic 30 English-language online Internet salts is based on animal studies, accounts of users, and accounts of Defining “bath salts” those who’ve observed people using the drug. Bath salts consist of a powder that’s inhaled, ingested, injected, or smoked because Supplied as a white, tan, or brown it produces an effect similar to that of amphetamine or cocaine. These drugs are clumpy powder, bath salts may be synthetic derivatives of cathinone, a substance that comes from an African plant encapsulated or compressed into called “khat.” Cathinone is a Schedule I controlled substance under the Federal Controlled Substances Act. Although the contents of packets of bath salts vary, they crystal to resemble actual bath salts. usually include one or more of these six chemicals: They’re sold in packages containing • 3,4–methylenedioxypyrovalerone (MDPV) 50 to 200 mg of the synthetic cathi- • 4–methylmethcathinone (mephedrone, 4-MMC) none or in larger vials containing up • 3,4–methylenedioxymethcathinone (methylone, MDMC) to 500 mg.14 The powder can be • 4–fluoromethcathinone (flephedrone, 4-FMC) consumed orally or rectally, snorted • 3–fluoromethcathinone (3-FMC) (insufflated), injected, or smoked. As • 4–methoxymethcathinone (methedrone, BK-PMMA, PMMC). with most drugs, the route of admin- Source: New Jersey Office of the Attorney General. Designer drugs labeled as “bath salts”: facts about synthetic cathinones. http://www.nj.gov/oag/ca/bathsalts/SyntheticCathinonesFacts.pdf. istration determines the onset, peak, and duration of the effects. Many

28 l Nursing2012 l January www.Nursing2012.com

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. frequent users prefer snorting bath salts combined with oral dosing Startling cases from the popular media because that provides a more rapid These accounts from the United States tell of the effects experienced by users of onset with a substantially longer bath salts: duration of effect.15 • A man, 25, broke into a monastery and assaulted a sleeping priest with a knife and wooden club after using bath salts.28 Clinical effects • After consuming bath salts, a woman attacked her mother with a machete while 28 The cathinones in bath salts are re- she slept. • 29 ported to cause effects similar to After a 4-day binge on bath salts, a father, 45, was found dead by his young son. • After experimenting with bath salts, a man, 31, committed suicide because of the those of amphetamines, cocaine, paranoia he was experiencing.30 and ecstasy without causing the • A man, 23, was taken to the hospital because he was acting irrationally. His body hangover, comedown, or depression temperature was over 106º F; he developed cerebral edema and multiple-organ that normally follows the next day system failure and died the next day.31 with these drugs.13 Some users have reported that the drug produces an elevated mood, decreased hostility, because it can cause bruxism like are high on other drugs, including higher energy levels, and an overall that experienced by users of ecstasy PCP (phencyclidine), LSD, cocaine, sense of well-being. Some report an and amphetamines.7 amphetamines, and alcohol. Spe- increased attention span and atten- Unfortunately, many patients who cifically identifying bath salts as the tion to detail, similar to the effect of come to the ED are combative, self- causative agent of the patient’s psy- amphetamines.9 destructive, suicidal, or homicidal. chosis isn’t as important as deliver- Reports of euphoria, empathy, in- After they receive several doses of ing effective evidence-based care to creased alertness, and improved con- sedatives and antipsychotic medica- help the patient. centration and focus are frequently tions, their psychosis, delusions, and Because bath salts have come into reported by recreational users.9,13 hallucinations begin to resolve, only widespread use only recently, most Although several people have re- to be replaced with depression, sad- hospitals haven’t yet developed the ported a diminished desire for sexual ness, and suicidal thoughts.18 capability to test for their metabo- activity, most report increased sexual Patients with underlying neuro- lites, which involves sending a urine stimulation.16 logic or psychiatric conditions are at specimen to a specified lab for analy- greatest risk for these adverse psychi- sis. This process can take several Psychosis and other atric reactions.19 The long-term effects hours to days. Unless the patient ad- adverse reactions and the potential for recurrence of mits to taking bath salts or someone Many users present to the ED with signs and symptoms (flashbacks) with the patient can confirm the in- severe anxiety and paranoia, agita- aren’t known. gestion, determining that the patient tion, bizarre behavior, tremors, and Suicidal patients should have an has consumed bath salts requires persecutory hallucinations.11 Signs emergency psychiatric evaluation healthcare professionals to rule out and symptoms can last for several as soon as possible. After being the use of other substances as well as days after the initial ingestion of bath searched for objects of potential medical conditions that can cause a salts. Most people without acute harm, patients should have a “safety change in mental status. (See Many psychosis present with palpitations, sitter” remain with them to ensure names for bath salts.) shortness of breath, diaphoresis, hot their continued safety. No informa- Urine toxicology can rule out use flashes, headaches, hyperthermia, tion has been published about po- of PCP, cocaine, and amphetamines. overwhelming thirst with polydipsia, tential increased risk for suicide on Blood chemistries can rule out serum and other signs and symptoms asso- a long-term basis following ingestion electrolyte imbalances, abnormal ciated with sympathetic nervous of bath salts. glucose levels, and a metabolic aci- system stimulation. These signs and dosis seen in sympathomimetic tox- symptoms are consistent with those Is your patient on bath salts? icity; a complete blood cell count of amphetamine and cocaine intoxi- As discussed, the patient who’s will help to rule out an infection or cation.16,17 Many users report bilat- high on bath salts has signs and severe anemias.20 A computed to- eral jaw pain after using bath salts symptoms similar to those who mography scan of the head rules out www.Nursing2012.com January l Nursing2012 l 29

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. a subarachnoid hemorrhage or other Assess and support the patient’s air- intracranial pathology, such as hy- Many names for bath way, breathing, and circulation first. drocephalus. A 12-lead ECG will salts1,2,4 Assessing the patient’s neurologic likely demonstrate tachycardia. Some of the many names for bath status will provide clues about the Ischemic changes are possible with salts include: degree of impairment the patient’s extreme increases in heart rate or • Bliss experiencing from the bath salts. myocardial oxygen demands. • Blue Silk Obtain a full set of vital signs and • Down2Earth White Horse monitor the patient frequently, ob- Symptomatic treatment • Energizing Aromatherapy serving for a trend of abnormalities No antidote for bath salt toxicity is • Ivory Wave that show the patient is beginning currently available. Treatment is sup- • Kamikaze to decompensate from the over- • portive and directed at the signs and Purple Wave whelming sympathetic stimulation. • symptoms.21 The adverse reactions Red Dove Monitor the patient’s temperature • Vanilla Sky experienced, which are typical of to aid in early identification of poten- • White Lightning. sympathomimetic agents, include tially fatal hyperthermia. An elevated tachycardia, hypertension, palpita- body temperature after use of me- tions, anxiety, tremors, sweating, and consume a large dose, then continue phedrone, a common component of headaches. They can be attributed to to take smaller doses every 1 to 2 bath salts, can suggest a serotonin alpha- and beta-adrenergic receptor hours to sustain their high, some- syndrome-induced hyperthermia.26 stimulation and a sustained release times for several days.13 Hyperthermia increases the risk for of endogenous norepinephrine, do- To decrease the patient’s anxiety, rhabdomyolysis, renal failure, meta- pamine, and serotonin.16 Although agitation, tremors, and psychosis, a bolic acidosis, disseminated intravas- beta-adrenergic blocking agents such sedative is typically required. It’s usu- cular coagulation, coma, and death.26 as propranolol aren’t contraindicated ally a drug from the benzodiazepine Nurses and other healthcare (as they are with cocaine intoxication), class, such as diazepam or lorazepam, professionals, first responders, and they should be used with caution. or a first- or second-generation anti- police should be sure appropriate Because bath salts cause a strong ad- psychotic such as haloperidol or zipra- policies and procedures are in place renergic response, inhibiting one of sidone, respectively.24 When the pa- to protect caregivers. Before engaging the adrenergic receptors could lead tient is hyperthermic, sedation helps any potentially violent patient, keep to an overwhelming stimulation of decrease muscle hyperactivity and in mind that over 50% of ED staff the other receptors.22 decrease the metabolic demands on become victims of patient violence, The same hepatic pathways that the body. and over 5% of violent patients pos- metabolize ecstasy are used to me- According to the American College sess a concealed weapon.24 Follow- tabolize some forms of bath salts.23 of Emergency Physicians, benzodi- ing facility policies and procedures, Patients are also at risk for hepatic azepines are the preferred first-line immediately contact hospital security injury or insufficiency due to the agent because they have a quick on- or the appropriate officials to search overwhelming burden that impuri- set and short duration, and can be the patient for concealed weapons. ties in bath salts place on the liver.23 given I.M.25 Because several doses Healthcare professionals must first N-Acetylcysteine may help to curb may be required to achieve the de- ensure their own safety before they some of the hepatotoxic effects experi- sired clinical effect, the patient may approach the patient. Make sure that enced by those showing signs of liver also experience respiratory depres- the exit is accessible; never let the injury following the use of bath salts.23 sion. Monitor patients’ sedation lev- patient block your route to the exit. Although the rate of bath salt ad- el and respiratory status, and assess Patients with the highest risk for diction is reported to be low, several neurologic, psychiatric, and cardio- engaging in healthcare-directed vio- users and former users have admit- pulmonary status. lence are male and have a history of ted to developing a strong, constant violent behavior, psychiatric illness, urge to use bath salts every day.12 Nursing considerations and/or drug or alcohol abuse.16 Addiction potential is more com- Nurses should focus first on ensur- Because of the spectrum of bath salts’ monly reported by those who prefer ing their own safety while addressing effects, violent behavior can appear to “mini-dose,” meaning they initially the immediate needs of the patient. without warning. Remaining alert for

30 l Nursing2012 l January www.Nursing2012.com

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. subtle clinical indicators may give an legislation and bans, bath salts are early warning that your patient is at still being used quite frequently. high risk for acting out. Be especially Caregivers need a safe environment cautious around patients who speak to provide patient care and protect increasingly loudly and abusively; everyone from injury. ■ have clenched fists; avoid eye contact; have tense posturing; and are REFERENCES 20,24,27 pacing. 1. Melton ST. Bath salts: an “Ivory Wave” epidemic? These behaviors have all been 2011. http://www.medscape.com/viewarticle/ observed in acutely psychotic pa- 748344. 2. New Jersey Office of the Attorney General. tients using bath salts, but be aware Designer drugs labeled as “bath salts”: facts about that bath salts are usually ingested synthetic cathinones. 2011. http://www.nj.gov/oag/ with other substances, such as al- ca/bathsalts/SyntheticCathinonesFacts.pdf. 3. Kavanagh PV, McNamara S, Angelov D, cohol, marijuana, opioids, amphet- McDermo tt S, Mullan D, Ryder SA. The character- amines, or cocaine. Every substance ization of ‘legal highs’ available from head shops in Dublin (Poster). Dublin, Ireland: The National Drug that patients have in their system Advisory and Drug Treatment Board; 2010. will affect their behavior and influ- 4. U.S. Drug Enforcement Administration. Chemi- ence the appropriate course of cals used in “bath salts” now under federal control Many patients who come treatment.11 and regulation. 2011. http://www.justice.gov/dea/ to the ED after using pubs/pressrel/pr102111.html. Verbal deescalating techniques, bath salts are combative, 5. National Institute on Drug Abuse. NIDA Info- such as using a calm, steady voice, Facts: Hallucinogens—LSD, peyote, psilocybin, self-destructive, suicidal, may not be successful in abusers of and PCP. http://www.drugabuse.gov/infofacts/ or homicidal. hallucinogens.html. bath salts who are psychotic. For 6. U.S. Department of Justice. Drug Enforcement hostile, combative patients who Administration. Office of Diversion Control. Con- trolled Substance Schedule. 2011. http://www. don’t respond to verbal interven- deadiversion.usdoj.gov/schedules/index.html. tions and who meet the indications isn’t always possible. Assuming the 7. Dargan PI, Albert S, Wood DM. Mephedrone for emergency restraints, use seda- patient was oriented before con- use and associated adverse effects in school and college/university students before the UK legislation and nonrestrictive methods of suming bath salts, the care team tion change. QJM. 2010;103(11):875-879. restraint first. Keep in mind that should begin to plan for disposi- 8. Wood DM, Greene SL, Dargan PI. Clinical pat- physical restraints will probably be tion when the patient is once again tern of toxicity associated with the novel synthetic cathinone mephedrone. Emerg Med J. 2010;28(4): needed for the safety of everyone oriented and no longer an immi- 280-282. involved in their care. These pa- nent threat to self or others. Prior 9. Brunt TM, Poortman A, Niesink RJ, van den tients include those who are an to discharge, as appropriate, a Brink W. Instability of the ecstasy market and a new kid on the block: mephedrone. J Psychophar- imminent danger to themselves, comprehensive psychiatric evalua- macol. 2010. Epub ahead of print. http://blog.ecu. other patients, or staff, and those tion should be completed. Some edu/sites/penderst/files/2011/01/0269881110378 who need restraints so that the staff patients are discharged to home, 370.full_.pdf. 20 10. Farrell M. New drugs. Presentation. Lisbon, can provide care. Refer to your some released to police custody, Portugal: European Monitoring Centre for Drugs institution’s policies and procedures and others admitted to psychiatric and Drug Addiction; 2010. to guide appropriate and safe re- units. 11. American Association of Poison Control Cen- ters. Bath salts data. 2011. http://www.aapcc.org/ straint use. dnn/Portals/0/8.02.2011Bath%20Salts%20Data% Be prepared 20for%20Website.pdf. Determining the patient’s Because the Drug Enforcement Ad- 12. ACMD: Advisory Council on the Misuse of Drugs. Consideration of the cathinones. http:// disposition ministration has designated bath webarchive.nationalarchives.gov.uk/+/http://www. The patient may require several salts as Schedule I substances, the homeoffice.gov.uk/publications/drugs/acmd1/ hours of ED care and monitoring most restrictive category under the acmd-cathinodes-report-2010?view=Binary. 13. The Vaults of Erowid. Psychoactive vault. 2011. before a final disposition can be Controlled Substances Act, and sev- http://erowid.org/psychoactives/psychoactives. made. Due to the unpredictable eral states have passed legislation to shtml. duration and half-life of many il- ban the drug, bath salts’ popularity 14. Delaware Health Alert Network. Designer drug “bath salts” use in Delaware. 2011. Delaware Health licit substances, determining when may decline as they become less Alert #257. http://dhss.delaware.gov/dhss/dph/php/ psychiatric symptoms will resolve accessible. Unfortunately, despite alerts/dhan257.html. www.Nursing2012.com January l Nursing2012 l 31

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 15. Schifano F, Albanese A. Fergus S, et al. Me- 22. McCord J, Jneid H, Hollander JE, et al. Man- 28. Bath salts blamed for deaths, crimes. Houston, phedrone (4-methylmethcathinone; ‘meow meow’): agement of cocaine-associated chest pain and TX: KPRC Local 2; March 21, 2011. http://www. chemical, pharmacological and clinical issues. myocardial infarction: a scientific statement from click2houston.com/news/27268930/detail.html. Psychopharmacology (Berl). 2011;214(3):593-602. the American Heart Association Acute Cardiac 29. More local deaths, injuries from bath salts. Care Committee of the Council on Clinical Car- 16. James D, Adams RD, Spears R, et al. Clinical Dayton, OH: WHIOTV.COM; July 25, 2011. diology. Circulation. 2008;117(14):1897-1907. characteristics of mephedrone toxicity reported to http://www.whiotv.com/news/28660869/detail. http://www.guidelines.gov/content.aspx?id= the U.K. National Poisons Information Service. html. 12951. Emerg Med J. 2011;28(8):686-689. 30. Craig T. Galveston dad wants ‘bath salts’ 23. Fröhlich S, Lambe E, O’Dea J. Acute liver 17. Kim HS, Aftab A, Shah M, Nayar J. Physical and banned after son’s death. Houston, TX: KHOU-TV failure following recreational use of psychotropic psychological effects of the new legal high ‘Ivory Channel 11; January 30, 2011. http://www.khou. “head shop” compounds. Ir J Med Sci. 2011;180(1): Wave’: a case report. Br J Med Practitioners. 2010; com/news/texas-news/Texas-could-consider- 263-264. 3(4):44-46. http://www.bjmp.org/files/2010-3-4/ banning-Bath-Salts-114880629.html. bjmp-2010-3-4-a343.pdf. 24. Moore G, Pfaff JA. Assessment and manage- 31. Morales I. Tampa man is first reported death in 18. Winstock A, Mitcheson L, Ramsey J, Davies S, ment of the acutely agitated or violent adult. 2011. http://www.uptodate.com/contents/assessment- Florida from ingesting ‘bath salt’ drug. Tampa Bay, Puchnarewicz M, Marsden J. Mephedrone: use, FL: St. Petersburg Times; June 3, 2011. http://www. subjective effects and health risks. Addiction. 2011; and-management-of-the-acutely-agitated-or- violent-adult. tampabay.com/news/publicsafety/tampa-man-is- 106(11):1991-1996. first-reported-death-in-florida-from-ingesting- 19. Winstock AR, Marsden J, Mitcheson L. What 25. Katz ED. Combative, convulsing and crazy: bath-salt-drug/1173190. should be done about mephedrone? BMJ. 2010;340: care of the altered and agitated patient. Presenta- c1605. tion at the Boston Scientific Assembly. Boston, MA, October 5-8, 2009. http://www.acep.org/workarea/ Mark M. McGraw is a staff nurse in the ED and a 20. Babu KM, Boyer EW. Emergency department downloadasset.aspx?id=46517. mobile intensive care nurse on the critical care evaluation of acute onset psychosis in children. transport team at Christiana Care Health Systems in 2011. http://www.uptodate.com/contents/ 26. Garrett G, Sweeney M. The serotonin syndrome Wilmington, Del. emergency-department-evaluation-of-acute- as a result of mephedrone toxicity. BMJ Case Re- onset-psychosis-in-children. ports. 2010. http://casereports.bmj.com/content/ 2010/bcr.04.2010.2925. The author and planners have disclosed that they 21. Hoecker CC. Designer drugs of abuse in have no financial relationships related to this article. children and adolescents. 2011. http://www. 27. Jibson MD. Overview of psychosis. 2011. uptodate.com/contents/designer-drugs-of-abuse- http://www.uptodate.com/contents/overview-of- in-children-and-adolescents. psychosis. DOI-10.1097/01.NURSE.0000408493.33519.d0

For more than 57 additional continuing education articles related to > emergency care topics, go to NursingCenter.com/CE. < Earn CE credit online: Go to http://www.nursingcenter.com/CE/nursing and receive a certiﬁ cate within minutes.

INSTRUCTIONS Is your patient high on “bath salts”?

TEST INSTRUCTIONS DISCOUNTS and CUSTOMER SERVICE • To take the test online, go to our secure website at • Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins http://www.nursingcenter.com/ce/nursing. together by mail, and deduct $0.95 from the price of each test. • On the print form, record your answers in the test • We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter. answer section of the CE enrollment form on page 33. com. Call 1-800-787-8985 for details. Each question has only one correct answer. You may make copies of these forms. PROVIDER ACCREDITATION • Complete the registration information and course Lippincott Williams & Wilkins, publisher of Nursing2012 journal, will award 2.0 contact hours evaluation. Mail the completed form and registration for this continuing nursing education activity. fee of $21.95 to: Lippincott Williams & Wilkins, CE Lippincott Williams & Wilkins is accredited as a provider of continuing nursing Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will education by the American Nurses Credentialing Center’s Commission on Accreditation. mail your certificate in 4 to 6 weeks. For faster service, Lippincott Williams & Wilkins is also an approved provider of continuing nursing include a fax number and we will fax your certificate education by the District of Columbia and Florida #FBN2454. This activity is also provider within 2 business days of receiving your enrollment approved by the California Board of Registered Nursing, Provider Number CEP 11749 for form. 2.0 contact hours. • You will receive your CE certificate of earned contact Your certificate is valid in all states. hours and an answer key to review your results. There The ANCC’s accreditation status of Lippincott Williams & Wilkins Department of Continuing is no minimum passing grade. Education refers only to its continuing nursing educational activities and does not imply • Registration deadline is January 31, 2014. Commission on Accreditation approval or endorsement of any commercial product.

32 l Nursing2012 l January www.Nursing2012.com