Bath Salts

The illegal status of the classical recreational substances, such as marijuana, cocaine, opioids, and methamphetamine, has encouraged teens and adults to seek newer “designer” drugs that offer the advantages of being legal and less expensive. These new “designer drugs” are synthetic substances produced for recreational use. They are readily available in smoke shops, convenience stores, gas stations, and online.  Many designer drugs have now been banned under the Synthetic Drug Abuse Prevention Act of 2012. Parents and other caregivers need to be aware of the emerging trends in substance abuse and knowledgeable about some of the most popular “designer drugs”: synthetic marijuana, “bath salts” and the new synthetic amphetamines. The “designer drugs” are generally pure (and very dangerous) but unfortunately, the contents of packaged synthetic marijuana and bath salts vary and may include chemicals not listed on the label. Users are often unaware of what or how much they are taking. Reliable clinical and experimental data are not available for many of these substances.

 

“DESIGNER DRUGS”

 

Synthetic designer drugs have stimulatory (ecstasy-like) effects and/or hallucinogenic properties. The internet sale and distribution has made the drugs easily available. As these substances are banned or regulated by State and/or Federal agencies, producers simply alter the product’s chemical structure and sell the product under a new name. The new substance is often more potent than the old product, marketed until limited by legal regulations and then changed again. There are a wide variety of synthetic drugs available in smoke shops and the internet. Most are legal and available without a prescription. The most common and widely used families of synthetic drugs are the synthetic cannabinoids, synthetic cathinones (“Bath Salts”) and synthetic amphetamines.

 

Synthetic Bath Salts

Novel synthetic “designer” drugs with ecstasy-like properties have become increasingly popular among recreational drug users. Cathinone is a Schedule I controlled substance that occurs naturally in the Khat plant. The majority of “Bath Salts” are chemically classified as substituted cathinones, meaning they have a phenethylamine core with various additional substitutions. These drugs act at multiple brain receptor sites and either increase dopamine or act as the neurotransmitter serotonin. Ingestion or injection of phenethylamines results in the release of dopamine at a rate 10x that of cocaine. The drugs trigger intense cravings (or a compulsive urge to use the drug again). Frequent consumption may induce tolerance, dependence, and strong withdrawal symptoms.

 

These drugs are known as psychedelic stimulants, meaning they fire up the central nervous system like amphetamine or cocaine and cause hallucinations similar to ecstasy (MDMA) and mescaline. Some of the substituted cathinones are; Methylone (MDMC, Explosion, bk-MDMA), Naphyrone (NRG-1, 4-total), Mephedrone (drone, M-Cat, Meow-meow, bubbles, 4-MMC), MDPV (methylenedioxypyrovalerone) four times more potent than Ritalin or  Concerta (ADHD drugs), Alpha-PVP (cloud 9, magic, black rob, super coke), and Buphedrone. They typically have little or no odor and are sold as a white, off-white, or yellowish powder, in tablet form, capsules or in crystal form. These drugs sell for $5 to $60 a package and each package contains 300-500 mg of the powdered chemical and are often sold as “plant food” or “plant fertilizer.” These drugs are man-made (synthetic) and are extremely pure, anywhere from 98-100%. They are typically ingested or snorted with peak effects from 2 hours and lasting about 8 hours. They may also be injected resulting in more rapid onset of action but shorter duration. Most users assume that 300-500 mg is a normal dose, but in fact, 10 mg or less is an effective dose. This unintentional overdose may result in severe hallucinations and serious side effects. The desired effects from these substituted cathinones are euphoria, increased alertness, energy and concentration, and aphrodisiac effects. However, many side effects occur from using too much; bruxism (teeth grinding), sweating and dehydration, increased heart rate and blood pressure, anxiety and panic attacks, temporary erectile dysfunction in males, hallucinations, psychosis, and depression. Deaths have occurred. Many of these are According to the American Association of Poison Control Centers, calls to poison control centers for exposure to “bath salts” increased from 303 cases in 2010 to 4,137 in 2011 (1,300 % increase).

Methylone (MDMC, Explosion, bk-MDMA)

 

First synthesized in 1996 for use as an antidepressant, and chemically very similar to MDMA.  In 2004 it was being sold as a liquid called “Explosion” and advertised as a “room odorizer vanilla” and stated the product should not be ingested and not to consume more than one bottle. Users report effects to be similar to MDMA (Ecstasy). The effects on the Central Nervous System can include; euphoria, stimulation, increases in sociability, emotional distress, insomnia, restlessness, depression, hallucinations, and psychosis. Some effects on the Sympathetic Nervous System include: increased heart rate and blood pressure, sweating, dilated pupils, bruxism (grinding of the teeth), nausea and vomiting.

 

MDPV (methylenedioxypyrovalerone)

 

MDPV is a relatively new drug that is becoming very popular, and is often sold as “Molly” on the street.  Many people use it for its stimulant properties. In low doses, it is similar to Meth and Cocaine and acts as a norepinephrine-dopamine reuptake inhibitor. MDPV has a high potential for abuse, and can be addictive as it causes the user to crave the drug and use multiple doses.  High doses have adverse ‘bath salt” type effects; extreme paranoia, violence, increased heart rate and blood pressure, panic attacks and mild convulsions, Affects can last about 3 ½  hours with negative side effects lasting 8-48 hours. Severe depression for 5-7 days after use has been reported. It will test in a specialized urine test using GC/MS, however, it should be noted that it   can sometimes trigger false positives for PCP in a standard 12 panel drug test. Because these drugs are relatively new, the short- and long-term effects are not known.

 

The abuse of 3,4-methylenedioxypyrovalerone (MDPV) is a growing public health concern, yet little is known about its pharmacology. Four documented deaths have been reported due to MDPV intoxication, and multiple studies have been released. One study shows MDPV is at least 10 times more potent than cocaine at producing locomotor activation, tachycardia, and hypertension in rats. Their data shows that MDPV is a monoamine transporter blocker with increased potency and selectivity for catecholamine’s when compared with cocaine. The robust stimulation of dopamine transmission by MDPV predicts serious potential for abuse and may provide a mechanism to explain the adverse effects observed in humans taking high doses of 'bath salts' preparations. (Baumann MH, Neuropsychopharmacology. 2013 Mar 13;38(4):552-62.)

 

This case study is that of a 39-year-old male who died of cardiac arrhythmia after use of MDPV.  Postmortem concentrations of MDPV were measured in various tissues. (Wyman JF, et al. “Postmortem Tissue Distribution of MDPV Following Lethal Intoxication by “Bath Salts”.” J Anal Toxicol. Feb 18, 2013)

 

One of the first documented cases of MDPV resulting in death was a 40-year-old male who injected and snorted “bath salts” which contained MDPV. The male became aggressive, very agitated, and had a heart attack. After resuscitation he developed hyperthermia, rhabdomyolysis, coagulopathy, acidosis, anoxic brain injury, resulting in death. (Murray BL, et al. “Death following recreational use of designer drug “bath salts” containing 3,4-Methylenedioxypyrovalerone (MDPV)”  J Med Toxicol. Mar 2, 2012;8(1):69-75.)

 

Alpha-PVP (alpha-pyrrolidinovalerophenone)

 

Known on the street as “flakka”, gravel, cloud 9, magic, α-PVP, or super coke it’s mechanism of action is unknown. It was created in 1960 as a stimulant in the Cathinone family, and is structurally similar to MDPV. It is believed to act similar to MDPV which is a norepinephrine – dopamine uptake inhibitor. Alpha-PVP has been reported to be the cause, or at least a contributor to deaths from suicide and poly drug overdoses. According to DEA, 614 cases involving “Flakka” (alpha-PVP) in 2014, and has been found in Ohio, Texas, Tennessee, and Florida, but is spreading across the US. Florida reported 126 deaths from synthetic Cathinone’s in 2013.  On January 28, 2014, DEA listed alpha-PVP and nine other Cathinone’s as a Schedule I drug under federal law.

 

Most “bath salts” are manufactured in China, Pakistan, India, or New Zealand and repackage into gram packets in the US. Alpha –PVP can be snorted, swallowed, injected, and is being smoked in e-cigarettes or vapes. “Flakka” is small crystal pebbles resembling gravel, another common street name for alpha-PVP. Taking additional “flakka” when already high (known as snacking), or combining it with other drugs can result in serious health effects such as rapid heart rate, extreme agitation, paranoia, aggression, and psychosis. Cathinone’s can cause hyperthermia, with body temperature of 105 degrees, excited delirium, rhabdomyolysis resulting in kidney failure, and adrenaline type strength. Once subjects are restrained they need immediate medical attention or they could die.

The 2-C series of phenethylamines are relative newcomers to the club scene and are very potent and dangerous. They are known as psychedelic phenethylamines and are more potent and longer lasting than ecstasy. Most of the currently known 2C compounds were first synthesized by Alex Shulgin in the 1970s and 1980s, and published in his book, PiHKAL (Phenethylamines i Have Known And Loved) A love story. These compounds are structurally similar to mescaline and ecstasy, and were sold as a “legal” substitute for ecstasy in raves for years. This family of drugs includes 2C-I, 2C-B, 2C-T, 2C-N, 2C-D, 2C-G, 2C-G-3, 2C-O, and 2C-T-7. Some street names include smiles, tootsie, blue mystic, 7-up, bees, nexus, and tripstasy. They are sold online as a white crystalline powder, tablets, or pellets and can be very pure, 98-100%. These drugs are ingested (pill or tablet form), smoked, snorted and used rectally. The high can last anywhere from 4-24 hours with affects similar to ecstasy, but more intense. Common side effects include rapid heart rate, high blood pressure, dilated pupils, dangerously high body temperature, paranoia, hallucinations, chest pain, suicidal ideation, violence and seizures. These substances have been linked to a number of deaths from serotonin syndrome and prolonged vasoconstriction. The vasoconstrictive effect may persist for days and result in sudden death from coronary artery constriction. Injection of the drug may lead to limb gangrene. Other complications include agitation, hallucinations, seizure, liver failure, or kidney failure. Toxicity may be dose related, and when mixed with other drugs such as alcohol, ecstasy, or cocaine can be lethal.

25I-NBOMe
25I-NBOMe is a very potent psychedelic stimulant and considered by users to be a legal version of LSD. It is often in liquid form and put on blotter paper. They are active at very low doses (micrograms) and are generally administered on paper placed under the tongue. The drug is inactive if taken orally and swallowed. It may also be vaporized and inhaled. The onset of effects is rapid. Effects plateau in 2-4 hours, and can last 6-10 hours – sometimes much longer depending on dose. Side effects may last up to 7 days. Users experience visual hallucinations with color shifts, euphoria, dilated pupils, changes in perception of time, increased awareness, feelings of love and empathy and mental and physical stimulation. Undesired side effects include confusion, scrambled communication, paranoia, panic, and seizures. Death has been reported. This substance is now a scheduled I drug and is known as 25i, dimes, or smiles.

Bromo-DragonFLY
This is an extremely potent psychedelic drug and is highly toxic. Known on the street as 7-up, blue mystic, lucky 7, and tripstasy, it is easily ordered online as a research chemical. It can be smoked, ingested in capsules, and injected. It has very similar effects to the substituted phenethylamines (2C family of drugs) and includes rapid heart rate, high blood pressure, dilated pupils, dangerously high body temperature, paranoia, hallucinations, chest pain, suicidal ideation, violence, and seizures. It is different from the 2C family in that Bromo-DragonFLY is a long acting vasoconstrictor and can cause gangrene and amputation. Overdose is believed to be very violent and can result in terrifying hallucinations, massive seizures, spewing of blood, and death. This drug is illegal and should be avoided at all costs.


Intoxication with "Bath Salts"

 

Users may present with the syndrome known as “excited delirium” accompanied by dehydration, breakdown of skeletal muscle and kidney failure. Intoxication from synthetic cathinones has proved fatal in several instances. The dangers of bath salts are compounded by the fact that these products may contain other unknown ingredients that may have their own harmful effects.

 

Bath salts cause the release of large amounts of the neurotransmitter, serotonin, resulting in “serotonin syndrome.” Symptom onset is usually rapid often occurring within minutes. Mild symptoms may only consist of increased heart rate, shivering, sweating, dilated pupils, intermittent tremor, or twitching and over-responsive reflexes. Moderate intoxication includes additional abnormalities such as high blood pressure and elevated body temperature. Temperature may rise to above 41.1 °C (106.0 °F) in life-threatening cases. Mental status changes include hypervigilance and agitation. Severe symptoms include suicidal ideation, violence, seizures, and death.

 

Bath salts and pregnancy

 

 Scientific information on the use of cathinones during pregnancy are limited to case studies and small case series. The use of these drugs should be avoided during pregnancy; however, fetal exposure is currently not grounds for termination of pregnancy or further diagnostic studies.

 

 “Molly”

 

Molly is believed to be 100% pure Ecstasy (MDMA), got its name from “molecule” or “molecular,” and is in crystalline form like sugar. However, currently Molly is considered to be a  mixture of other designer drugs in the phenethylamine/cathinone family, which act like Ecstasy, and is causing overdose and death. The composition of Molly on the street is unknown and can vary. Ecstasy is known for inducing feelings of euphoria, closeness, diminished anxiety, increased body temperature (sweating), and is frequently used at raves.

 

The popularity of the Molly is attributed largely to hip hop. Many rap songs released in the last year have references to Molly. In "Mercy," Kanye West says "something 'bout Mary she gone off that Molly." In "All Gold Everything" Trinidad James raps "popped a Molly, I'm sweatin." Lil Durk and Wiz Khalifa released a track called "Molly Girl." Madonna recently referred to the drug at one of her concerts and received a standing ovation after saying “Molly.”

Molly can cause muscle tension, nausea, blurred vision, and increased heart rate and blood pressure. Forceful clenching of the teeth can occur and individuals at clubs often chew on pacifiers to relieve some of the tension. Even if a person takes only one dose, the side effects of Molly—including feelings of sadness, anxiety, depression, and memory difficulties—can last for several days to a week or longer in people who use MDMA regularly.

 

Molly also causes users to become dehydrated through vigorous activity in a hot environment (club). It interferes with the body's ability to regulate its temperature resulting in dangerous overheating. This can lead to serious heart and kidney problems or, rarely, death. Molly can be extremely dangerous in high doses or when multiple small doses are taken within a short time period to maintain the high. High levels of the drug in the blood stream can increase the risk of seizures and affect the heart's ability to maintain its normal rhythms.

 

Researchers that study the brain think that Molly may affect the way that nerve cells communicate with each other by altering the effects of the serotonin. The serotonin system plays a direct role in controlling our mood, aggression, sexual activity, sleep, and sensitivity to pain. Memory loss is a problem among regular users of Molly.

 

Substituted Amphetamines

 

PMA (para-methoxyamphetamine)

PMA looks like and is usually sold as an ecstasy tablet. It is known on the street as Red Mitsubishi, Killer, Death, Dr. D., Pink Ecstasy, and Chicken Powder. PMA shares the same initial buzz and hallucinogenic qualities of Ecstasy but can cause a fatal rise in temperature in some users. PMA has been associated with numerous adverse reactions including death. Effects of PMA ingestion include many of the side effects of other amphetamines including accelerated and irregular heartbeat, blurred vision, and a strong feeling of intoxication that is often unpleasant. PMA is reportedly euphoric at low doses but at higher doses has unpleasant effects such as nausea, vomiting, dangerously high body temperature, and hallucinations. These effects quickly overpower any pleasurable effects. The effects of PMA also seem to be much more unpredictable and variable between individuals than those of Ecstasy and sensitive individuals may die from a dose of PMA that a less susceptible person tolerates.

 

There are approximately twice as many deaths caused by PMA as by Molly or Ecstasy, even though the actual proportion of PMA on the market is only a fraction of that of MDMA. While PMA alone may cause significant toxicity, the combination of PMA with MDMA has a combined effect that seems to be particularly hazardous. Since PMA has a slow onset of effects, several deaths have occurred where individuals have taken a pill containing PMA followed by a pill containing MDMA some time afterwards due to thinking that the first pill was not active.

 

PMA overdose can be a serious medical emergency that may occur at doses only slightly above the usual recreational dose range, especially if PMA is mixed with other stimulant drugs such as cocaine or MDMA. Characteristic symptoms are a severe increase in body temperature, rapid heart rate, and high blood pressure along with agitation, confusion, and seizures. Complications sometimes include more serious symptoms such as muscle breakdown and bleeding into the brain requiring emergency surgery.

 

MDA (methylenedioxyamphetamine)

 

Known on the street as “sass,” “Mandy,” or “sass-a-frass,” this is another psychedelic designer drug that has been used since the 1960’s. Even though it is illegal (sch I, it can be purchased on line as a research chemical. MDA is related to MDMA, but is more potent in its psychedelic effects and can overstimulate the central nervous system and cardiovascular system. Symptoms include agitation, sweating, increased heart rate and blood pressure, dramatic increase in body temperature, convulsions and death.

3,4-CTMP (methylphenidate family ADHD drugs)
It is known to be 7X more potent than Ritalin, and cause mild stimulation, increased heart rate, reduced appetite, and insomnia. 3.4-CTMP has no medicinal use and is sold online as a research chemical, “not for human consumption.”

Benzo Fury (Benzofurans: amphetamine-like)

 

Benzo Fury is one of the most popular "legal highs" in Britain and is gaining in popularity in the United States. Benzo Fury is an entactogenic compound like ecstasy and amphetamine. It is a popular party drug and is available over the Internet. The risks of taking this substance are not known but it affects the brain in the same way as amphetamine or ecstasy and it is addictive. It has strong vasoconstriction and jaw clinching effects, as well as increased heart rate, sweating, tingling of extremities, euphoria, insomnia, dilated pupils, and depression. Some of the Benzo’s out there are 5-MAPB, 5-APB, 6-APB, 5-EAPB, and 5-API.

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