Pharmacology

Awash in “bath salts”: The dangers and skyrocketing use of mephedrone

Matt Pearson, a 36-year-old white male, is brought to the emergency department (ED) by his wife about an hour after snorting 1 g of mephedrone. He is agitated, hallucinating, and diaphoretic. His wife states he has a history of cocaine abuse and cardiovascular problems, most likely inherited from his father. She adds that he has been out of work and feeling depressed; after seeing an Internet advertisement for an inexpensive drug called “bath salts,” he ordered it, then snorted it immediately after it arrived in the mail.

On his arrival at the ED, the nurse who admits Mr. Pearson completes a full assessment, which finds the following: heart rate 180 beats/minute and irregular, respirations 30 breaths/minute, blood pressure 168/98 mm Hg, temperature 39.1° C (102.4° F), peripheral oxygen saturation 94% on room air, and blood glucose 98 mg/dL. Electrocardiography shows supraventricular tachycardia. Blood tests are negative except for an elevated sodium level.

Although alert, Mr. Pearson is incoherent. He states, “There are bugs crawling on the walls!” Otherwise, physical findings are unremarkable. He complains of extreme thirst.

Over the past few years, numerous patients (especially adolescents and young adults) have presented to EDs with life-threatening arrhythmias, dehydration, and hallucinations after ingesting mephedrone—a synthetic stimulant and psychoactive drug known by such street names as bath salts, plant food, Meow Meow, M Cat, meph, and moonshine.

Considered a legal high until the U.S. Drug Enforcement Administration (DEA) banned it in September, mephedrone contains compounds derived from plant and fungal material that could easily be purchased on the Internet without restriction. Many people have resorted to using mephedrone and similar synthetic drugs in fear of losing their jobs or being arrested if caught using cocaine, methylenedioxymethamphetamine (MDMA or “Ecstasy”), or other methamphetamines. The effects of mephedrone mirror those of cocaine, Ecstasy, and methamphetamines. The drug contains the stimulant cathinone, found in Catha edulis, whose leaves are chewed for medicinal effects in Somali, Yemeni, and Ethiopian communities. Cathinone derivatives are similar structurally to amphetamine.

Mephedrone has been marketed aggressively on the Internet since 2004. By 2008, it was being used in France, Denmark, and Australia. It reached the United Kingdom (UK) in 2009 and the United States soon after. It owes its popularity to its easy access and desired physiologic and psychological effects—increased alertness, confidence, euphoria, sociability, plus stimulation and auditory enhancement. Many young people reportedly have decreased their use of cocaine, Ecstasy, and amphetamines in favor of mephedrone. Users typically take mephedrone in higher dosages than they would amphetamines and Ecstasy. The drug is hard to stop using once started and can lead to toxic physiologic and psychological effects.


Rapid rise in use and regulation

After mephedrone became popular in the UK, its increased use and devastating side effects (including numerous deaths) quickly led to legislation banning the drug in 2010. In the UK, mephedrone is now a Class B controlled substance. Widespread international restrictions rapidly increased; currently, the drug is a controlled substance in Denmark, Israel, Sweden, Norway, Germany, Finland, and Australia.

In 2010, the United States began to see a similar surge in mephedrone use. In 2010, the American Association of Poison Control Centers (AAPCC) reported that 45 states and the District of Columbia had received telephone inquiries regarding mephedrone. By April 2011, AAPCC was receiving five times the number of mephedrone-related calls than in all of 2010. One Michigan ED saw 71 mephedrone-related visits in 6 months; before that, it saw none. In Louisiana, 84 people reportedly were admitted to EDs for paranoia, fighting, hallucinations, suicidal thoughts, hypertension, and tachycardia related to mephedrone use. Such reports have occurred throughout the United States.

In September, the DEA invoked its emergency authority to temporarily ban mephedrone and two other stimulants (3,4-methylenedioxypyrovalerone and methylone). The action makes possessing or selling these drugs or the products that contain them illegal for at least 1 year while the DEA and U.S. Department of Health and Human Services study whether they should be permanently controlled. According to DEA Administrator Michele Leonhart, the action was necessary “to protect the public from the imminent hazard posed by these dangerous chemicals.” Before the DEA banned them, 33 states had already taken action to control or ban these substances.

Pharmacologic effects

Mephedrone acts as a powerful central nervous system (CNS) stimulant by promoting release of monoamine neurotransmitters and inhibiting their reuptake. It binds with dopamine, noradrenaline, and serotonin transporters. Common physiologic effects include excessive sympathomimetic stimulation (such as agitation, tachycardia, systolic hypertension, seizures, nausea, headache, increased libido, and cold blue fingers). Some people use the drug to attain such psychological effects as increased alertness, confidence, euphoria, sociability, stimulation, auditory enhancement—with little or no hangover effect the next day.

The drug comes in capsules, tablets, and powder. The most common administration routes are nasal insufflation (snorting) and oral ingestion. Snorting produces effects within a few minutes. Dissolved in water, mephedrone can be used rectally and I.V. When wrapped in cigarette paper, the powder can be swallowed in a method called “bombing.” See the box below for key facts about mephedrone.

Mephedrone at a glance

Please click the PDF icon above to view.

Emergency treatment and nursing care

Clinical findings and adverse reactions in patients who’ve taken mephedrone mimic those of other sympathomimetic stimulants, such as Ecstasy and cocaine. Currently, no treatment guidelines exist. The key to effective care is rapid treatment of signs and symptoms, as described below.

CNS adverse effects

Anxiety: Benzodiazepines are the drugs of choice to manage agitation; higher-than-normal dosages may be needed. Provide emotional support and comfort measures throughout the acute anxiety phase. Reassure the patient and family that mephedrone has a short half-life; after it’s metabolized completely, anxiety and paranoia should resolve. Allow family members to comfort the patient, if possible.

Seizures: If seizures occur, rule out other possible causes, such as dehydration, hyperthermia, or metabolic acidosis. As ordered and needed, give benzodiazepines. Follow seizure precautions according to facility protocol.

Hallucinations: No medications are available to manage hallucinations. Benzodiazepines and haloperidol may decrease the associated agitation, but hallucinations won’t disappear fully until mephedrone is metabolized. Keep the patient safe and provide one-to-one care if sufficient staff are available.

Tremors, bruxism, mild muscle clenching, headache, pupil dilation, blurred vision, and numbness: Reassurance and support may be the only effective interventions until mephedrone is metabolized. Benzodiazepines may be used in severe cases.

Cardiovascular adverse effects

Reassure patients, and tell them that continuous cardiac monitoring and use of appropriate medications most likely will resolve cardiovascular adverse effects until mephedrone is metabolized by the body.

Tachycardia: Review laboratory results for indicators of dehydration. Be aware that tachycardia may result from increased sweating and decreased fluid intake. Treatment may include fluid replacement. If tachycardia doesn’t resolve and atrial or ventricular arrhythmias occur, follow advanced cardiac life support protocols.

Hypertension: As mephedrone is metabolized, hypertensive crisis may resolve. Alpha or beta antagonists or vasodilators may be given, if needed.

Chest pain: Mephedrone can cause severe vasoconstriction, impairing oxygenation to coronary arteries. Standard vasodilators, such as nitroglycerin and analgesics, are recommended.

Respiratory adverse effects

Rapid respiratory rate: Provide supplemental oxygen and bronchodilators as needed and ordered for bronchoconstriction. Monitor pulse oximetry values continuously until the respiratory rate returns to normal. Stay with the patient during respiratory distress and provide comfort measures to reduce anxiety and fear.

Patient teaching

Advise patients to stop using mephedrone immediately due to its harmful effects. If they choose to continue using it, advise them to avoid using it with other stimulants, alcohol, or depressants. Caution them not to inject the drug because of possible impurities, toxic effects on the veins, and quick onset of slow breathing and numbness. Teach them to maintain adequate hydration and avoid getting overheated during mephedrone use.

Suggest drug and alcohol rehabilitation services for patients who use the drug repetitively or have become addicted. Provide information and support to the patient and family; as appropriate, refer the patient for an evaluation for treatment or rehabilitation. Some patients may need psychological counseling and support to prevent further use.

Help raise awareness

Mephedrone use has been the source of countless life-threatening incidents and has caused numerous deaths. Unfortunately, epidemiologic evidence is scant. No evidence-based studies have been published on the drug’s effects on humans or animals, and its long-term effects are unknown.

As a healthcare professional, you need to be aware of mephedrone’s physiologic and psychological effects, and be prepared to provide emergency care as needed. Your understanding of presenting symptoms and emergency care can promote rapid treatment. Take steps to raise public awareness of the dangers of mephedrone and other synthetic drugs. Education can be a powerful tool in reducing both its use and its devastating consequences.

Selected references

American Association of Poison Control Centers. U.S. poison centers raise alarm about toxic substance marketed as bath salts; states begin taking actions. Alexandria, VA: American Association of Poison Control Centers; 2011. http://www.aapcc.org/dnn/portals/0/prrel/bathsaltsmarch22.pdf. Accessed September 22, 2011.

Brunt T, Poortman A, Niesink R, and Brink W. Instability of the ecstasy market and a new kid on the block: mephedrone. Psychopharmacol. 2010 Sept 8. doi:10.1177/0269881110378370.

Drugs Forum. Mephedrone. http://www.drugs-forum.com/forum/showwiki.php?title=Mephedrone. Accessed September 22, 2011.

Manghi R. Khat use: lifestyle or addiction. J Psychoactive Drugs. 2009 Mar;41(1):1-10.

McConnaughey J. Drugs disguised as bath salts send users to ERs. Updated December 23, 2010. http://www.msnbc.msn.com/id/40797021/ns/health-addictions/t/drugs-disguised-bath-salts-send-users-ers/. Accessed September 22, 2011.

Measham F, Moore K, Newcombe R, Welch Z. Tweaking, bombing, dabbing, and stockpiling: the emergence of mephedrone and the perversity of prohibition. Drugs Alcohol Today. 2010;10(1):14-21.

Schifano F, Albanese A, Fergus S, et al; Psychonaut Web Mapping; ReDNet Research Groups. Mephedrone (4-methylmethcathinone; ‘meow meow’): chemical, pharmacological and clinical issues. Psychopharmacology (Berl). 2010 Apr;214(3):593-602.

U.S. Drug Enforcement Administration. DEA moves to emergency control synthetic stimulants. September 7, 2011. http://www.justice.gov/dea/pubs/pressrel/pr090711.html. Accessed September 22, 2011.

Winstock A, Mitcheson L, Deluca P, et al. Mephedrone, new kid for the chop? Addiction. 2011 Jan;106(1):154-61. doi:10.1111/j.1360-0443.2010.03130.x.

Wood DM Greene SL, Dargan PI. Clinical pattern of toxicity associated with the novel synthetic cathinone mephedrone. Emerg Med J. 2011 Apr;28(4):280-2.

Catherine P. Lovecchio is an assistant professor in the nursing department at the University of Scranton in Scranton, Pennsylvania.

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