title: Clinical experience with and analytical confirmation of "bath salts" and "legal highs" (synthetic cathinones) in the United States.
abstract: Recently, there has been a worldwide rise in the popularity and abuse of synthetic cathinones. In 2009 and 2010, a significant rise in the abuse of a new group of synthetic cathinones was reported in Western Europe. In 2010, the rapid emergence of a new drug of abuse, referred to as bath salts or "legal high," occurred in the USA. The growing number of cases along with the alarming severity of the effects caused by the abuse of these substances prompted significant concern from both healthcare providers and legal authorities. We report the experience of the first 8 months of two regional poison centers after the emergence of a new group of substances of abuse.
  
  
  METHODS
  This was a retrospective case series of patients reported to two poison centers with exposures to bath salts. Additionally, 15 "product samples" were obtained and analyzed for drug content using GC/MS.
  
  
  RESULTS
  There were 236 patients of which 184 (78%) were male. Age range was 16-64 years (mean 29 years, SD 9.4). All cases were intentional abuse. There were 37 separate "brand" names identified. Clinical effects were primarily neurological and cardiovascular and included: agitation (n = 194), combative behavior (n = 134), tachycardia (n = 132), hallucinations (n = 94), paranoia (n = 86), confusion (n = 83), chest pain (n = 40), myoclonus (n = 45), hypertension (n = 41), mydriasis (n = 31), CPK elevations (n = 22), hypokalemia (n = 10), and blurred vision (n = 7). Severe medical outcomes included death (n = 1), major (n = 8), and moderate (n = 130). Therapies included benzodiazepines (n = 125), antipsychotics (n = 47), and propofol (n = 10). Primary dispositions of patients were: 116 (49%) treated and released from ED, 50 (21%) admitted to critical care, 29 (12%) admitted to psych, and 28 (12%) lost to follow up. Nineteen patients had blood and/or urine analyzed using GC/MS. MDPV was detected in 13 of 17 live patients (range 24-241 ng/mL, mean 58 ng/mL). The four samples with no drug detected, reported last use of bath salts >20 h prior to presentation. Three of five patients had MDPV detected in urine (range 34-1386 ng/mL, mean 856 ng/mL). No mephedrone or methylone was detected in any sample. Quantitative analysis performed on postmortem samples detected MDPV in blood at 170 ng/mL and in urine at 1400 ng/mL. No other synthetic cathinones were detected.
  
  
  CONCLUSIONS
  This is the first report of MDPV exposures with quantitative blood level confirmation. Clinical effects displayed a sympathomimetic syndrome, including psychotic episodes often requiring sedation, movement disorders, and tachycardia. Within 8 months of their appearance, 16 states had added synthetic cathinones to the controlled substances list as a Schedule I drug.
  
  
  CONCLUSIONS
  We report the emergence of a new group of substances of abuse in the USA, known as bath salts, with quantitative results in 18 patients. State and federal authorities used timely information from poison centers on the bath salt outbreak during investigations to help track the extent of use and the effects occurring from these new drugs. Close collaboration between state authorities and poison centers enhanced a rapid response, including legislation.
authors.affiliation: Kentucky Regional Poison Center, Louisville, KY 40232-5070, USA. henry.spiller@nortonhealthcare.org
authors.forename: Henry A
authors.initials: HA
authors.lastname: Spiller
authors.forename: Mark L
authors.initials: ML
authors.lastname: Ryan
authors.forename: Robert G
authors.initials: RG
authors.lastname: Weston
authors.forename: Joanne
authors.initials: J
authors.lastname: Jansen
mesh_terms: D000293:Adolescent; D000328:Adult; D000470:Alkaloids; D014150:Antipsychotic Agents / Q000627:therapeutic use; D002138:Calibration; D002849:Chromatography, Gas; D005260:Female; D008401:Gas Chromatography-Mass Spectrometry; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007202:Indicators and Reagents; D007880:Legislation, Drug; D008297:Male; D008875:Middle Aged; D009207:Myoclonus / Q000139:chemically induced / Q000188:drug therapy; D020258:Neurotoxicity Syndromes / Q000523:psychology; D011039:Poison Control Centers; D012015:Reference Standards; D012189:Retrospective Studies; D015813:Substance Abuse Detection; D019966:Substance-Related Disorders / Q000175:diagnosis* / Q000401:mortality / Q000523:psychology; D014481:United States; D055815:Young Adult
chemical_list: D000470:Alkaloids; D014150:Antipsychotic Agents; D006993:Hypnotics and Sedatives; D007202:Indicators and Reagents; C023665:cathinone