INTRODUCTION: New novel drugs have appeared in recent years to circumvent improved routine drug screening. A class of drugs known as “bath salts” has emerged and has a high abuse potential but leaves no identifiable markers in routine drug screens. We present a patient who abused an unknown substance that was later identified as bath salts.
CASE PRESENTATION: A previously healthy 21 year old male was brought to an outside hospital by his wife with a 2 week history of agitation and paranoia. She states that he was having visual and auditory hallucinations, as well as exhibiting violent behavior. He had poor hygiene and had been running barefoot throughout the house and yard for the past several days. Her main reason for bringing him into the emergency department was that he had run into his eight month year-old baby’s crib, broken it, fallen through a window, and became unconscious. He regained consciousness in the emergency department, and was very violent and agitated,requiring heavy sedation. His vitals were stable and physical exam was unremarkable. There were no track marks or signs of intravenous drug abuse. His labs, including a drug screen were unremarkable. After an extensive work-up, the etiology of his agitation was unknown until his wife and mother arrived to the emergency department with a bag of a substance called “ Red Dove.” This was further identified to be what is known as bath salts, and his wife and mother report that he had been “snorting” the drug for approximately 2 weeks. He was kept sedated to allow time for the drug to wear off, and discharged the following day.
DISCUSSION: The use of bath salts as recreational drugs has greatly escalated in recent years. According to the American Association of Poison Control Centers, calls for poisonings related to bath salts have sky rocketed, with 1,782 since January compared to just 302 last year(1). They are sold for as little as $10 in grocery stores, smoke shops, truck stops and the internet, marketed as bath salts or sometimes plant food and come with the (often ignored)disclaimer, "not for human consumption." They possess a high abuse potential and are similar to methamphetamine and cocaine. The powdery substances contain synthetic stimulants including MDPV (3,4-methylenedioxypyrovalerone) and mephedrone. Unfortunately, these substances are not detectable on drug screens. The synthetic products are given benign names such as: Ivory Snow, Cloud Nine, Blue Silk, Red Dove, Vanilla Sky, Ivory Wave, Bliss, White Lightning and Hurricane Charlie(2). Despite their modest appearance, they produce frightening side effects in addition to the “high” that users seek. The effects include increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia and delusions. These drugs are not regulated by the FDA, yet have caught the attention of the White House, which on Feb 2, 2010 issued a statement to the American public warning of the dangers of the drugs(3). On Thursday, Jan. 6, Louisiana Gov. Bobby Jindal announced he was classifying the substances as a Schedule 1 drug in Louisiana, meaning selling, buying, or possessing the substances would incur the same legal penalties as someone selling, buying or possessing heroin. Since then, twenty-six states including Florida, Alabama, Utah and Kentucky have followed suit to make substances in these products illegal. Treatment of patients that have ingested bath salts include sedation until the drug’s side effects wear off along with supportive care.
CONCLUSIONS: This rising scourge of bath salts as a drug of abuse is highly concerning, and should be considered in the differential of patients presenting to the emergency department with symptoms of methamphetamine and cocaine abuse, but with negative drug screens.
Reference #1 American Academy of Poison Control Centers. Home Page. 20 April 2011. http://www.aapcc.org/dnn/Portals/0/prrel/april20bathsalts.pdf
Reference #2 American Academy of Poison Control Centers. Home Page. 21 Dec 2010. www.aapcc.org/dnn/Portals/0/prrel/bathsalts-final.pdf
Reference #3 AFP."White House Warns ‘Bath Salt’ Stimulants. Montreal Gazette 2 Feb 2011. http://www.montrealgazette.com/health/White+House+warns+bath+salt+stimulants/4209456/story.html
DISCLOSURE: The following authors have nothing to disclose: Jeremy Moad, Gary Kinasewitz
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