“Bath Salts” Are Not for Bathing Anymore
How harmful are the illicit drugs known as “bath salts”?
When you hear the words “bath salts,” images of hot water, relaxation, and pleasant aroma should be conjured up. However, there is a twist to the colloquial use of bath salts (now called PABS, or psychoactive bath salts), and it can be fatal. Today’s variety (marketed as “White Rush,” “Ocean Snow,” and “Red Dove” among many other names) is not intended for bathing at all, but contains stimulants (for example, MDPV or 4-methylmethcathinone) that are inhaled, injected, instilled per rectum, or taken by mouth.1,2.
The result is so toxic that it has been said that PABS have the worst characteristics of LSD, PCP, ecstasy, cocaine, and methamphetamine.2 Liver failure developed in one patient who used PABS. Other reported adverse effects are tachycardia, seizures, hyperthermia, rhabdomyolysis, panic attacks, and violent behavior, including self-mutilation—and all these effects can be ob- tained for about $20.1,2 Anything more than 50 mg is a dangerous dose, but packages of PABS may contain as much as 500 mg of active drug.
“LEGAL COCAINE”
One may inquire as to why these drugs are available at all, especially since they have been described as “legal cocaine.”2 They mimic the effect of illegal drugs but are structurally dissimilar and therefore may not be covered under the same legal umbrella. Labels on PABS also disingenuously warn that they are not for human consumption. To make matters worse, they are taken with multiple other drugs (marijuana, opiates, cocaine, and amphetamines) and in combination or alone have been fatal. Apparently, Michigan (a report decribed 35 patients in Michigan who abused bath salts)1 and other states are attempting to add PABS to their controlled substance lists. Recently, the US Drug En- forcement Administration issued an order to temporarily classify the stimulants used in PABS as Schedule I controlled substances while the agency studies whether these drugs should be permanently controlled 3.
TIPS FOR CLINICIANS
Treatment for an overdose should include a benzo- diazepine such as lorazepam in low or moderate doses. Antipsychotics have been used if lorazepam is not sufficient, which is often the case. Here are some helpful rules for clinicians regarding PABS2:
•Be aware of the abuse of these drugs; they are often not on our radar screen.
•PABS are not detected on routine drug screens.
•Realize that patients will need care in the ICU. Care may entail restraints and high-dose sedation (and seizure treatment) so as not to let abusers cause harm to themselves or others.
Designer drugs have included nonpharmaceutical fentanyl, levamisole-contaminated cocaine, synthetic marijuana or “spice,” and opiates. Now PABS have been added to the list.
1. Benzie F, Hekman K, Cameron L, et al. Emergency department visits after use of a drug sold as “bath salts”—Michigan, November 13, 2010-March 31, 2011. MMWR. 2011;60:624-627.
2. Ross EA, Watson M, Goldberger B. “Bath salts” intoxication. N Engl J Med. 2011;365:967-968.
3. Drug Enforcement Administration, Department of Justice. Schedules of Controlled Substances: temporary placement of three synthetic cathinones into Schedule I. Fed Regist. 2011;76(204): 65371-65375.