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Common or street names: Flakka, Ivory Wave, Vanilla Sky, Cloud Nine, Blue Silk, Purple Sky, Bliss, Purple Wave, Red Dove, Zoom, Bloom, Ocean Snow, Lunar Wave, White Lightening, Scarface, Hurricane Charlie, Drone, Energy-1, Meow Meow, Sextasy, Ocean Burst, Pure Ivory, Snow Leopard, Stardust, White Night, White Rush, Charge Plus, White Dove, plant fertilizer, plant food Psychoactive bath salts (PABS) are a designer drug of abuse that has led to reports of dangerous intoxication from emergency departments across the US. "Bath salts" are not a hygiene product, as the name might imply. "Bath salts" are central nervous system stimulants that inhibit the norepinephrine-dopamine reuptake system and can lead to serious, and even fatal adverse reactions. The most commonly reported ingredient in "bath salts" is methylenedioxypyrovalerone (MDPV), although other stimulants may be present, such as mephedrone and pyrovalerone.1 MDPV is of the phenethylamine class and is structurally similar to cathinone, an alkaloid found in the khat plant and methamphetamine.
Mephedrone has been reported to have a high potential for overdose.2 On September 7, 2011 the US Drug Enforcement Agency announced emergency scheduling to control MDPV, mephedrone and methylone, all chemicals found in "bath salts". In July of 2012, U.S. President Barack Obama signed into law a ban on mephedrone, methylone and MDVP, all chemicals found in "bath salts, by placing them on the Schedule I controlled substances list. Schedule I controlled substances cannot be sold under any circumstances and cannot be prescribed for medical purposes. The law also bans any future designer chemical compounds meant to mimic the effects of bath salts. Having possession or selling these chemicals or any product that contains them is illegal in the US.1 MDVP is structurally related to methylenedioxymethamphetamine (MDMA) and cathinone derivatives. MDMA is a schedule I hallucinogenic substance and cathinone derivatives (cathinone, methcathinone) are listed as schedule I stimulants. Animals studies have demonstrated elevated levels of extracellular dopamine 60 minutes after admininstration of MDVP.3
Before the DEA ruling, "bath salts" were noted to be easily accessible in convenience stores, gas stations, over the Internet and in "head" or smoke shops. "Bath salts", packaged in powder form in small plastic or foil packages of 200 to 500 milligrams, sold for roughly $20 per package. Most packages were labeled "not for human consumption". The "bath salt" powder appeared white, off-white or slightly yellow-colored.4 "Bath salts" are noted for producing a "high" similar to methamphetamine and have been called "legal cocaine". "Bath salt" users usually snort the drug intranasally, but it can also been injected, smoked, orally ingested or used rectally. Effects may occur with doses as low as 3 to 5 milligrams, but average doses range from 5 to 20 milligrams. There is a great risk for overdose because retail packages may contain up to 500 milligrams. If ingested orally, absorption is rapid with a peak "rush" at 1.5 hours, the effect lasting 3 to 4 hours, then a hard "crash". The total "bath salts" experience may last upwards of 8 hours.1
Reports from emergency departments note that "bath salt" use can lead to sympathetic nervous system effects such as tachycardia (fast heart rate), hypertension (high blood pressure), hyperthermia (elevated body temperature), seizures (convulsions). Death has been reported.4 Altered mental status may present as severe panic attacks, agitation, paranoia, delusions, hallucinations, and violent behavior (including self-mutilation, suicide attempts and homicidal activity.) The full extent of "bath salt" abuse is not known. In addition to use in the US, DEA reports of illicit MDPV use have been noted in Europe and Australia. The first reports of MDPV seizure was from Germany in 2007.3 The United Kingdom, Australia, Canada and Israel have banned the chemicals.6 According to the DEA, the first US reports came in during 2009.3 From 2010 to 2011, reports in the US increased dramatically. As of March 22, 2011, poison control centers in 45 states and the District of Columbia had received calls related to "bath salts".
In the first 3 months of 2011, US poison control centers have received 5 times as many calls relating to "bath salts" as compared to the total number of calls in 2010.5 In 2015, authorities in Florida have cited the use of a new type of cathinone called 'flakka" that illicits a delusional state in it's users. Prior to the federal ban, many states had enacted their own bans on at least some of the chemicals found in "bath salts". Marquette County, Michigan took quick and local action to restrict abuse of "bath salts" in February of 2011 due to a rash of emergency admissions from November 2010 through March 2011. An emergency public health order was executed by the Marquette County Health Department to allow seizure of "bath salts" from a local store. Subsequent testing found that the products contained MDPV. Among 35 patients, 17 were hospitalized, and one died. The median age of the patient was 28 years (range 20-55 years), with men accounting for 54% of admissions. Twenty-four of these 35 patients (69%) had a self-reported history of drug abuse, 16 patients (46%) had a history of mental illness, and six patients (17%) reported suicidal thoughts or attempts that may have been related to "bath salt" use.5
The pharmacological activity of MDPV, and related chemicals may result in serious and potentially fatal adverse effects. MDPV inhibits the norepinephrine-dopamine reuptake system and leads to central nervous system stimulation. Acute side effects may include rapid heart rate, high blood pressure, hyperthermia (elevated body temperature), vessel constriction, muscle spasm/tremor, and seizures. Higher doses can lead to behavioral and psychiatric effects such as severe panic attacks, psychosis (hallucinations, delusions), paranoia, agitation, insomnia (inability to sleep), irritability, and violent behavior.1,4 In the reported Marquette County, Michigan cases the most common signs and symptoms of toxicity were agitation (66%), tachycardia (63%), and delusions/hallucinations (40%). Accidental deaths due to overdose and "bath salt"-related suicides have been reported.5,6 Care of patients with an overdose may require admission to the intensive care unit, use of intravenous sedatives, antipsychotics, and/or restraints, or other measures to protect the patient and health care providers from harm.
Rhabdomyolysis (the destruction of muscle fibers and the release of myoglobin, a protein, into the bloodstream that may lead to kidney damage) may occur, as well.1,5 Supportive care is given in overdose cases as there is no known antidote. "Bath salts" have been reported to have a powerful addictive potential, as well as the ability to induce tolerance (more of the drug is required over time to get an equivalent "high"). Reports note intense cravings similar to what methamphetamine users experience.2 As "bath salts" may be cut with other unknown and potentially addictive substances, the true magnitude of toxicity and addiction may be even higher. As of September 2011, routine drug screens do not detect "bath salt" psychoactive ingredients.1 Ross EA, Watson M, Goldberger B, et al."N Engl J Med 2011; National Institute on Drug Abuse (NIDA). Nora D. Volkow, MD. Message from the Director on "Bath Salts" - Emerging and Dangerous Products. Bath Salts of Designer Cathinones (Synthetic Stimulants).