Bath salts in the emergency department

Psychosis, agitation, disorientation, or bizarre behavior due to drug ingestion is a common presentation to the emergency department (ED), and frequently psychiatry is consulted to assess for an underlying psychiatric illness. A working knowledge of how different substances are expected to affect patients is an important part of keeping up-to-date as a psychiatric emergency clinician. Thus it was particularly disturbing to learn from a recent NYU study that up to 40% of the “Molly” or “ecstasy” (common names for MDMA) consumed by club-goers in New York City may be contaminated with cathinone-derived substances, otherwise known as the dreaded “bath salts.”

Bath salts are synthetic stimulants which were previously legal in many states, undetectable by many drug urine screens and contain multiple compounds. They were labeled as “bath salts” and “not for human consumption” so that they could be sold legally in retail settings – most states have now banned them explicitly. MDMA, previously marketed as “ecstasy” is now more commonly sold as “Molly,” reputed to be purer and more effective than previous versions.

The study from NYU’s Department of Population Health consisted of two parts. First, an electronic survey was completed by 679 festival- or nightclub-attending 18-25 year-olds. The survey queried participants about demographic information, frequency of attendance at rave/dance party events and whether they had ever knowingly used any drugs from a provided list, which included 35 varieties of substances associated with “bath salts,” including Flakka, Mephedrone (“meow-meow”), “Ivory Wave,” and others. Then, they were asked to give a hair sample. Approximately 26% provided a sample. The majority of participants listed no lifetime use of bath salts. Of the participants who reported no lifetime use of “bath salts” or similar compounds, 41.2% tested positive for a bath salt-related compound. A positive test on hair sample was also associated with lower educational level and being from a racial minority; however, the strongest correlation was with frequency of attendance at these types of events.

A few things about this study are particularly interesting. Bath salts have a very negative connotation in the media, associated with horrible outcomes such as severe violence, bizarre behavior, and cannibalism, although notably in the most publicly known case, no link was found. Molly is distributed as a powder and is perceived to be the “love-drug” that fosters interconnectedness and positive feelings. Aside from the profound irony that this population believed they were taking a drug intended to cause a happy, connected euphoria, but instead inadvertently ingested something reputed to turn people into zombies, we see two drugs that are supposed to have diametrically opposed effects on their users where the users had no idea what they were actually consuming even after the fact. The power of suggestion may be at play here.

What does this mean for psychiatric clinicians treating patients in the emergency department? Many drugs are not detected by routine urine toxicology in most hospitals or in pre-employment or legally-mandated surveillance drug screens (such as for people on probation or parole). In fact, part of the allure of synthetics such as MDMA, synthetic cannabinoids, Flakka, and bath salts is the ability of these compounds to avoid detection in typical urine drug screening tests for cannabis, opiates, cocaine, benzodiazepines, and barbiturates. Many screens can also test for phencyclidine (PCP) and amphetamines. However, there are exceptions even in standard screens: some synthetic opiates are missed, and phencyclidine screenings can cross-react with other substances such as dextromethorphan, or even the antiepileptic lamotrigine. Bath salts are largely cathinone-derivatives that have an entirely different chemical structure from typical amphetamines. Compounds synthesized in a lab can also be changed rapidly to avoid detection and have evolved over time, which makes producing a reliable screening test almost impossible. Because of the variety of the compounds, testing technology has not caught up.

In clinical practice, clinicians should be suspicious that any drug the patient reports to have consumed may be tainted with something else and should not rely entirely on urine or blood toxicology results to come to a diagnosis. Both MDMA and bath salts can cause adverse medical reactions such as hyperthermia, autonomic instability, electrolyte abnormalities and rhabdomyolysis, and death. Consequently, patients should be monitored carefully. ED presentations suspicious for toxic ingestion should be reported to local poison control, who can help monitor for trends and help direct public health efforts.

Featured image credit: People at a night club by stuv. CC0 Public Domain via Pixabay.