Synthetic Cathinones (Bath Salts, Molly)

Agents

Naturally-Occurring Cathinone ((S)-2-Amino-1-Phenyl-1-Propanone)

Naturally Occurring Compound from Catha Edulis (Khat) Plant
- Chewing the Leaves of this Plant is Popular in Middle Eastern Countries (Such as Yemen)

Synthetic Cathinones

General Comments

Synthetic Cathinones are Phenethylamines (Similar to Amphetamines/Methamphetamine)
- Synthetic Cathinones are Often Called “bk-Amphetamines” (Due to the Presence of the Beta-Ketone Group)

Compounds

General Comments
- The List Below are Typical Components of Bath Salts, Although the Composition Varies Widely (Depending on the Geographic Location)
Butylone
Dimethylcathinone
Ethcathinone
Ethylone
Flephedrone (4-Fluoromethcathinone)
Mephedrone (4-Methylenemethcathinone)
- Occurrence in Preparations: common in European bath salt preparations
Methcathinone
- Historically was Widely Abused in the Former Soviet Union, Eastern Europe, and the US in the 1990’s
- Methcathinone Has Been Banned Worldwide
Methedrone (4-Methoxymthcathinone)
Methylenedioxypyrovalerone (MDPV)
- Occurrence in Preparations: common in US bath salt preparations
Methylone (MDMC, M1, bk-MDMA, beta-keto-MDMA, 3,4-methylenedioxy-N-methylcathinone)
- Occurrence in Preparations: occasionally used
- Chemistry
  - Close Structural Analog of MDMA (see Ecstasy): MDMC has an added beta-ketone group
  - Note that this is Not the Same as the Prescription “Methylone” (Which is a Brand Name for IV Methylprednisolone)
Pyrovalerone Derivatives
- Occurrence in Preparations: occasionally used
Pipradrol Derivatives
- Occurrence in Preparations: occasionally used

Pharmacology

Increased Synaptic Concentrations of Dopamine, Serotonin, and Norepinephrine Neurotransmitters

Mechanisms of Specific Synthetic Cathinones
- Mephedrone: tends to cause dopamine reuptake inhibition
- Methylone: inhibits the reuptake of norepinephrine and dopamine, with few serotonin effects
- Pyrovalerone: inhibits the reuptake of norepinephrine and dopamine, with few serotonin effects
Stimulation of α-Adrenergic and β-Adrenergic Receptors
- Similar to Amphetamines/Methamphetamine (see Methamphetamine)
  - Synthetic Cathinones are Essentially “Beta-Keto Amphetamines”
  - However, in Contrast to Methamphetamines, Bath Salts Have a Prolonged Duration of Action with Symptoms Which May Last for Days-Weeks
- Bath Salts are Less Able to Cross the Blood-Brain Barrier than Amphetamines (Due to the Presence of the Beta-Keto Group)

Cytotoxicity of Hepatocytes

Has Been Reported with Some of the Synthetic Cathinones

Metabolism

Hepatic
- Renal Excretion of Metabolites (Some of Which are Active)

Administration

Route of Exposure

Ingestion
- “Bombing”: mephedrone is wrapped in cigarette paper and swallowed
- “Keying”: dipping a key into powder and then insufflating
Nasal Insufflation
Gingival Delivery: has been described
Inhalation: has been described
Intramuscular Injection: has been described
Intravenous Injection: has been described
Rectal Administration: has been described

Diagnosis

Urine Toxicology Screen (see xxxxx)

Synthetic Cathinones (and Synthetic Cannabinoids) are Not Detected by Routine Urine Toxicology Screen

Effects/Adverse Effects

General Comments

Duration of Effects
- Effects of Bath Salts May Last for Days-Weeks in Some Cases
  - In Contrast, Methamphetamines Have a Shorter Duration of Action, with Effects Rarely Lasting More than a Few Days

Cardiovascular Effects/Adverse Effects

Chest Pain (see Chest Pain)
Hypertension (see Hypertension)
Palpitations (see Palpitations)
Tachycardia (see Diaphoresis)
Skin Rash

Gastrointestinal Effects/Adverse Effects

Abdominal Pain (see Abdominal Pain)
Anorexiab (see Anorexia)
Nausea/Vomiting (see Nausea and Vomiting)

Genitourinary Effects/Adverse Effects

Anorgasmia
Erectile Dysfunction (see Erectile Dysfunction)
Increased Libido (see Increased Libido)

Neurologic/Psychiatric Effects/Adverse Effects

Agitation (see Agitation)
- Most Common Manifestation in Patients Requiring Medical Care
- Ranges from Mild Agitation to Severe Psychosis (Requiring Restraints)
Aggressiveness
Akathisia (see Akathisia)
Anger
Anxiety (see Anxiety)
Auditory/Visual Hallucinations (see Hallucination)
Depression (se Depression)
Dizziness/Lightheadedness (see Dizziness)
Dysphoria
Empathy
Euphoria (see Euphoria)
Fatigue (see Fatigue)
Formication (see Formication)
Headache (see Headache)
Increased energy
Increased/Decreased Concentration
Insomnia (see Insomnia Insomnia)
Loquaciousness
Memory Loss (see Memory Loss)
Nightmares (see Nightmares)
Panic
Paranoia (see Paranoia)
Perceptual Distortions
Seizures (see Seizures)
Tremor (see Tremor)

Ophthalmologic Effects/Adverse Effects

Blurred Vision (see Blurred Vision)
Mydriasis (see Mydriasis)
Nystagmus (see Nystagmus)

Otolaryngologic Effects/Adverse Effects

Bruxism (see Epistaxis)
Nasal Pain
Oropharyngeal Pain
Tinnitus (see Xerostomia)

Pulmonary Effects/Adverse Effects

Dyspnea (see Dyspnea)

Rheumatologic Effects/Adverse Effects

Arthralgias (see Arthralgias)
Extremity Changes
- Coldness
- Discoloration
- Numbness
- Tingling
- Muscular Tension/Cramping

Toxicologic Effects/Adverse Effects

Serotonin Syndrome (see Serotonin Syndrome)

Other Effects/Adverse Effects

Body Odor (“Mephedrone Stink”)
Hyperthermia/Fever (see Fever)

Treatment

Control of Agitation (see Agitation)

Goal Should Be to Prevent Harm to Patient
Technique
- Physical Restraints
- Benzodiazepines (see Benzodiazepines): preferred agents
- Intubation/Mechanical Ventilation (see Mechanical Ventilation-General)

Management of Hypertension (see Hypertension)

Benzodiazepines (see Benzodiazepines): may be useful

Management of Tachycardia/Arrhythmias (see MEDLINE] Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States. Clin Toxicol (Phila). 2011 Jul;49(6):499-505. doi: 10.3109/15563650.2011.590812 [MEDLINE] The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol. 2012 Mar;8(1):33-42. doi: 10.1007/s13181-011-0193-z [MEDLINE] Serotonin syndrome associated with MDPV use: a case report. Ann Emerg Med. 2012 Jul;60(1):100-2 [MEDLINE]