Acute amphetamine and synthetic cathinone ("bath salt") intoxication
- Thomas C Arnold, MD, FAAEM, FACMT
Thomas C Arnold, MD, FAAEM, FACMT
- Professor and Chairman, Department of Emergency Medicine
- Louisiana State University Health Sciences Center - Shreveport
- Medical Director, Louisiana Poison Center
- Mark L Ryan, PharmD
Mark L Ryan, PharmD
- Director, Louisiana Poison Center
- LSU Health Sciences Center - Shreveport
- Assistant Professor of Clinical Emergency Medicine
- LSU Health Sciences Center
- Department of Emergency Medicine
- Section of Clinical Toxicology
- Section Editor
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
This topic will discuss the basic pharmacology, clinical presentation, and management of acute intoxication with traditional amphetamines (eg, ephedrine, ma-huang, khat, propylhexedrine) and synthetic cathinones. Intoxication with other stimulants, such as methamphetamine, cocaine, and methylenedioxymethamphetamine, is reviewed separately. (See "Methamphetamine: Acute intoxication" and "Cocaine: Acute intoxication" and "MDMA (ecstasy) intoxication" and "General approach to drug poisoning in adults".)
Amphetamines first appeared as a nasal decongestant in the form of a Benzedrine inhaler and were then used by the military as agents to promote alertness in battle-fatigued troops. In the 1950s, they gained popularity as weight-loss drugs and shortly thereafter became popular substances of abuse. Amphetamine sulfate and other stimulants like ephedra have a long history of abuse in the United States. Cathinones are beta-ketone amphetamine analogs. Abuse of the new synthetic cathinones (bath salts) emerged in Europe in 2009 and spread to the United States in 2010 [1,2]; these drugs were initially marketed in the United States as "bath salts" or "plant food" to avoid restrictions under the United States Controlled Substances Act.
PHARMACOLOGY AND CELLULAR TOXICOLOGY
Phenethylamines, including traditional amphetamines and the newer synthetic compounds, share multiple pharmacodynamic properties. Stimulation of alpha and beta adrenergic receptors is primarily responsible for the acute effects of amphetamines, which include hyper-alertness, hypertension, tachycardia, mydriasis, and diaphoresis. Together, these symptoms are part of the sympathomimetic toxic syndrome (or toxidrome) (table 1). Adrenergic receptors are reviewed separately. (See "Use of vasopressors and inotropes", section on 'Physiologic mechanisms of vasoconstriction'.)
Phenylethylamines cause the release of neurotransmitters, such as dopamine, serotonin, and norepinephrine and may also inhibit their reuptake. Some cause the release of serotonin from central axons, and some are serotonin receptor agonists [1,3].
Psychotic symptoms in overdose occur from excess dopamine and serotonin. Ring substitutions and other "designer" modifications have produced various psychoactive properties. Hallucinogenic properties appear to be enhanced by greater 5HT-2a receptor agonism.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol 2012; 8:33.
- Spiller HA, Ryan ML, Weston RG, Jansen J. Clinical experience with and analytical confirmation of "bath salts" and "legal highs" (synthetic cathinones) in the United States. Clin Toxicol (Phila) 2011; 49:499.
- Hill SL, Thomas SH. Clinical toxicology of newer recreational drugs. Clin Toxicol (Phila) 2011; 49:705.
- Emerson TS, Cisek JE. Methcathinone: a Russian designer amphetamine infiltrates the rural midwest. Ann Emerg Med 1993; 22:1897.
- Baselt RC. Disposition of Toxic Drugs and Chemicals in Man, 7th, Biomedical Publications, Foster City 2004.
- Chiang WK. Amphetamines. In: Goldfrank’s Toxicologic Emergencies, 9th, Goldfrank LR (Ed), McGraw-Hill, New York 2011. p.1078.
- Winstock AR, Mitcheson LR, Deluca P, et al. Mephedrone, new kid for the chop? Addiction 2011; 106:154.
- Warrick BJ, Hill M, Hekman K, et al. A 9-state analysis of designer stimulant, "bath salt," hospital visits reported to poison control centers. Ann Emerg Med 2013; 62:244.
- Lynton RC, Albertson TE. Amphetamines and designer drugs. In: Medical Toxicology, 3rd, Dart RC (Ed), Lippincott Williams & Wilkins, Philadelphia 2004. p.1071.
- Meng H, Cao J, Kang J, et al. Mephedrone, a new designer drug of abuse, produces acute hemodynamic effects in the rat. Toxicol Lett 2012; 208:62.
- Nicholson PJ, Quinn MJ, Dodd JD. Headshop heartache: acute mephedrone 'meow' myocarditis. Heart 2010; 96:2051.
- Wood DM, Davies S, Greene SL, et al. Case series of individuals with analytically confirmed acute mephedrone toxicity. Clin Toxicol (Phila) 2010; 48:924.
- Durham M. Ivory wave: the next mephedrone? Emerg Med J 2011; 28:1059.
- Wood DM, Davies S, Puchnarewicz M, et al. Recreational use of mephedrone (4-methylmethcathinone, 4-MMC) with associated sympathomimetic toxicity. J Med Toxicol 2010; 6:327.
- Sammler EM, Foley PL, Lauder GD, et al. A harmless high? Lancet 2010; 376:742.
- Adebamiro A, Perazella MA. Recurrent acute kidney injury following bath salts intoxication. Am J Kidney Dis 2012; 59:273.
- Russo R, Marks N, Morris K, et al. Life-threatening necrotizing fasciitis due to 'bath salts' injection. Orthopedics 2012; 35:e124.
- Dorairaj JJ, Healy C, McMenamin M, Eadie PA. The untold truth about "bath salt" highs: A case series demonstrating local tissue injury. J Plast Reconstr Aesthet Surg 2012; 65:e37.
- elSohly MA, Jones AB. Drug testing in the workplace: could a positive test for one of the mandated drugs be for reasons other than illicit use of the drug? J Anal Toxicol 1995; 19:450.
- Gibbons S. 'Legal highs'--novel and emerging psychoactive drugs: a chemical overview for the toxicologist. Clin Toxicol (Phila) 2012; 50:15.
- Tekulve K, Alexander A, Tormoehlen L. Seizures associated with synthetic cathinone exposures in the pediatric population. Pediatr Neurol 2014; 51:67.
- De Silva DA, Wong MC, Lee MP, et al. Amphetamine-associated ischemic stroke: clinical presentation and proposed pathogenesis. J Stroke Cerebrovasc Dis 2007; 16:185.
- Centers for Disease Control and Prevention (CDC). Emergency department visits after use of a drug sold as "bath salts"--Michigan, November 13, 2010-March 31, 2011. MMWR Morb Mortal Wkly Rep 2011; 60:624.
- Levine M, Levitan R, Skolnik A. Compartment syndrome after "bath salts" use: a case series. Ann Emerg Med 2013; 61:480.
- Smith HJ, Roche AH, Jausch MF, Herdson PB. Cardiomyopathy associated with amphetamine administration. Am Heart J 1976; 91:792.
- Schaiberger PH, Kennedy TC, Miller FC, et al. Pulmonary hypertension associated with long-term inhalation of "crank" methamphetamine. Chest 1993; 104:614.
- Westover AN, Nakonezny PA. Aortic dissection in young adults who abuse amphetamines. Am Heart J 2010; 160:315.
- Regunath H, Ariyamuthu VK, Dalal P, Misra M. Bath salt intoxication causing acute kidney injury requiring hemodialysis. Hemodial Int 2012; 16 Suppl 1:S47.
- Ramoz L, Lodi S, Bhatt P, et al. Mephedrone ("bath salt") pharmacology: insights from invertebrates. Neuroscience 2012; 208:79.
- Shoptaw SJ, Kao U, Heinzerling K, Ling W. Treatment for amphetamine withdrawal. Cochrane Database Syst Rev 2009; :CD003021.
- PHARMACOLOGY AND CELLULAR TOXICOLOGY
- CLINICAL FEATURES OF OVERDOSE
- Vital signs
- Cardiovascular system
- Central and peripheral nervous system
- Musculoskeletal system
- Renal and hepatic systems
- Electrolyte disturbances and other effects
- LABORATORY EVALUATION
- General testing
- Specific testing
- DIFFERENTIAL DIAGNOSIS
- General approach
- Airway management
- Gastrointestinal decontamination
- Psychomotor agitation
- PEDIATRIC CONSIDERATIONS
- ADDITIONAL RESOURCES
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS