TOXICOLOGY/ORIGINAL RESEARCH

A 9-State Analysis of Designer Stimulant, “Bath Salt,” HospitalVisits Reported to Poison Control Centers

Brandon J. Warrick, MD; Meredith Hill, DO; Kimberly Hekman, MPH; Rachelle Christensen, PharmD; Robert Goetz, PharmD;Marcel J. Casavant, MD; Michael Wahl, MD; James B. Mowry, PharmD; Henry Spiller, MS; Deborah Anderson, PharmD;Alfred Aleguas, PharmD; David Gummin, MD; Ronald Thomas, PhD; Christopher Nezlek, DO; Susan Smolinske, PharmD

Study objective: A new generation of designer stimulants marketed as “bath salts” emerged in late 2010. Thegoal is to describe the epidemiologic emergence of designer stimulants in 9 states in the Midwest.

Methods: A retrospective review of the National Poison Data System was performed between November 1,2010, and November 30, 2011. Inclusion criteria were health care–evaluated bath salts or other syntheticstimulants exposures. Cases were excluded if the exposure was unrelated to a designer stimulant. Demographicand clinical characteristics of cases were calculated and differences in outcome and exposure by generationwere examined.

Results: One thousand six hundred thirty-three patients met the inclusion criteria. Age ranged from 1 day to 61years (mean�29.2 years), with 67.9% male patients. The most common clinical features were agitation(62.2%), tachycardia (55.2%), and hallucinations (32.7%). In addition to 15.5% of patients having a majormedical effect, 0.6% died. Reason for use was primarily intentional abuse (88.5%). However, 0.7% of patientsreported withdrawal. Treatment involved primarily benzodiazepines (58.5%), with 8.7% of patients beingintubated. Baby Boomers were more likely to have a major medical outcome (24.2%) and to report injection asthe method of administration (8.6%-12.9%).

Conclusion: Synthetic stimulants rapidly swept across the Midwest, resulting in more than 1,600 patientsseeking medical care. Serious medical effects or death was observed in 16.1% of cases. Older generationswere more likely to inject and to have a major medical outcome. [Ann Emerg Med. 2013;62:244-251.]

Please see page 245 for the Editor’s Capsule Summary of this article.

A feedback survey is available with each research article published on the Web at www.annemergmed.com.A podcast for this article is available at www.annemergmed.com.

0196-0644/$-see front matterCopyright © 2013 by the American College of Emergency Physicians.http://dx.doi.org/10.1016/j.annemergmed.2012.12.017

aH“anc

crlctoliB

INTRODUCTIONThe latest designer stimulants marketed as “bath salts”

emerged in the United States at the end of 2010. Laboratorytesting conducted on bath salts has found a variety ofpsychoactive chemicals classified as phenethylamines, morespecifically cathinones, such as methylenedioxypyrovalerone(MDPV), methylone, mephedrone, and ethylone.1 In additionto these cathinones, lidocaine and a variety of piperazinederivatives were also found. Phenethylamines are a broad classof more than 1,000 compounds that includemethamphetamine, methylenedioxymethamphetamine(ecstasy), and methcathinone (Khat).2 Structurally andfunctionally, phenethylamines resemble the neurotransmittersdopamine, norepinephrine, and serotonin in structure andfunction.3 A plethora of compounds results from chemists beingable to make small molecular changes. To prevent new

legislation with the development of each new compound, the s

244 Annals of Emergency Medicine

nalog drug law, 21 U.S.C.§813, was enacted in 1986.owever, the act applies only to compounds intended for

human consumption.” Therefore, these products are marketeds “bath salts,” “plant food,” “ladybug attractant,” or otheronedibles and labeled “not intended for humanonsumption.”4-7

Nationwide, a dramatic increase in cases reported to poisonontrol centers was observed in 2011, with 6,670 exposureseported by January 31, 2012.8 To control designer stimulants,ocal, state, and federal agencies have tried a variety of response andontrol measures. In October 2011, the Drug Enforcement Agencyemporarily added methylone, mephedrone, and MDPV to the listf Schedule I agents. In July 2012, President Obama signed federalegislation into law banning 31 specific designer chemicals,ncluding many of those sold as bath salts and synthetic marijuana.ecause more than 1,000 phenethylamines already exist, new

timulants are likely to emerge.2

Volume , . : September

citcAoirIpchbthulm

fcMAFo

epyYa

Warrick et al Nine-State Analysis of “Bath Salt” Visits

The primary purpose of this study was to use poison controlcenter data collected from 9 states in the Midwest tocharacterize demographic, clinical, health treatment, andoutcome data of designer stimulants, or bath salts. Secondarygoals were to evaluate differences among generation or agegroups and identify risk factors for fatal outcome.

MATERIALS AND METHODSA retrospective study collected data from 9 Midwest poison

control centers covering Illinois, Indiana, Kentucky, Michigan,Minnesota, North Dakota, Ohio, South Dakota, andWisconsin. Data were collected between November 1, 2010,and November 30, 2011. A coordinating institutional reviewboard approval was obtained for the primary site, and all othersites had independent institutional review board approvals.

Deidentified cases were shared through the National PoisonData System, using a special project report designed to captureall designer stimulant–related cases. The search terms usedwere “bath salt,” “synthetic cathinones,” “synthetic cathinonederivatives,” “MDPV,” or “4-methylmethcathinone” and thestudy was performed in August and December 2011. Data werecollected by specialists in poison information into a regionaldata collection system, which uploads the cases into theNational Poison Data System. The specialists are health careproviders who have received extensive training outlined by theAmerican Association of Poison Control Centers. Neither thespecialists nor the reporting physicians were aware of the detailsof the study.

Once a case was identified through the National Poison Data

Editor’s Capsule Summary

What is already known on this topic“Bath salts” are covert products containing variousamphetamine-like drugs, primarily cathinones.

What question this study addressedThis poison center–based, retrospective,observational study characterized the epidemiologicand clinical features of patients using theseproducts.

What this study adds to our knowledgeThis new class of abused drug became rapidlypopular during 2011 and produced potentially life-threatening stimulant effects in 16% of reportedcases.

How this is relevant to clinical practiceUnderstanding the composition of illicit bath saltsand the clinical manifestations will allow targetedtherapy with sedation and cooling.

System shared report, one or more authors at each regional poison w

Volume , . : September

ontrol center reviewed and verified the accuracy of the substancenvolved, management, and coding of clinical effects and added therade name if known. A final review of coding consistency wasonducted by the coordinating center, using published Americanssociation of Poison Control Centers category requirements forutcomes and treatments, followed by correspondence with thenitial reviewer to confirm changes. A collective agreement amongeviewers was reached on cases in which accuracy was questioned.n cases of death, redacted chart notes were obtained from therimary site so that more detail could be provided. Becauseonfirmation testing of patient biological samples added to theospital cost and generally did not produce results soon enough toe clinically useful, it was rarely performed. Cases were excluded ifhe call was for information or the patient was not evaluated by aealth care professional or the exposure was determined to benrelated to a designer stimulant. For privacy, the zip code was

imited to the first 3 digits. Exposure cases were plotted by state andonth.Variables collected included age, sex, location of reporting

acility, substance involved, reason for exposure, coingestants,linical effects, pertinent diagnostic results, and therapies.

edical outcome designation used the standard Americanssociation of Poison Control Centers categories and detailed inigure 1.8 In cases of death, a written attempt was made tobtain the medical examiner report.

�2 Analysis was used to evaluate differences betweenxposure route among generations. Generational analysis waserformed by creating age fields for baby boomers (aged 47ears or older), Generation X (aged 30 to 46 years), Generation(aged 18 to 29 years), Generation Z (aged 12 to 17 years),

nd children younger than 11 years. Binary logistic regression

Figure 1. Inclusion criteria.

as used to calculate risk factors for major medical outcome or

Annals of Emergency Medicine 245

wpccs2mRK

Nine-State Analysis of “Bath Salt” Visits Warrick et al

death. Rate of exposure per state population was calculated with2010 US census data.9 All data were analyzed with SPSS(version 18.0; SPSS, Inc., Chicago, IL) and SAS (version 9.2;SAS Institute, Inc., Cary, NC). Geographic Information Systemmapping was performed with ArcView (version 10; RockWareInc., Golden, CO).

RESULTSTwo thousand eighteen human cases were identified from

Figure 2. A, Map of cases by first-3-digit zip code. B, Displaenacted measures to control the synthetic cathinones.

National Poison Data System during the study period; 385 cases r

246 Annals of Emergency Medicine

ere excluded because they were not evaluated by health careersonnel or clinical effects were unrelated to syntheticathinones (Figure 1). One thousand six hundred thirty-threeases met inclusion criteria, with 21 cases reported in 2010. Aharp increase in cases occurred in the winter and spring of011. A decrease began in late spring and summer 2011 forost states and continued through November 2011 (Figure 2).ates of exposure per population varied by state, with Ohio andentucky having the highest, at 58 and 43 cases per million

cases by state per month. The stars indicated when states

y of

esidents, respectively. North Dakota and Wisconsin were the

Volume , . : September

Tt

C

SMFUA113�ICUSOIIKMMWSNCATHHCCDMTECFNDHHVCLRCSTBAIAANNAVMDMMMN

Warrick et al Nine-State Analysis of “Bath Salt” Visits

lowest, at zero and 6 cases per million residents, respectively(Table 1 and Figure 2).9

Sex was predominantly male (n�1,108; 67.9%) (Table 1). Ageranged from 1 day to 61 years, with a mean age of 29.2 years(median�28.0 years). The highest proportion of patients were aged18 to 29 years (n�782; 47.9%), followed by patients aged 30 to 46years (n�580; 35.5%), 12 to 17 years (n�103; 6.3%), and olderthan 47 years (n�93; 5.7%), and 68 (4.2%) patients were ofunknown age. Seven patients (0.4%) were younger than 12 years.There was no difference in sex across different generations or states.

Clinical effects were primarily neurologic and cardiovascular,detailed in Table 1. The most common findings were agitation(n�1,016; 62.2%), tachycardia (n�901; 55.2%), andhallucinations (n�534; 32.7%). Medical outcomes werecategorized as major (n�253; 15.5%), moderate (n�938;57.4%), minor (n�253; 15.5%), no effect (n�19; 1.2%), and(n�161; 9.9%) cases were not followed to outcome. There were9 deaths, with medical examiner reports available for 5.

The route of administration was primarily inhalation(n�684; 43.9%), ingestion (n�366; 23.6%), and injection(n�169; 10.8%) (Table 2). Exposure route varied bygeneration, with Generation Z (2.9%) significantly less likely touse injection compared with Generations Y (12.9%) and X(9.8%), as well as compared with baby boomers (8.6%).Although not statistically significant, a higher proportion ofusers in Generation Z (27.2%) used ingestion as the route ofadministration than users in Generation Y (24.4%) or X(22.4%) or baby boomers (18.3%). Of the 2 dermal exposures,one was in a 5-month-old, with no effect, and second was in a36-year-old, with moderate outcome. The deaths are outlined inTable 3.

The first fatality with confirmation testing and medicalexaminer evaluation was a 36-year-old man who arrived byemergency medical services asystolic after a 3-day binge of“White Rush.” According to his partner, he was expressingsuicidal thoughts related to his bath salts addiction. Postmortemgas chromatography/mass spectrometry (GC/MS) urine analysisfound MDPV and tetrahydrocannabinol (THC) in addition tohis prescribed medications. State police confirmed the presenceof MDPV in White Rush. The second fatality was a 23-year-oldwoman who died from complications of serotonin syndrome.GC/MS identified methylone and butylone in her initial urinesample and also in a capsule similar to what she ingested andwhat was found on her person when she presented to theemergency department. The medical examiner reported cause ofdeath as methylone and butylone intoxication.10 The third casewas a 34-year-old man who presented febrile and comatose,with confirmed MDPV in blood and urine. No other obviouscause of death was found at autopsy. The fourth case was a 20-year-old man with a self-inflicted gunshot to the head. Hisfriends reported paranoia after the use of bath salts. No drugtesting was performed at autopsy. The fifth case was a 34-year-old woman presenting with coma and seizures after the use of

bath salts. Although a variety of drugs were present on autopsy,

N

Volume , . : September

able 1. Sex, age, geographic source, clinical findings,reatment, and outcome (N�1,633).

haracteristic Number Percentage

exale 1,108 67.9

emale 523 32.1nknown 2 0.1ge, y2–17 (Generation Z) 103 6.38–29 (Generation Y) 782 47.90–46 (Generation X) 580 35.547 (Baby Boomers) 93 5.7

nfants 4 0.2hildren 1–11 3 0.2nknown age 68 4.2tate where exposure occurredhio 667 40.8

llinois 240 14.7ndiana 211 12.9entucky 188 11.5ichigan 162 9.9innesota 117 7.2isconsin 34 2.1outh Dakota 14 0.9orth Dakota 0 0linical findinggitation 1,016 62.2achycardia 901 55.2allucination 534 32.7ypertension 427 26.1onfusion 320 19.6reatine phosphokinase 239 14.6rowsy 199 12.2ydriasis 116 7.1

remor 115 7.0lectrolytes abnormality 115 7.0hest pain 111 6.8ever 103 6.3ausea 80 4.9iaphoresis 78 4.8yperventilation 66 4.0ypotension 65 4.0omiting 64 3.9oma 4 3.3iver function test elevation 58 3.6habdomyolysis 54 3.3reatine increase 54 3.3eizures 38 2.3reatmentenzodiazepine 956 58.5ntipsychotic 250 15.3

ntubation 142 8.7ntihistamine 70 4.3lkalinization 70 4.3aloxone 53 3.2-acetylcysteine 37 2.3ntihypertensive 30 1.8asopressor 16 1.0edical outcomeeath 9 0.6ajor effect 253 15.5oderate effect 938 57.4inor effect 253 15.5o effect 19 1.2

ot followed 161 9.9

Annals of Emergency Medicine 247

bblsg(c1

8c1awcr

Nine-State Analysis of “Bath Salt” Visits Warrick et al

death was determined to be the result of bath salts according todrug testing.

Pediatric cases included 4 infants younger than 1 year and 3children aged 3 to 4 years. Withdrawal was reported in 2 of 3neonates, both with major outcomes. The third neonate was 1day old, and it was unclear whether the infant was in withdrawalor intoxicated. All 3 mothers had 1 or more coingestants andGC/MS results that were unavailable. Three children, aged 3 to4 years, had minor outcomes or were not followed afteraccidental ingestion.

Coingestions occurred in 26% of cases. The most commoncoingestions were opioids (n�97; 6.2%), followed by marijuana(n�84; 5.4%), ethanol (n�69; 4.4%), and syntheticcannabinoids (n�69; 4.4%) (Table 2). A higher proportion(10.7%) of patients in Generation Z used syntheticcannabinoids in comparison with other generations (4.3%

Table 2. Prevalence estimates of route of administration, reasogeneration (n�1,558).

All CasesGeneration Z

(12–17 Years

Route of administrationInhalation only 684 (43.9) 52 (50.5)Ingestion only 366 (23.6) 28 (27.2)Injection only 169 (10.8) 3 (2.9)Other 138 (8.9) 9 (8.7)Unknown 201 (12.9) 11 (10.7)

Reason for exposureAbuse 1,379 (88.5) 94 (91.3)Suicide 80 (5.1) 3 (2.9)Unintentional 42 (2.7) 1 (1.0)Other 31 (2.0) 2 (1.9)Unknown 26 (1.7) 3 (2.9)

CoingestantOpioids 97 (6.2) 2 (1.9)Marijuana 84 (5.4) 8 (7.8)Ethanol 69 (4.4) 5 (4.9)THC homologs 69 (4.4) 11 (10.7)

Major medical outcomeYes

†252 (17.6) 18 (18.6)

*Cases missing age (n�68) and patients younger than 11 years (n�7) were excl†Category includes death; denominator�1,431.

Table 3. Summary of fatal cases.

Age, Years Sex Reason/Duration Presenting C

36 M Suicide after 3-day binge Found in asy

23 F Abuse after 2 doses Serotonin syseizures, f

34 M Abuse Fever/coma20 M Paranoia from abuse Self-inflicted34 F Abuse Coma/seizur

Generation Y, 3.8% of Generation X, and 2.2% of baby (

248 Annals of Emergency Medicine

oomers). The difference was significant compared with babyoomers (P�.02). Younger generations were significantly more

ikely to coingest marijuana compared with baby boomers. Notatistically significant differences were found betweeneneration groups and coingestion. A higher proportion24.2%) of baby boomers had a major medical outcomeompared with the younger generations (18.6% Generation Z,7.2% Generation Y, and 16.9% Generation X).

The primary reason for use was intentional abuse (n�1,379;8.5%), followed by suicide (n�80; 5.1%) (Table 2). Fourteenases were reported as victims of malicious intent and there were2 cases of withdrawal. One patient ingested to lose weight, andnother swallowed packets of bath salts and hydromorphonehen pulled over by police. The reason was unclear for 1.7% of

ases. Baby boomers were more likely to have suicide as theeason for exposure (8.6%) compared with Generations Z

r exposure, coingestant, and major medical outcome by

ases by Generation, No. (%)*

Generation Y(18–29 Years)

Generation X(30–46 Years)

Baby Boomers(47–61 Years)

336 (43.0) 249 (42.9) 47 (50.5)191 (24.4) 130 (22.4) 17 (18.3)101 (12.9) 57 (9.8) 8 (8.6)66 (8.4) 55 (9.5) 8 (8.6)88 (11.3) 89 (15.3) 13 (14.0)

698 (89.3) 509 (87.8) 78 (83.9)33 (4.2) 36 (6.2) 8 (8.6)23 (2.9) 14 (2.4) 4 (4.3)15 (1.9) 11 (1.9) 3 (3.2)13 (1.7) 10 (1.7) 0

56 (7.2) 36 (6.2) 3 (3.2)54 (6.9) 21 (3.6) 1 (1.1)27 (3.5) 30 (5.2) 7 (7.5)34 (4.3) 22 (3.8) 2 (2.2)

122 (17.2) 90 (16.9) 22 (24.2)

l Findings Product NamePostmortem

Analysis

White Rush (confirmed tocontain MDPV)

MDPV/THC

e, Red capsule (confirmed tocontain methylone/butylone)

Methylone butylone

Bath salts MDPVhot wound Bath salts No testing done

Bath salts Positive for bath saltcompounds

n fo

C

)

uded.

linica

stole

ndromever

gunses

2.9%), Y (4.2%), and X (6.2%).

Volume , . : September

ds

D

stb

sUotIhgoraticdmorwci

stmdetpssbtmm

iJwrmp

a9f

Warrick et al Nine-State Analysis of “Bath Salt” Visits

Many of the products were labeled with specific identifiers,and of these, 303 were identified with brand names. The mostprevalent names were White Rush (14.2%), White Lightning(9.6%), Zoom (5.0%), and Ivory Wave (4.6%). The mostcommonly found ingredient was MDPV (2.6%) and it wasmost frequently identified from tested samples of White Rush,Ivory Wave, and Zoom. Two samples of White Lightning wereobtained, with one sample sold as “insect repellent” and theother as a “natural stain remover” (Table 4).

Benzodiazepines were the most frequently used identifiedtreatment (n�956; 58.5%), followed by sedation (n�250;15.3%) (Table 1). Sedation is defined as a nonbenzodiazepinesedative that includes propofol, barbiturates, and antipsychotics.Of patients receiving sedation, 81% were givenbenzodiazepines; 8.7% of patients were intubated andventilated. The benzodiazepine dose was obtained for 24 casesreported in Michigan, with the mean dose of 5 mg, a mediandose of 2 mg, and a range of 1 to 24 mg.

Logistic regression showed that route of bath salt use was asignificant predictor of a major adverse outcome or death.Age was not a significant covariate in the model. Snortingcompared with injection was a negative predictor (odds ratio[OR]�0.516; 95% confidence interval [CI]�0.319 to 0.834),whereas there was no significant difference between ingestioncompared with injection (OR�0.707; 95% CI�0.427 to 1.17).When analyzed by generation, baby boomers were more likelyto have a major outcome or death than the younger age groups,although no other age comparisons were significant. Otherpredictors included administration of sodium bicarbonate(OR�5.73; 95% CI�2.77 to 11.87), use of vasopressors(OR�13.99; 95% CI�2.11 to 92.90), being in a coma (OR�10.14; 95% CI�3.19 to 32.25), and having respiratorydepression (OR�18.00; 95% CI�3.80 to 85.37) and were thestrongest predictors of a major outcome or death. Fever(OR�6.248; 95% CI�2.05 to 19.01), hypertension

Table 4. Frequency of Bath Salt Products

Product Frequency Percentage*

White Rush 43 14.2White Lightning 29 9.6Zoom 15 5.0Ivory Wave 14 4.6White Horse 13 4.3Cloud Nine 10 3.3MDPV 8 2.6Bliss 8 2.6Red Dove 8 2.6Night Lights 8 2.6White Girl 8 2.6Plant food 7 2.3Other 132 43.6Unknown

*Percentage is based on the 303 identified names. 1330 cases had an un-known product.

(OR�1.66; 95% CI�1.04 to 2.64), and cardiac conduction o

Volume , . : September

isturbance (OR�2.67; 95% CI�1.05 to 6.80) were alsoignificant predictors of major outcome or death.

ISCUSSIONTo our knowledge, this is the largest study to date on bath

alts, the first study to compare generational use patterns, andhe first to assess risk factors for major outcomes or death withath salts or designer stimulants.

Previous studies focused on clinical effects and treatment,uch as after mephedrone use in Europe or bath salts in thenited States.4,7,11,12 Consistent with those in previous reports,

ur study patients most often displayed a sympathomimeticoxidrome, including agitation, hallucinations, and tachycardia.n contrast to that of previous reports, our population had aigher percentage requiring intubation (8.7%). Older ageroups were more likely to have a major medical outcome, andur patient population was on average 9 years older than thoseeported in Europe. Although coma and respiratory depressionre not usually part of the classic sympathomimetic toxidrome,hey have been previously reported in cases of stimulantntoxication and may be the result of treatment.4,6,10 Cases ofentral nervous system and autonomic depression have beenescribed with stimulants such as methamphetamines,ethylenedioxymethamphetamine, and cocaine either directly

r as a withdrawal “washout” phenomenon. In addition, aeview of the coordinating center charts suggests that patientsho abuse synthetic phenethylamines may become so

ombative that heavy sedation or anesthesia requiringntubation may be required.

Our clinical findings are consistent with those for manycheduled stimulants, including methylenedioxymethamphe-amine, methamphetamine, methcathinone, andethamphetamine.3,13 In comparison with “club and street

rugs,” the incidence of major outcome was high. Possiblexplanations include repeated dosing, which leads to higherotal doses, or variable ingredients even with identicalackaging.1 Furthermore, wide availability of products at gastations, convenience stores, or head shops may impart a falseense of safety. Chronic users of bath salts demonstrate addictiveehaviors, suggesting some users escalate dosing because ofolerance. An in vitro study suggests that methylone andephedrone are similar to or slightly less potent thanethylenedioxymethamphetamine (MDMA, or Ecstasy).14

These new drugs have shown a rapid escalation in popularityn contrast to conventional drugs of abuse. The Department ofustice has suggested that some of this may be the result ofidespread easy availability through the electronic media.5 This

apid increase in popularity was also observed with Foxyethoxy in 2005 and synthetic cannabinoids found in K2/Spice

roducts.8,15

Although it has been widely presumed that these are drugs ofbuse, to our knowledge we are the first to document that nearly0% of users reported intentional abuse as the primary reasonor use. The rate of abuse most likely reflects the marketing and

ur selection criterion of only hospital-treated patients; 5.6% of

Annals of Emergency Medicine 249

mTce

S

ARTCPCC(t(((

ASiisaJrstat

Ftraoe

PRp2

P2T

Ab

R

Nine-State Analysis of “Bath Salt” Visits Warrick et al

patients used this as an attempt to end their lives and 0.9% werevictims of malicious intent. Because to our knowledge this is thefirst reported use of synthetic stimulants as a means of harm,additional studies are needed to categorize this population.

In comparison to that in Europe, rates of injection andinhalation in the United States are higher.11,12 It is unclearwhether this is a user preference or a difference in regionalpharmacology. Additional studies may be helpful.

Although coingestants are likely underreported, the lowfrequency of coingestants in our study suggests that many usersseek a “legal high.” Further supporting this idea is the incidenceof synthetic cannabinoid coingestants. Synthetic cannabinoidswere widely available in most states during the study period.Because coingestants have not been commonly reported, furtherstudies are needed to verify these findings.

Our primary study limitation was the passive nature ofvoluntary reporting by hospitals and medical examiners, withthe exception of Michigan, which mandated hospital reportingfor 6 months during the study period. We also suspect that therewas reporting bias, with clinicians more likely to report the mostsevere cases and the first few exposures to an unfamiliar substance.Additionally, medical examiner data are collected passively andfrequently not reported to poison control centers. All cases werereviewed by one or more of the authors to ensure accurate datacollection. We relied on health care worker reporting for diagnosisand did not require urinary drug confirmation because routinedrug testing does not detect the presence of synthetic cathinonesand the methodology was unavailable during the study period.Therefore, most cases were not confirmed.

Even though synthetic or “designer drugs” can lead tosignificant outcomes, legislation has been difficult despitedecades of work. Outright banning of each of these specificdrugs is problematic because many of them are easilymanipulated into a different compound. The drug class ofphenethylamines cannot be outright banned because manyFood and Drug Administration–approved medications,including bupropion, L-dopa/dopamine, and epinephrine, arephenethylamines. In an attempt to deal with this issue, theFederal Analog Act (21 USC 813) was passed so that legislationwas not needed for every new analog. However, the Analog Actis limited to products meant for human consumption, so theseproducts are labeled as “not for human consumption” andmarketed as nonedibles such as bath salts. A new legislativeapproach is needed. Even the recent addition of 31 newchemicals to the scheduled substance list will likely cause only atemporary response and result in the emergence of innovativenew chemicals.

Synthetic stimulants, or bath salts, rapidly emerged in 2011in the Midwest, resulting in more than 1,600 individualsseeking medical care, with 16% of cases resulting in majoroutcomes or death. Risk factors for a major outcome or deathinclude clinical presentation of coma or respiratory depressionand older age. There appears to be a generational effect, with older

generations more likely to inject the drugs and attempt suicide. The

250 Annals of Emergency Medicine

ost widely used treatments for intoxication are benzodiazepines.his study highlights the value of poison center surveillance and

oordination between health departments to detect and controlmerging new drugs of abuse.

upervising editor: Lewis S. Nelson, MD

uthor affiliations: From the Children’s Hospital of Michiganegional Poison Center, Detroit, MI (Warrick, Hill, Christensen,homas, Nezlek, Smolinske); the Michigan Department ofommunity Health, Lansing, MI (Hekman); the Cincinnatioison Center, Cincinnati, OH (Goetz); the Central Ohio Poisonenter, Columbus, OH (Casavant); the Illinois Poison Center,hicago, IL (Wahl); the Indiana Poison Center, Indianapolis, IN

Mowry); the Kentucky Poison Center, Lexington, KY (Spiller);he Hennepin Regional Poison Center, Minneapolis, MNAnderson); the Northern Ohio Poison Center, Cleveland, OHAleguas); and the Wisconsin Poison Center, Milwaukee, WIGummin).

uthor contributions: BJW, MH, and SS conceived the study.S recruited cooperative centers. MH obtained the primary

nstitutional review board approval and assisted other centersn obtaining institutional review board approval. BJW and SSupervised the conduct of the data collection. RM oversawnd provided the bulk of data collection. BJW, RG, MJC, MW,BM, HS, DA, AA, and SS reviewed cases from theirespective centers. KH and RT provided statistical advice ontudy design and analyzed the data. KH and CN helped createhe majority of the figures. BJW and KH drafted the article,nd all authors contributed substantially to its revision. BJWakes responsibility for the paper as a whole.

unding and support: By Annals policy, all authors are requiredo disclose any and all commercial, financial, and otherelationships in any way related to the subject of this articles per ICMJE conflict of interest guidelines (see www.icmje.rg). The authors have stated that no such relationshipsxist.

ublication dates: Received for publication July 10, 2012.evision received November 24, 2012. Accepted forublication December 17, 2012. Available online March 26,013.

resented at the American College of Emergency Physicians,011; and the North American Academy of Clinicaloxicologists, Washington, DC; September 2011.

ddress for correspondence: Brandon J. Warrick, MD, E-mailrandon_warrick@hotmail.com.

EFERENCES1. Schneir A, Ly BT, Smollin C, et al. Comprehensive drug analysis

of “bath salts” purchased in the United States. Clin Toxicol.2012;50:574.

2. Shulgin AT, Manning T, Daley PF, eds. The Shulgin Index Vol. I:Psychedelic Phenethylamines and Related Compounds. Berkeley,

CA: Transform Press; 2011.

Volume , . : September

1

1

1

1

1

1

Warrick et al Nine-State Analysis of “Bath Salt” Visits

3. Jacob P 3rd, Shulgin AT. Structure-activity relationships of theclassic hallucinogens and their analogs [review]. NIDA ResMonogr. 1994;146:74-91.

4. Spiller HA, Ryan ML, Weston RG, et al. Clinical experience withand analytical confirmation of “bath salts” and “legal highs”(synthetic cathinones) in the United States. Clin Toxicol (Phila).2011;49:499-505.

5. United States Department of Justice National Drug Center.Synthetic Cathinones (Bath Salts): An Emerging Domestic Threat.2011. Available at www.justice.gov/archive/ndic/pubs44/44571/44571p.pdf. Accessed February 4, 2013.

6. Benzie F, Hekman K, Cameron L, et al. Emergency departmentvisits after use of a drug sold as “bath salts”—Michigan,November 13, 2010–March 31, 2011. MMWR Morb Mortal WklyRep. 2011;60:624-627.

7. Forrester MB. Synthetic cathinone exposures reported to Texaspoison centers. Am J Drug Alcohol Abuse. 2012;38:609-615.

8. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2010 Annualreport of the American Association of Poison Control Centers’National Poison Data System (NPDS): 28th annual report. Clin

Toxicol (Phila). 2011;49:910-941.

Volume , . : September

9. United States Census Data. Available at: http://www.census.gov/.Accessed June 13, 2012.

0. Warrick BJ, Wilson J, Hedge M, et al. Lethal serotoninsyndrome after methylone and butylone ingestion. J MedToxicol. 2012;8:65-68.

1. James D, Adams RD, Spears R, et al. Clinical characteristicsof mephedrone toxicity reported to the UK National PoisonsInformation Service. Emerg Med J. 2011;28:686-689.

2. Regan L, Mitchelson M, Macdonald C. Mephedrone toxicity in aScottish emergency department [review]. Emerg Med J. 2011;28:1055-1058.

3. Cozzi NV, Sievert MK, Shulgin AT, et al. Inhibition of plasmamembrane monoamine transporters by beta-ketoamphetamines.Eur J Pharmacol. 1999;381:63-69.

4. Baumann MH, Ayestas MA Jr, Partilla JS, et al. The designermethcathinone analogs, mephedrone and methylone, aresubstrates for monoamine transporters in brain tissue.Neuropsychopharmacology. 2012;37:1192-1203.

5. Smolinske SC, Rastogi R, Schenkel S. Foxy methoxy: a new drug

of abuse. J Med Toxicol. 2005;1:22-25.

Did you know?

Podcasts are available for almost every article in Annals.

Visit http://www.annemergmed.com/content/podcast to find out more.

Annals of Emergency Medicine 251