Synthetic Cathione and Cannabinoid Toxicity and Treatment

Abstract

Submit Manuscript | http://medcraveonline.com [4] and 4-methylcathinone (mephedrone). MDPV is a dopamine and norepinephrine reuptake inhibitor that acts as a stimulant. Mephedrone is thought to be a monoamine reuptake inhibitor. The mechanism of action includes an increase in serotonin, norepinephrine, and dopamine levels. Mephedrone [5] is a derivative of phenethylamine, which is the active ingredient in the African plant khat. Khat is similar to amphetamine and is associated with a history of abuse. Federal legislation was passed in September of 2011 to restrict the possession or distribution of any substance containing MDPV, methadone, or methylone. However, synthetic stimulants are difficult to regulate. These substances are easily manipulated into other compounds as soon as legislation banning a specific compound is passed. The drug class of phenethylamines, which these compounds belong to, is unable to be banned outright because this class also contains FDA-approved medications, such as bupropion, dopamine, and epinephrine. The Federal Analog Act (21 USC 813) was passed in an effort to avoid the need for legislation to be passed on each individual analog. However, the Analog Act only applies to products meant for human consumption. Bath salts are labeled “not for human consumption” as a way around this law. The American Association of Poison Control Centers [6] report the number of calls related to bath salts increasing from 304 in 2010 to 2,655 in 2012. The patients’ ages ranged from 1 day to 61 years, with a median age of 29.2 years. The clinical effects were primarily neurological or cardiovascular. In a recent retrospective review of hospital visits reported to poison control centers, 1,633 patients with reported bath salt toxicity were examined. Death resulted in 0.6% of patients. The reported reasons for death include suicide, serotonin syndrome, fever, and seizures. Major outcomes, defined as life threatening or resulting in significant disability or disfigurement, occurred in 15.5% of patients. The route of administration and age of the patient have been shown as factors influencing the occurrence of major outcomes or death. The injection of bath salts was predicted to have more serious effects than snorting bath salts. There was no difference in major outcomes or death between oral ingestion and injection. Patients aged 47 years or greater also had a higher risk of major outcomes than the younger populations. This older population also was shown to have higher rates of injection and co-ingestions, as well. Co-ingestions of other substances presenting with bath salt toxicities have a relatively low occurrence as compared to other substances of abuse, around 26%. The most common co-ingestion was with opioids in 6.2% of the reported cases from November 2011 to November 2012, followed by marijuana in 5.4% of reported case. This data suggests that the majority of bath salt abusers are seeking “legal highs” [7]. The treatment of the sympathomimetic toxidrome associated with bath salts should start with the administration of benzodiazepines. It is reported that benzodiazepines are used in about 60% of patients. Amphetamine-induced seizures typically result from an imbalance of excitatory and inhibitory neurotransmitters that do not originate in a specific location of the brain. Amphetamine-induced seizures respond to benzodiazepines, which also act to sedate the patient for the safety of the healthcare team. Phenytoin and Fosphenytoin should not be used as they work by isolating the focal point of a seizure and can induce arrhythmias. Lorazepam and Diazepam are the preferred agents via the intravenous route. Sedation is also a common treatment strategy used in this patient population. Sedative agents commonly used include propofol, barbiturates, and antipsychotics. Almost 10% of patients presenting with bath salt intoxication require ventilation. Psychotic symptoms typically resolve within 12 hours to 3 days of admission, although one patient remained symptomatic for 11 days. Caution must be used when administering anti-psychotic medications for drug-induced psychoses, as they may lower the seizure threshold.