Alarming new stimulant: Bath salts labeled “not for human consumption”

Update 09/21/2011: DEA Moves to Make 'Bath Salts' Illegal as Overdoses Rise

What are these “bath salts”?

The abuse of psychoactive “bath salts” (PABS) has become commonplace, and patients with PABS overdoses are presenting to emergency departments with increasing frequency. The main ingredient of the synthetic designer drugs in these bath salts, which are not related to any hygiene product, is methylenedioxypyrovalerone (MDPV).

What is the clinical presentation?

From the NYTimes: "Doctors could not believe what he was seeing this spring in the emergency room: people arriving so agitated, violent and psychotic that a small army of medical workers was needed to hold them down.

They had taken new stimulant drugs that people are calling “bath salts,” and sometimes even large doses of sedatives failed to quiet them. Director of Poison Center. “If you gave me a list of drugs that I wouldn’t want to touch, this would be at the top.”

Bath salts contain man-made chemicals like mephedrone and methylenedioxypyrovalerone, or MDPV, also known as substituted cathinones. Both drugs are related to khat, an organic stimulant found in Arab and East African countries that is illegal in the United States." These products are easily obtained over the Internet under such names as Ivory Wave or Vanilla Sky.

What to do when evaluating and treating a patient intoxicated with psychoactive “bath salts” (PABS)?

Clinicians need to be aware of several issues (source: NEJM):

- severity and potential lethality from overdoses often require admission to the intensive care unit (ICU)

- routine drug screens do not detect PABS

- PABS can be cut with other psychoactive substances, which can confound the clinical presentation

- patients may need physical restraints and high doses of sedatives to prevent self-harm or harm to others.

Treatment is largely supportive, with IV benzodiazepines (for sedation or to control seizures) and IV fluids, particularly if there is rhabdomyolysis

References:

An Alarming New Stimulant, Sold Legally in Many States. NYTimes.
“Bath Salts” Intoxication. NEJM.
Bath Salt Drug Abuse - INFOGRAPHIC goo.gl/JrI6V

Comments from Google+:

Nancy Onyett, FNP-C: UDS cannot screen for this yet it has severe effects on CV/neuro system acting like cocaine. People are snorting it smoking it, a few cases of injection with death. Also, "Spice" herb is being used in rampant amounts Dominion Labs is who I use for UDS which picks up metabolites of Spice. DEA has it listed as a Class I controlled substance. No listing for bath salts yet but there needs to be. Police have an ampule that can check bath salts vs. cocaine. It is a rapid check on the street. Any physician nurse practitioner working in FP needs to be aware of Spice and bath salts. Unfortunately, there is not a metabolite designated yet to pick up on UDS , soon to be if DEA classifies the drug. Also, for those that don't know

Spice is flavored but looks just like Marijuana. Police have an ampule to differentiate the two on street.

Ian Miller: Interested from an emergency department nurse perspective on how you manage these highly agitated patients (refractory to sedation) that are also potentially very unwell. Do you have a specialized treatment area within the ED, do you just use lots of manpower to restrain?

A very difficult management situation with respect to patient and staff safety.

Joan Justice: Are people doing this "for fun"? What is fun about this? I read today that doctors have to put some of these patients under anesthesia because they cannot restrain or calm them. What a drain on resources, and again, what is the benefit for the user here?

"Wonder drug" dogs are the only animals that look at right side of human face where emotions are expressed

Dogs are the most diverse mammal species on the planet (http://buff.ly/1pxxt0k). People who have dogs as pets are much less likely to have a heart attack. If they do have a heart attack, they are 2-3 times more likely to survive it.

Mitochondrial genetics studies have shown conclusively that dogs have descended from wolves. Dogs' genes are 99.8% the same as the wolf genes, yet dogs behave in a fundamentally different way.

Over more than 100,000 years dogs have evolved to recognize human emotions. It has been a collaborative process all along. Humans are able to recognize 6 types of dog barks expressing emotions and "intentions" such as fear, excitement, aggression and so on. Dogs are the only animals that specifically look at the right side of the human face where emotions are expressed (see the NOVA video and website below).

Dogs follow directions while chimpanzees, the apes evolutionary closest to humans, do not. The smartest dog can learn 300 different words which is the vocabulary size of a 2-year-old child.

The "400 mnemonic":

400 million dogs worldwide
400 breeds of dogs have been developed by humans

According to a Cleveland Clinic psychologist, "dogs could be called wonder drugs":

"Dogs can provide people with many things. Protection, friendship, and unconditional love top the list, but they may also provide health benefits, too." How smart are dogs, and what makes them such ideal companions? Dogs Decoded: Nova. Netflix. Comments from Twitter: Heidi Allen @dreamingspires: I want one! References: Dogs Decoded transcript and more. NOVA. Image source: Yellow Labrador Retriever, Wikipedia, GNU Free Documentation License.

RNA-only genes: ancient infections hide in human genome and get themselves passed from generation to generation

From the Economist:

Not so long ago, received wisdom was that most of the human genome—99% of it—was “junk”. If this junk had a role, it was just to space out the remaining 1%, the genes in which instructions about how to make proteins are encoded.

That, it now seems, was far from the truth. The decade since the completion of the Human Genome Project has shown that lots of the junk must indeed have a function. Almost two-thirds of human DNA, rather than just 1% of it, is being copied into molecules of RNA. As a consequence, rather than there being just 23,000 genes, there may be millions of them.


Human chromosomes (grey) capped by telomeres (white). Image source: Wikipedia, public domain.

One new genetic class is known as lincRNAs. Molecules of lincRNA are similar to the messenger-RNA molecules which carry protein blueprints. However, they do not encode proteins. More than 9,000 sorts are known, and their job is the regulation of other genes.

LincRNA is rather odd, though. It often contains members of a second class of weird genetic object. These are called transposable elements - “jumping genes” - because their DNA can hop from one place to another within the genome. Transposable elements come in several varieties, but one group of particular interest are known as endogenous retroviruses. These are the descendants of ancient infections that have managed to hide away in the genome and get themselves passed from generation to generation along with the rest of the genes.

This Nature video takes you on an audio-visual journey, diving into a cell to show how genes are transcribed to make messenger RNA (mRNA) and how RNAi can silence specific mRNAs to stop them from making proteins:



References:

RNA-only genes: The origin of species? The Economist.

Atul Gawande: "Doctors are human. We miss stuff" - Checklists can help

Atul Gawande on NPR:

Doctors are human, and that their profession is like any other.

"We miss stuff. We are inconsistent and unreliable because of the complexity of care," Gawande says. "I got a chance to visit Boeing and see how they make things work, and over and over again they fall back on checklists. The pilot's checklist is a crucial component, not just for how you handle takeoff and landing in normal circumstances, but even how you handle a crisis emergency when you only have a couple of minutes to make a critical decision."

References:
Atul Gawande's 'Checklist' For Surgery Success. NPR.

Related:

"Microscopic cancers are forming in human body all the time"

From TEDtalksDirector — May 17, 2010 - William Li presents a new way to think about cancer treatment: angiogenesis, targeting the blood vessels that feed a tumor. The crucial first (and best) step: Eating cancer-fighting foods that beat cancer at its own game.

"We're probably forming microscopic cancers all the time in our body. Autopsy studies from people who died in car accidents have shown that about 40 percent of women between the ages of 40 and 50 actually have microscopic cancers in their breasts. About 50 percent of men in their 50s and 60s have microscopic prostate cancers. And virtually 100 percent of us, by the time we reach our 70s, will have microscopic cancers growing in our thyroid. Yet, without a blood supply, most of these cancers will never become dangerous. Dr. Judah Folkman, who was my mentor, and who was the pioneer of the angiogenesis field, once called this "cancer without disease."

Weight lifters turning to human growth hormone - and that's just the tip of the iceberg

From WebMD and the American Journal on Addictions:

In the study of 230 male weight lifters aged 18 to 40:

- 12% reported use of human growth hormone (HGH) or a similar supplement known as insulin-like growth factor-1

- all weight lifters reported use of anabolic steroids

- 56% percent had a current or past dependence on opioids, cocaine, and/or Ecstasy

HGH was prohibitively expensive in the 1990s, but now pills, powders, and injections can be purchased at low cost on the Internet.

Weight lifters who already take steroids add HGH as a "turbo boost". “You can always tell which elite athletes are on HGH because their bones are growing at a faster rate and their faces look distorted.”

References:
Weight Lifters Turning to Human Growth Hormone. WebMD.

Image source: OpenClipart, public domain