February 2013Vikas Mangewala, MD; Sajjad R Sarwar, MD; Kavit Shah; and Tanvir Singh, MD
From the Kobacker Center, University Of Toledo, Toledo, Ohio

Innov Clin Neurosci. 2013;10(2):10–16

Funding/financial disclosures: No funding was received for the preparation of this article. The authors have no conflicts relevant to the content of this article.

Introduction. Over the past few years, addiction professionals have been facing a new challenge of treating people who abuse synthetic chemicals. Because these synthetic chemicals are relatively new, they may not be detectable on routine urine drug screens, and users may be unaware of the specific chemicals contained in them. These drugs, which we have collectively termed synthetic legal intoxicating drugs (SLIDs), are increasing dramatically in use leading to multiple emergency room (ER) visits and hospital admissions.[1–3] One such SLID, which goes by the street name “bath salts,” has similar effects as those seen with amphetamine use.[4]

A recent survey identified 35 people who reported to ERs in Michigan with signs and symptoms of bath salts toxicity, including agitation, tachycardia, and delusions or hallucinations.[2] Case reports describing episodes of transient paranoid psychosis resulting from bath salts ingestion are emerging in the literature.[5] We report a unique case of persistent psychosis a month following the ingestion of bath salts mixed with marijuana.

Case report. Our patient was a 15-year-old boy with no previous psychiatric history. He came to the ER with complaints of agitation and psychotic symptoms. Reportedly, the patient smoked marijuana that was laced with bath salts. Soon after use, the patient became paranoid, barricading himself in his father’s home. Police were called to gain forcible entry into the house, and the patient was brought to the ER. The patient’s agitation continued to worsen, and lab workup revealed a raised creatine phosphokinase (CPK) level. Urine toxicology report was negative. Patient was managed in the hospital intensive care unit (ICU), where he continued to exhibit psychotic and agitated behavior, and at one point assaulted a staff member. He went home after medical stabilization a few days later, though he continued to exhibit paranoia at home. When the patient was continuing to exhibit paranoia a month later, his father brought him back to the hospital where he was then referred to us for inpatient psychiatric management.

During initial interview, the patient was noted to have extreme periods of psychomotor retardation during which he was nonverbal. At other times, he appeared confused, repeating questions to himself. He would make paranoid statements, such as, “Don’t let them take me!” and “How do I get out of this?” The patient reported that nothing around him was real. He reported that his father was replaced by an imposter and his sister would be harmed by unknown people. At times during the interview, he was able to acknowledge that part of his paranoia was not real. He reported feeling scared but denied any suicidal or homicidal thoughts, intent, or plan. The patient’s family was also interviewed, and they denied any previous psychiatric history or such behavior in the patient. They further denied any history of head injury or seizure disorder and also denied a family history of psychiatric conditions. They did report, however, that the patient had used marijuana in the past without any bad side effects. As stated previously, the patient reported that he believed he had smoked marijuana laced with bath salts prior to his ER presentation. During his inpatient psychiatric stay, the patient was treated with combination of olanzapine 5mg once daily and lorazepam 0.5mg twice daily. The dose of olanzapine was increased to 7.5mg daily, and this combined with the lorazepam improved his symptoms of psychosis and agitation. He began to interact with the peers on the unit. Symptoms of paranoia improved within three days of treatment, and the patient was discharged home on olanzapine 7.5mg once daily and lorazepam 0.5mg twice daily with outpatient follow-up. The patient had no relapse of symptoms in the eight-week follow-up period. He denied current substance use. No further adjustments in the medication dosages were required.

Discussion. Previous reports of bath salts toxicity have often occurred among individuals with other illicit substance intoxication.[2] Our patient’s use of bath salts in conjunction with marijuana use suggests a common demographic risk and the possibility of an additive risk of psychosis due to the combination.[6] Mechanistically, both substances have the potential to induce psychosis through mesolimbic hyperdopaminergia. Bath salts contain methylenedioxypyrovalerone (MDPV), which causes cathecholamine reuptake inhibition, and marijuana increases dopaminergic activity through modulating effects on dopamine neurons in the ventral tegmentum.[7] However, our patient’s psychotic symptoms were not present during previous marijuana use and seemed related to acute bath salts use, with full and sustained resolution upon discontinuation. This suggests a primary role for bath salts in producing acute psychosis.

Synthetic substances present a real challenge to the addiction treatment community. There is currently no way to routinely test for these substances. Also the intoxication has variable symptoms of presentation. These substances are ingested, smoked, and injected as legal alternatives to stimulants that are detected in routine drug testing.[2] Our case adds to a rapidly evolving literature that indicates the potential for acute psychiatric toxicity due to recreational use of compounds, such as MDPV. Consumers, clinicians, and policy makers deliberating about the future legal status of compounds such as bath salts should be apprised of this risk.

1. Wehrman J. Fake marijuana spurs more than 4,500 calls to US poison centers. American Association of Poison Control Centers (AAPCC), May 12, 2011. http://www.aapcc.org/dnn/Portals/0/prrel/updatedk2-may112011.pdf. Accessed February 20, 2012.
2. Centers for Disease Control and Prevention. Emergency department visits after use of a drug sold as “bath salts”—Michigan, November 13, 2010–March 31, 2011. Morb Mortal Wkly Rep. 2011;60(19):624–627.
3. Canton L. Poison control centers applaud DEA’s ban of bath salts. American Association of Poison Control Centers (AAPCC). September 8, 2011. http://www.mc.vanderbilt.edu/root/vumc.php?site=poisonce nter&doc=36028. Accessed February 20, 2012.
4. Penders TM, Gestring RE, Vilensky DA. Excited delirium following use of synthetic cathiones (bath salts). Gen Hosp Psychiatry. 2012;34(6):647–650.
5. Antonowicz JL, Metzger AK, Ramanujam SL. Paranoid psychosis induced by consumption of methylenedioxypyrovalerone: two cases. Gen Hosp Psychiatry. 2011;33(6):640.
6. Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370(9584):319–328.
7. Kuepper R, Morrison PD, van Os, J, et al. Does dopamine mediate the psychosis-inducing effects of cannabis? A review and integration of findings across disciplines. Schizophr Res. 2010;121(1–3):107–117.