Overdose and Withdrawal Timelines from Bath Salts

The term bath salts refers to a number of substances that are known as synthetic cathinones. The stimulant drug cathinone is found in the African and Middle Eastern Khat plant. The indigenous people of these areas chew the leaves of the khat plant or brew them in a tea for their stimulant effects. The synthetic cathinones are far more potent and generally classified as Schedule I controlled substances by the DEA.

The most common drugs found in bath salts are the substances MDPV (3, 4 methylenedioxypyrovalerone), mephedrone (4-methylmethcathinone), and pyrovalerone (4-methyl-β-keto-prolintane), all of which are potent stimulants and can be extremely dangerous. These substances are typically manufactured overseas in countries, such as Pakistan and China, and marketed in the United States under various names, such as white lightning, flakka, white dove, and many others.

The effects of bath salts are similar to the effects of ecstasy (MDMA) or methamphetamine (crystal meth). One source reports that the effects of bath salts consist of the worst possible effects associated with LSD, phencyclidine (PCP), cocaine, ecstasy, and methamphetamine.

Individuals who use bath salts are most often young adult males, employed or in school, who have used other drugs (particularly stimulant drugs). Bath salts are also commonly taken in conjunction with other drugs of abuse, most often alcohol, cannabis products, cocaine, ketamine, or ecstasy. Bath salts are usually snorted in powder form but can be taken orally, smoked, and even injected.

The Effects of Using Bath Salts

The New England Journal of Medicine reports that people who have taken bath salts present with a significantly altered mental status and extreme stimulation of the sympathetic nervous system (the part of the peripheral nervous system that is involved in speeding up various functions, such as heartbeat, breathing rate, etc.). The altered mental status that occurs as a result of bath salts can be quite variable and may consist of extreme anxiety, agitation, self-mutilating behavior, paranoia, and hallucinations, with individuals often becoming suicidal, homicidal, or self-harming.

An individual who is suspected of overdosing on bath salts requires monitoring in an intensive care unit, as an overdose can be potentially fatal. These drugs are typically not detectable on routine drug screens, and overdose is often determined by the clinical presentation of the individual and reports of friends. Treatment for overdose typically involves the use of behavioral supports, benzodiazepines to control for violent behavior and seizures, antipsychotic medications to control for psychotic effects or hallucinations, and other intravenous fluids.

Individuals who chronically abuse bath salts may develop physical dependence on them in addition to potentially developing a formal substance use disorder. The symptoms of physical dependence as a result of abuse of bath salts appear to resemble the symptoms that occur with other stimulant medications.

Treatment of Withdrawal from Bath Salts

Both research using animals and observations of individuals who have chronically abused bath salts indicate that tolerance to and cravings for bath salts develop rapidly. Cravings for bath salts, or for any drug where one has developed physical dependence, are strengthened by a behavioral mechanism known as negative reinforcement. When an individual has stopped taking the drug and it is eliminated from the system as a result of normal detoxification, withdrawal symptoms will begin to appear. These symptoms are unpleasant, and the most efficient way to eliminate them is to take more of the drug. Eliminating unpleasant physical and emotional effects as a result of drug use strengthens the behavior of using the drug; negative reinforcement occurs when repeating a behavior removes unwanted or negative symptoms or effects.

Observational research in individuals who have developed physical dependence on bath salts indicate that most individuals will experience the following withdrawal effects to some extent:

• Difficulty falling asleep or sleepiness
• Issues with anxiety or jitteriness
• Suspiciousness
• Tremors or shakiness, particularly in the extremities
• Running nose
• Fatigue
• Depression
• Irritability
• Difficulties with concentration, learning, and memory
• In rare cases, psychotic behaviors (hallucinations or delusions)
• Cravings

There is no established timeline for the withdrawal process associated with bath salts, though it is believed to be very similar to the withdrawal process that occurs with other stimulant medications. There are no specific medications designed to treat withdrawal from bath salts, but again, as the process is similar to the withdrawal from other stimulant medications, there are some general protocols that are typically followed.

Because there is quite a bit of diversity in the different chemicals that are labeled as “bath salts,” the actual symptoms and timeline that an individual experiences may vary greatly. Based on the literature, one can estimate that most individuals who stop using bath salts after significant periods of chronic abuse would experience effects according to the following general timeline:

• The withdrawal process will begin within 12-24 hours after discontinuation of bath salts. The primary symptoms include issues with mood swings, jitteriness, fatigue, and cravings. Because bath salt use results in massive releases of the neurotransmitters dopamine and norepinephrine, individuals often become very moody and depressed, and may become suicidal as the levels of these neurotransmitters become depleted.
• The symptoms generally peak within 48-72 hours and then slowly subside.
• After 5-7 days following discontinuation, symptoms are generally mostly resolved, though the individual could continue to experience some minor issues with mood swings and cravings.

Treatment for an individual who has discontinued bath salts should begin with a full assessment to ascertain the effects of any polysubstance abuse that could complicate the withdrawal process and to identify any other co-occurring conditions. Individuals should be placed in a physician-assisted withdrawal management program that monitors their recovery and uses medications to address the specific withdrawal symptoms experienced. Most likely, medications would include benzodiazepines and possibly antipsychotic medications. If individuals are very fatigued, mild stimulants like Provigil (modafinil) may be prescribed. Other medications, such as antidepressant medications, may be of use; however, these medications would not be effective for acute depression as they typically do not begin working until 1-2 weeks after they have been initiated. Other behavioral interventions for mood, such as relaxation techniques, Cognitive Behavioral Therapy, etc., are also important, depending in the specific case. Individuals are encouraged to drink fluids, eat a balanced diet, and engage in mild exercise.

There is one reference in the literature where an individual with longstanding psychosis who had chronically abused bath salts was successfully treated with electoral compulsive therapy (ECT), but this would not be a normal intervention. Individuals who have chronically abused other drugs, such as alcohol, along with bath salts require formal treatment interventions for complications associated with discontinuing those substances as well.

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It’s extremely important to get involved in a formal substance use disorder treatment program following bath salts withdrawal. Such a program should include treatment for any co-occurring conditions, substance use disorder therapy, social support, and other treatment interventions as needed in the individual case. Simply going through the withdrawal process is insufficient when attempting to deal with a substance use disorder. Individuals need to become involved in long-term and extensive treatment to address the substance abuse issues.

Those in recovery from any substance use disorder will experience a number of challenges, including potential setbacks. Individuals who maintain participation in a solid treatment program are better prepared to deal with setbacks and challenges that will inevitably occur during recovery than individuals who do not receive formal treatment.