Shortly after psychiatrist Anthony Ng, M.D., joined Acadia Hospital in Bangor, Maine, in February 2010, he noticed patients arriving in emergency rooms at the psychiatric hospital and elsewhere with various combinations of psychosis, paranoia, auditory hallucinations, agitation, delirium, and sometimes “super-human strength,” as Ng put it. Some also had rapid heart rates or other cardiac abnormalities, rhabdomyolysis, and kidney problems.
The collection of symptoms reminded him of the PCP cases he saw in his previous job in Manhattan, but these new cases were not caused by PCP, he soon discovered.
A newer drug of abuse had reached rural Maine: cheap, potent, synthetic stimulants, street-named “bath salts,” usually mephedrone, but sometimes methylenedioxypyrovalerone (MDPV) or its metabolite, pyrovalerone (Psychiatric News, April 15, 2011).
Bath-salts usage varies from casual to chronic, said Karen Simone, Pharm.D., director of the Northern New England Poison Center, which covers Maine, New Hampshire, and Vermont. Simone began checking with her counterparts in Louisiana and Los Angeles, where the drug had showed up even earlier.
Heavy users may take “high doses, all day, every day,” she said in an interview. “And we don’t know the long-term effects.”
Local police got involved early. “We started getting calls in February or March of 2011,” said Bangor’s police chief, Ron Gastia. “There were isolated eruptions in little pockets, where people were acting strangely or getting violent.”
The police assumed they were dealing with some sort of mental health crisis, but crisis intervention team officers found that de-escalation techniques weren’t working. By April, they learned they were dealing with bath salts and logged more incidents as time went by—33 in June and 77 in August.
The Bangor police soon developed a protocol to handle calls possibly related to bath salts. Two officers had to respond, as they would to domestic violence or a robbery. They must stand back from the subjects initially and evaluate their behavior, which is often highly agitated.
“They need medical attention, but we have to get them under control first,” said Gastia. Sometimes EMTs are called in to administer a shot of Versed, for extreme cases.
At Acadia, Ng and the staff began treating these patients with massive doses of antipsychotics, usually haloperidol. The drugs seemed to work in controlling symptoms, but the psychosis often returned for up to two weeks once medications were stopped.
Patients using bath salts may need hospitalization for a variety of physical and psychiatric issues, said Ng. They use up more staff time and resources and increase the burden on the emergency department. As more cases flowed into the hospital, Ng understood that a broader public-health approach was necessary.
So Gastia, Simone, and Ng gathered local mental health, medical, law-enforcement, and education personnel to discuss the outbreak, exchange information about the drugs and their effects, and formulate a response. They chose a three-part approach: working through the media and school systems to make the drugs’ harmful effects better known; training emergency department staff in the best ways to treat incoming cases; and preparing substance-abuse treatment programs to manage users before or after hospitalization.
Bath salts were not illegal, so the group also urged state and federal legislators to outlaw them. Maine did so in July 2011, and the state’s senators and representatives on Capitol Hill last fall helped pass a one-year ban on the drug to allow officials time to sort out how to deal with the problem. One concern, said Ng, is that new designer drugs not covered by existing legislation may appear at any time.
Follow-up can be difficult for some patients. Acadia is a psychiatric hospital serving a mixed urban and rural population, including the large expanse of rural northern Maine. That introduces challenges to acute and follow-up care, when users need community programs to enter after discharge from emergency settings.
“Some people may have a two-hour drive to get here,” said Ng. “So we struggle to find care in their home areas, which often have no psychiatrists.”
A discussion of bath salts by Nora Volkow, M.D., director of the National Institute on Drug Abuse, is posted at http://drugabuse.gov/about/welcome/MessageBathSalts211.html.