Off it! Part 2: Synthetic Cathinones

MCAT/Mephedrone/Bath Salts

[- mental model – amphetamines , ‘UP’]

Legal status: Class B

You will not have spent long in the ED before coming across someone who is off their face on MCAT.  This drug isn’t well described in the literature as it’s only been in the UK since 2008(1).

khatIt is a synthetic derivative of Khat (Catha edulis).  Which is a leafy green plant which in it’s natural form acts as a mild stimulant.  If the leaves are chewed, or put into tea it delivers a feeling somewhere between a big coffee and a small dose of speed.

MCAT comes as a powder, or is sprayed onto dead plant matter.  It can be eaten, smoked, snorted, or injected.  With onset times and length of action fluctuating depending on the method.  Dosage depends on delivery, but most people ‘bomb’ (MCAT wrapped in a rizla)  up to a gram.  They may take more than one bomb a night.

Information on the toxidrome for MCAT is limited because nearly all of the published material is from patients reporting what they think they may have taken.   When someone says they have taken MCAT, they may have taken MCAT, or a derivative (there are over 30 described in recent review articles(2).

synthetic cathinones

 

The derivatives have different attributes, mostly in their ability to cross the BBB, but their affinity to certain parts of the brain seems to be different too.  Most commercially available preparations that people seem to buy contain a mixture of lots of different molecules.  So when someone says they’ve taken MCAT what they’ve actually taken is a mixture of random cathinone derivatives.

Cathinone derivatives are thought to work by increasing the concentration of dopamine, serotonin, and noradrenaline in the synaptic cleft(1,3).  They do this by upregulating secretion, and blocking MAO (which breaks them down).  It is therefore theoretically possible I suppose that people on SSRIs and TCAs might get more than they bargained for.

Clinical Features

Patients attend the ED with paranoia, anxiety, agitation, aggression, they can hallucinate.   Look for tachydysrhythmias, diaphoresis and tremor.   Patients on MCAT have HUGE pupils.   One of the metabolites is thought to be an ephedrine derivative, and causes vasoconstriction so in theory you could get all of the sequelae associated with vasospasm (ACS, Dissection, ICH).

Rhabdomyolysis has been reported with mephedrone toxicity so a CK is probably worth sending if you think they are bad enough to require bloods.

A malignant hyperthermia like affect has also been reported probably due to it’s serotonergic effect.  I’ve found a handful of confirmed deaths, some due to renal failure, some due to arrhythmia.  However we are very much in case series territory.

Treatment (consensus)

Agitation – Benzodiazepines (3)

Tachycardia – Beta blockade (3)

Renal Impairment – Fluids and dialysis

Withdrawl

Not been studied well,  most information comes from research on Khat.  People who have become habituated to it, can get anhedonia, paranoia, and psychosis, but little is known about withdrawl from synthetic cathinones.

 

  1. Zaitsu, Kei, et al. “Recently abused synthetic cathinones, α-pyrrolidinophenone derivatives: a review of their pharmacology, acute toxicity, and metabolism.”Forensic Toxicology 32.1 (2014): 1-8.
  2. Valente, Maria João, et al. “Khat and synthetic cathinones: a review.” Archives of toxicology 88.1 (2014): 15-45.
  3. Richards, John R., et al. “Treatment of toxicity from amphetamines, related derivatives, and analogues: A systematic clinical review.” Drug and alcohol dependence 150 (2015): 1-13.

 

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