Synthetic Cathinones: Bath Salts or Flakka Poisonings and Use in the United States 2021 to 2023

This study reports that from 2021 to 2023, the national prevalence of lifetime synthetic cathinone (bath salts) use in the United States ranged from 0.2% to 0.3% with minimal past-12-month use, while poison center data identified 148 cases of intentional bath salt-related poisonings during the same period.

The Gist

Imagine the United States as a massive, bustling city where people are constantly trying new things, including dangerous substances. This paper is like a detective's report card, looking at a specific, chaotic group of drugs known as "Bath Salts" or "Flakka."

Think of these drugs not as the clean, white powder you see in movies, but as a shapeshifting monster. They are synthetic chemicals (man-made in a lab) designed to mimic the effects of amphetamines or cocaine, but they are constantly changing their "costume" (chemical structure) to sneak past the law. Just when the police ban one version, the drug makers create a new disguise, like a villain changing masks.

Here is the story of what this study found between 2021 and 2023, broken down into simple parts:

1. The "Who" and "How Many" (The Population Survey)

The researchers acted like a giant census taker, asking a representative sample of over 170,000 Americans (from age 12 up) a simple question: "Have you ever tried these 'bath salts'?"

• The Result: It turns out, not many people are trying this. If you imagine the entire U.S. population as a stadium filled with 10,000 people, only 2 or 3 of them have ever tried these drugs.
• The Trend: The numbers stayed very low and steady over the three years. It's not a raging fire; it's more like a few scattered embers.
• The Demographics: Who are these few people? The data suggests they are mostly men, often living in big cities, and the majority are Non-Hispanic White. Interestingly, most of the people who have tried it haven't touched it in the last year. They tried it once, maybe got a bad taste, and moved on.

2. The "Poison Control" Count (The Emergency Room Calls)

While the drug use is rare, the researchers also looked at the "911 calls" of the drug world: Poison Control Centers. They wanted to know: Of the people who intentionally tried to get high on these drugs, how many ended up in trouble?

• The Count: Over three years, there were 148 specific cases where someone intentionally took bath salts and called for help.
• The Risk Rate: This is the scary part. The researchers calculated a "danger ratio."
  • In 2021, for every 10,000 people who tried the drug, about 6 ended up needing poison control help.
  • In 2022 and 2023, that number dropped to about 2 or 3 per 10,000.
  • Analogy: Imagine a rollercoaster. If 10,000 people ride it, and 6 of them get so sick they need an ambulance, that's a high-risk ride. The study shows that while fewer people are riding the coaster now, the ride is still very dangerous for those who do.

3. Why is this a big deal? (The "Hidden Ingredient" Problem)

The paper explains a tricky situation. Sometimes, people don't even know they are taking "Bath Salts."

• The Bait and Switch: Imagine you go to a store to buy a specific brand of candy (like MDMA), but the seller swaps it for a different, dangerous candy (Bath Salts) without you knowing.
• The Mix: Often, these drugs are mixed with even deadlier substances, like fentanyl. It's like putting a tiny bit of poison in a cup of coffee; you might not know it's there until it's too late. The study focused only on people who intentionally tried to take the drug, but the reality is that many people get poisoned accidentally.

4. The Takeaway (The Conclusion)

Think of this study as a weather report for a specific type of storm.

• The Storm: It's not a hurricane sweeping the whole country. It's a localized, low-frequency event.
• The Danger: Even though the storm isn't hitting everyone, when it does hit, it can cause severe damage (poisoning, heart issues, hallucinations).
• The Future: The researchers are saying, "We know where the storm is happening, but we need to learn more about why some people get caught in it and how to stop the damage."

In a nutshell:
"Bath Salts" are a dangerous, shape-shifting drug that a very small percentage of Americans use. While not everyone is using it, the few who do intentionally are at a significant risk of getting sick or poisoned, often because the drug is mixed with other deadly substances. The study helps us understand that while the problem isn't exploding, it remains a serious, hidden danger in the background.

Technical Summary

1. Problem Statement

Synthetic cathinones (colloquially known as "bath salts" or "flakka") are psychoactive stimulants with effects similar to amphetamines and cocaine. While previous studies have estimated usage prevalence in specific subpopulations (e.g., nightclub attendees, college students, high school seniors), there is a significant lack of data regarding:

• The national prevalence of lifetime and past-12-month use among the general U.S. population.
• The rate of intentional poisonings specifically attributed to bath salts among users, distinct from cases where bath salts are unknowingly ingested as adulterants in other illicit drugs (e.g., fentanyl or MDMA).

2. Methodology

This study utilized a secondary analysis of two distinct, publicly available datasets covering the period from 2021 to 2023.

• Data Sources:

  1. National Survey on Drug Use and Health (NSDUH): A nationally representative annual survey of civilian, non-institutionalized persons aged 12 and older. The study analyzed the 2021–2023 files (total unweighted cases: 173,808).
     • Selection Criteria: Respondents who answered "Ever used" to the specific question regarding synthetic stimulants ("bath salts" or "flakka").
     • Sample Size: An unweighted sample of 534 respondents was identified, which was then weighted to generate national estimates.
  2. National Poison Data System (NPDS): Annual reports from America's Poison Centers (55 centers nationwide).
     • Selection Criteria: Cases involving "Synthetic Cathinones, Analogs and Precursors" where the exposure was intentional (misuse, self-harm, or abuse), excluding accidental exposures or adulterant scenarios.

• Variables:

  • Demographics: Age, sex, race/ethnicity, population density (metro/non-metro).
  • Usage Metrics: Lifetime use, past-12-month use, and recency of last use (past 30 days vs. 30–365 days).
  • Poisoning Metrics: Total case mentions, single substance exposures, and intentional exposures.

• Statistical Analysis:

  • SPSS (v31.0): Used for applying sample weights and generating univariable statistics for prevalence rates and demographic characteristics.
  • R (v4.5.2) with epiR package: Used to calculate the estimated rate of intentional poisonings per 10,000 users (95% Confidence Intervals).
  • Rate Calculation: Defined as (Number of intentional poisonings / Number of weighted past-12-month users) × 10,000.

3. Key Contributions

• First National Estimates: Provides the first nationally representative estimates of bath salt use prevalence in the U.S. for the years 2021–2023.
• Risk Quantification: Calculates the specific rate of intentional poisonings per 10,000 active users, offering a metric for the acute risk associated with intentional use.
• Demographic Profiling: Characterizes the demographic profile of both lifetime and recent users at a national level, moving beyond localized or specific cohort studies.
• Data Integration: Successfully bridges self-reported survey data (NSDUH) with real-world clinical reporting data (NPDS) to contextualize usage against adverse outcomes.

4. Key Results

Prevalence of Use

• Lifetime Prevalence:
  • 2021: 0.2% (n = 670,611)
  • 2022: 0.3% (n = 838,941)
  • 2023: 0.3% (n = 836,128)
  • Aggregate (2021–2023): 0.3% of the U.S. population aged 12+ reported ever using bath salts.
• Past-12-Month Prevalence:
  • 2021: 0.0% (n = 111,039)
  • 2022: 0.1% (n = 167,815)
  • 2023: 0.1% (n = 152,276)
• Demographics of Users:
  • Gender: Predominantly male (approx. 63% of lifetime users; 57% of past-year users).
  • Race/Ethnicity: Predominantly Non-Hispanic White (77% of lifetime users; 44–55% of past-year users).
  • Age: Highest concentration among adults aged 26–49, though a notable portion (4.4% lifetime) are aged 12–17.
  • Geography: Users are primarily located in large metropolitan areas (43% aggregate).
  • Recency: Approximately 81.6% of lifetime users have not used the substance in the past 12 months. Among past-year users, 70.8% used within the last 30 days.

Poisoning Rates

• Total Intentional Cases (2021–2023): 148 cases reported to poison centers.
  • 2021: 69 cases.
  • 2022: 40 cases.
  • 2023: 39 cases.
• Poisoning Rate per 10,000 Past-Year Users:
  • 2021: 6.2 (95% CI: 4.8; 7.9)
  • 2022: 2.4 (95% CI: 1.7; 3.2)
  • 2023: 2.6 (95% CI: 1.8; 3.5)
  • Observation: The risk of intentional poisoning per user was significantly higher in 2021 compared to the subsequent two years.

5. Significance and Discussion

• Low Prevalence, High Risk: While the overall prevalence of bath salt use in the general population remains low (0.1–0.3%), the study highlights that a significant portion of users (approx. 70% of past-year users) are recent users (within 30 days), indicating active usage patterns.
• Intentional vs. Accidental: By isolating intentional exposures, the study clarifies the direct risk profile of users seeking the drug, distinguishing them from those accidentally exposed via adulterated substances (a common issue with fentanyl).
• Public Health Implications: The data suggests that while bath salts are not as ubiquitous as other illicit drugs, they pose a specific, acute toxicity risk. The high rate of poisoning in 2021 (6.2 per 10,000) compared to 2022/2023 warrants investigation into changing market dynamics, specific derivative potency (e.g., eutylone vs. mephedrone), or co-use with other substances like fentanyl.
• Limitations: The study acknowledges limitations inherent to self-reporting (NSDUH) and under-reporting in poison center data. Additionally, the combination of weighted survey data with raw count data from poison centers introduces methodological complexity in rate estimation.

Conclusion: The study establishes that synthetic cathinone use is a niche but persistent public health issue in the U.S., characterized by a specific demographic (young to middle-aged males, predominantly White, urban) and a measurable, albeit fluctuating, risk of severe poisoning among active users. Future research should focus on the specific risk factors driving the high poisoning rates observed in 2021.