Frequent hospitalization for synthetic cathinone poisonings: a case series reported to the Dutch Poisons Information Center

Objective: In Europe, synthetic cathinones (SCs) are among the most commonly detected new psychoactive substances (NPS) in consumer drug samples and forensic seizures. Although the prevalence of use of NPS is low, health incidents are reported. From 2013 onwards, the annual number of SC poisonings reported to the Dutch Poisons Information Center (DPIC) has increased from 8 cases in 2013 to 42 cases in 2019, and currently SCs represent the largest group of NPS poisonings. Therefore, we investigated the circumstances and clinical course of SC poisonings.

Case series: Between January 2016 and July 2019 61 SC poisonings were reported to the DPIC, and were followed-up by telephone using standardized questionnaires with the patient and/or physician. Male patients were overrepresented (N ¼ 49, 86%) and the median age was 25 years (IQR 19-39 years, range 15-61 years). Two patients were repeatedly exposed, with a total of 6 poisonings. Use of 3-methylmethcathinone (3-MMC) was reported most often (N ¼ 18, 30%), followed by alpha-pyrrolidinopentiophenone (alpha-PVP) (N ¼ 15, 25%) and mephedrone (4-MMC) (N ¼ 14, 23%). Other reported SCs were 4-methylethcathinone (4-MEC), 3-chloromethcathinone (3-CMC), methylone, N-ethylhexedrone (Hex-en), alpha-pyrrolidinohexiophenone (alpha-PHP), 4-chloro-alpha-PVP, and ethylone. The most common routes of exposure were ingestion (N ¼ 22, 36%), snorting (N ¼ 14, 23%), and injection (N ¼ 13, 21%). In about one third of the poisonings (N ¼ 23, 38%) multiple doses were used in one session. Common reasons for using SCs were recreational (N ¼ 15), to reduce stress (N ¼ 6), because of addiction (N ¼ 6), and as an aphrodisiac (N ¼ 5). Co-exposure to other illicit substances and/or alcohol (>2 standard drinks) was frequently reported (70%), including cannabis, amphetamine, cocaine, 3,4-methylenedioxymethamphetamine (MDMA), alkyl nitrites (“poppers”), and gammahydroxybutyrate/gamma-butyrolactone (GBH/GBL). Symptoms in cases of poisonings with SCs only (N ¼ 16) included agitation/CLINICAL TOXICOLOGY 555 aggression, anxiety, confusion, insomnia, tachycardia, mydriasis, perspiration, muscular effects (muscle twitching/spasms or tremor), and hallucinations. One 3-MMC-related fatality was reported. This male patient (60-65 years) suddenly developed coma and asystole after rectal exposure to 3-MMC, alkyl nitrites (“poppers”) and sildenafil. Resuscitation was unsuccessful. The majority of poisonings presented to an Emergency Department (N ¼ 46, 75%) and 51% were admitted to hospital (N ¼ 31). Twelve patients (20%) were admitted to an intensive care unit. The median duration of admission was 13 hours (IQR 6-38 hours, range 3 hours-11 days).

Conclusion: The majority of SC poisonings result in sympathomimetic toxicity requiring hospital admission. Most patients reported co-exposure to other illicit substances and/or alcohol, which may have aggravated the clinical course. Toxicological analysis of biological samples is needed to relate clinical characteristics to SC exposure.