In 2012, bath salts became synonymous with cannibal behavior after a man thought to be high on the substance chewed the face and eyeball off of another man. Subsequent toxicology tests revealed that the man was not on bath salts, but by then the misleading claim had taken off. Now, a new study suggests that bath salts users are often unaware that they’re using the substance, because they assume it’s connected to zombie-like proclivities.

The study, published Tuesday in the journal Drug and Alcohol Dependence, is also the first to estimate the prevalence of bath salt use among high school seniors in the US. Researchers report that nearly 1 percent of high school seniors reported using the drug “Flakka” at least once between 2016 and 2017.

Flakka (also known as “gravel”), the street name for the compound alpha-PVP, is one of the 127 compounds lumped into a group commonly referred to as bath salts — a class of highly potent psychoactive substances technically known as synthetic cathinones. They’re designed to copy and amplify the stimulant effects of the khant plant, a shrub grown in East Africa and southern Arabia.

Lead author Joseph Palamar, Ph.D., an associate professor at New York University, tells Inverse that the study’s result is in line with his previous research, which determined that only about 1 percent of teenagers have knowingly used bath salts in general. Prior to this evaluation of teenage use, Palamar hair-tested ecstasy and Molly users in the EDM scene and found that “quite a few” were knowingly using bath salts, including Flakka.

A package of the drug "bath salts" disguised as actual bath salts. Wikimedia Commons

“I’d be snipping hair samples from people entering nightclubs and festivals, and people would laugh and say things like, ‘Go ahead, take my hair, I’m not a zombie user,’ and then their hair would test positive for Flakka or other bath salts,” Palamar says. “Molly adulterated with bath salts is so common that I believe a lot of young users have no idea what actual MDMA feels like.”

"‘Go ahead, take my hair, I’m not a zombie user.’

Now, Palamar and his colleagues are the first to try to figure exactly how many young users there are. They analyzed data from the 2016/2017 Monitoring the Future study, which surveyed a national sample of 3,786 high school seniors from 130 public and private schools across the US. Students were asked about overall past drug and alcohol use and their home life.

Overall, 0.8 percent of high school seniors reported using Flakka. Students in families with a lower estimated socioeconomic status, with parents who have less than a high school education, and teenagers who did not live with their parents had higher odds of using the drugs. It’s important to note that this survey may underestimate use because the compound is often used unknowingly.

Crucially, the survey also demonstrates that Flakka use rarely occurs in isolation. Teenagers at the highest risk for Flakka use were also highly experienced users of other drugs: Within this group, 85.6 percent had used the synthetic cannabinoid spice, 72.3 percent had used ketamine, and 59.1 percent had used marijuana.

“Flakka is an extremely potent stimulant, and it’s by no means the type of drug someone starts off with,” Palamar explains. “People who use Flakka tend to have an extensive drug repertoire. Most highly-potent or very dangerous street drugs aren’t initiated by people who aren’t very experienced with a variety of other drugs.”

To use Flakka is to use something potentially quite dangerous. While the substance doesn’t turn one into a cannibal, it’s more potent than methamphetamine and is believed to have higher addiction potential. Classified into a group of drugs known as “new psychoactive substances,” it was linked to over 22,000 hospital visits in 2011. Over 100 Flakka-related deaths have occurred throughout Europe, and at least 80 deaths related to Flakka use happened in Florida between 2014 and 2015. Its use is linked to adverse effects like excited delirium syndrome, aggression, and suicidal tendencies.

And despite its zombie reputation, Palamar says that the potent stimulant likely doesn’t lead to bizarre behavior unless the person uses a big dose or uses too much over time. Like other drugs, it’s sometimes hard to tell if someone is even on Flakka, and because “the population most drawn to Flakka also tends to experience higher rates of mental disorders,” it can be hard to determine whether a serious reaction is caused by the drug or if existing psychiatric symptoms are exacerbated by the drug.

“I think we should be able to educate people about the dangers of this drug without implying that all users turn into zombies,” Palamar says. “I’m sure that these labels also don’t help the people who become dependent on Flakka get the help they need.”

To date, there have been no studies on the use of Flakka in the general population. That, the team here says, is needed in order to create a proper public health response. Prevention needs to target those at highest risk for use — a group that scientists are still working on helping.

Abstract:

Background: Use of synthetic cathinones, commonly referred to as “bath salts”, has been associated with tens of thousands of emergency department visits in the US; however, few national studies have estimated prevalence of use and we know very little about use among adolescents. In this study we estimate prevalence and correlates of use of “Flakka” (alpha-PVP), a highly-potent “bath salt” associated with at least 80 deaths in the US.

Methods: We analyzed data from the 2016/2017 Monitoring the Future study, which surveyed a nationally representative sample of high school seniors in the US (n = 3786). Bivariable and multivariable models were used to determine demographic and drug-related correlates of use.

Results: Overall, 0.8% (95% CI: 0.5–1.2) of high school seniors in 2016/2017 is estimated to have used Flakka in the past year. Students whose parents have less than a high school education were at higher odds for use (aOR = 4.12, 95% CI: 1.00–16.94). Flakka users reported high prevalence of use of other drugs, particularly synthetic cannabinoids (85.6%), ketamine (72.3%), marijuana (59.1%), and GHB (47.5%). Flakka use was also associated with use of a higher number of other drugs and higher frequency of use of other drugs, with 51.7% using 4–12 other drugs and 22.4% using 4–12 other drugs >6 times.

Conclusions: Students who use multiple drugs are an elevated risk for Flakka use, suggesting synthetic cathinone use alone is rare and the use of multiple substances may compound adverse effects of these drugs. Socio-economic disparities are concerning given reduced access to prevention and intervention.