Author: JP Loughrey / Codes: HAP25, HAP3, MHC1, PhC3, PhP3, SLO3 / Published: 01/09/2014
(thanks for Dr Fraser Denny for the use of his slides “What is in a Green Rolex?”, and to Dr Richard Stevenson for his algorithm published freely online)
1. What is “ecstasy”?
- MDMA (3,4-methylenedioxy-N-methylamphetamine) is an “empathogenic” drug of the amphetamine and phenethylamine classes of illicit drugs, commonly referred to as Ecstasy. Other colloquialisms for Ecstasy – E, X, XTC, Mandy (pure MDMA), Superman, Rolexes, Mitsubishi’s, Crystal, Eckies
- Originally developed by Merck in 1912, used in 1953 by the US Army in psychological warfare tests and in the 1960s as a psychotropic drug to induce disinhibition (marriage counselling!). Emerged as a “party drug” in the 1970s and 1980s.
- Causes release of Serotonin in the brain (and some dopamine). Central and peripheral catecholamine release also occurs.
- Metabolised predominantly in the liver (CYP450), half-life 6-10 hours, recreational effect 3-5 hours, renally excreted
- Onset of effect around 30 minutes from ingestion – peak effects at 60-90 minutes
- Significant “cracked-out” symptoms for up to 2 days later (due to significant depletion of serotonin) – depression can be a common symptom of ecstasy abuse
- Rarely “pure” MDMA in ecstasy – multiple adulterants including PCP, Ketamine, PMA (essentially a really, really toxic serotonergic drug of the amphetamine class, known as “Dr. Death” – see further reading), Mephedrone,
- Pure MDMA is a white, crystalline powder. It is usually stamped into tablets of varying colours and logos (extremely useful to ask about the colour and imprint on the tablet for public health surveillance and Police investigation when dealing with patients with ecstasy ingestion) but is increasingly sold as a white powder. Both powder and pills are usually taken orally, occasionally smoked or snorted, and rarely injected.
- Pills usually contain 30-150mg MDMA (higher quantities potentially dangerous, especially if paediatric patient or multiple doses ingested)
- Class A drug in the UK – illegal to possess, give away or sell. Possession can be punished with 7 years in jail, supplying can result in lifetime jail sentence and an unlimited fine.
2. What is the scope of the problem in the UK?
- Figures are difficult to come by – a survey of 16-24 year olds found 7% reporting having used ecstasy, though this was in 2000-2001, some surveys have put usage at around 1-2% of the 16-59 age group using ecstasy in the past year (therefore around 2.4million have used ecstasy in their lifetime in England and Wales, around 500k in the past year)
- Some pills cost up to £15 each, average price around £4 but potency has increased over the last 10 years, and some extremely high potency and PMA-containing pills appearing from 2011 onwards (spate of ecstasy deaths in the West of Scotland in 2013 – see further reading). Standard “street strength” ecstasy of today often as potent as “premium strength” of 10 years ago.
- Cases of ecstasy deaths often widely publicised in the press (with specifics on colour and branding of tablet – to discourage further ingestion and to hunt down dealers). One study of drug deaths in Scotland in the 1990s found every ecstasy death was reported in the press, with only 1 in 50 diazepam and 1 in 3 amphetamine related deaths published (Forsyth (2001), ‘Distorted? A quantitative exploration of drug fatality reports in the popular press’, International Journal of Drug Policy, 12:435-53)
- National Programme on Substance Abuse Deaths (2012), ‘Drug related deaths in the UK – Annual Report 2012’, International Centre for Drug Policy, St George’s, University of London – illustrative figures below:
Some stats about substance misuse among young people in England 2009-2010
3. How do these patients present?
- Severe toxic features are usually idiosyncratic (no correlation with dose ingested or previous duration of exposure).
- Serotonergic crisis can be subdivided by the severity of symptoms – courtesy of Dr. Richard Stevenson:
- Mild Toxicity
- Moderate Toxicity
- Pyrexia (38-39.9)
- Clonus & Hyperreflexia
- Severe Toxicity
- Severe pyrexia > 40
- Tachycardia & Hypertension (may be labile)
- Hypertonicity / Rigidity & Hyperreflexia
- Obtunded GCS
Mnemonic for the Hunter criteria for Serotonin Syndrome (some of them are a bit iffy!)
S-Spontaneous clonus (+ inducible clonus)
H-Hypertonicity, hypertension, hyperthermia
T-Tremor, tendon reflexes increased
S-Sweating & Struggling (agitated)
4. initial investigations
- Basic vitals – Temp, Pulse, BP, pupils, RR, SpO2
- Urine dip (blood and myoglobin)
- Blood glucose (can be staggeringly low and resistant to correction)
- ECG (sinus tachycardia, ischaemia, arrhythmias, hyperkalaemic changes)
- FBC and Coagulation screen
- Biochemistry – U+Es, LFTs, Blood Glucose, CK
- Quantitative MDMA levels rarely helpful – many are toxic from contaminants, some patients have spectacular idiosyncratic reactions to low doses
- Urine tox screen – useful for confirmation and detection of contaminants
- Police and Toxicology / NPIS useful for discussing testing of remaining pills to establish exact contents
- Pregnancy test in women of childbearing age (I would suggest doing this in all overdose / toxicity patients…)
- Rarely needed in milder cases
- CXR if suspected aspiration (low sats, respiratory distress)
- CT brain if suspected intracranial haemorrhage
5. prognostic indicators
Flow diagram based on the Hunter Serotonin Toxicity Criteria
Poor prognostic features include
- Persisting obtunded conscious level
- Hypoglycaemia resistant to corrective measures
- Rhabdomyolysis and resistant hyperkalaemia
- Fever correlates with severity and mortality (Temp >40 – severe toxicity)6. management plan
- Toxbase has a clear step-by-step management plan that outlines a pragmatic and safe approach
- Remember, the contaminants may not behave as MDMA toxicity – hyperthermia can be resistant to treatment. Check Toxbase articles thoroughly (http://www.toxbase.org/Poisons-Index-A-Z/M-Products/MDMA2/) (http://www.toxbase.org/Poisons-Index-A-Z/P-Products/PMA/) and discuss with the clever and interesting folks at NPIS – they are super friendly and have helped me with many a difficult case!
- Dr Richard Stevenson’s algorithm was devised in Scotland amidst an outbreak of “Ecstasy” related deaths – see below
7. appropriate disposition
- Patients asymptomatic at 6 hours post ingestion can safely be discharged with appropriate verbal and written advice and supervision with a responsible friend or relative (Toxbase says 4 hours if asymptomatic)
- Patients with mild symptoms should be managed as above and admitted to a monitored bed for regular observation (cardiac monitoring, BP, temp, BM).
- Any moderate symptoms – start treatment and consult EM senior – need a watchful eye (consider moving to Resus), early intervention and consideration for escalation to a high level of care (eg HDU)
- Patients with severe symptoms (rhabdomyolysis, hyperthermia, hypoglycaemia, hyponatraemia, reduced LOC) should be considered for ICU referral and admission – consult EM senior (Registrar or Consultant) early and get help
8. further reading and resources
- Center for Substance Abuse Research, USA
- Acute toxic effects of Ecstasy, BJA Article 2006
- MDMA Toxicity Medscape review
- http://www.bbc.co.uk/news/uk-scotland-glasgow-west-23258117 (Green Rolex)
Treatment of Serotonin Toxicity
- http://www.nta.nhs.uk/uploads/serotonintreatmentpostera3v2.pdf (Dr. Richard Stevenson’s poster – freely available, excellent resource and quick reference)
- http://www.toxbase.org (Toxbase – there’s also a useful App and telephone numbers for local NPIS)
Ecstasy in the Media
Film: Irvine Welsh’s Ecstasy
Songs: “XTC” by Boys Noize, “Ebeneezer Goode” by The Shamen, “Sorted for E’s and Whizz” by Pulp, “La La Land” by Green Velvet, “One Night in New York City” by The Horrorist, “Tainted Love” by Soft Cell, “All Gold Everything” by Trinidad James, “Take Ecstasy With Me” by The Magnetic Fields, “Molly” by Tyga, “Mercy” by Kanye West, “The Asphalt World” by Suede.
- Ben-Abraham R, Szold O, Rudick V et al. “Ecstasy” intoxication: Life-threatening manifestations and resuscitative measures in the intensive care setting. Eur J Emerg Med. 2003; 10(4):309-313
- Gahinger PM. Club drugs: MDMA, gamma-hydroxybutrate *GHB), Rohypnol, and ketamine. Am Fam Physician. 2004; 69: 2619-2626
- Kalant H. The pharmacology and toxicity of “ecstasy” (MDMA) and related drugs. Can Med Assoc J. 2001; 165: 917-928