Ecstasy (3,4-methylenedioxymethamphetamine): Cardiovascular effects and mechanisms

Differences in the clinical presentation of acute 3,4-methylenedioxymetamfetamine intoxication by co-intoxication and patient sex to European emergency departments

INTRODUCTION

This study hypothesized that 3,4-methylenedioxymetamfetamine intoxication presents with distinct clinical features and outcomes when combined with other substances of misuse, compared to mono-3,4-methylenedioxymetamfetamine intoxication. This study investigated the clinical presentation of acute mono-3,4-methylenedioxymetamfetamine intoxication, 3,4-methylenedioxymetamfetamine intoxication with exclusive co-usage of ethanol, and 3,4-methylenedioxymetamfetamine-co-intoxication with co-usage of other substances with or without ethanol, with a focus on patient sex differences.

METHODS

A retrospective analysis was conducted using the Euro-DEN Plus database (2013-2022), which collects data on emergency department presentations with acute drug intoxication from 28 sentinel centres in 18 European countries. Odds ratios for clinical features were calculated for the three study groups with mono-3,4-methylenedioxymetamfetamine intoxication as the reference group. A sub-analysis explored patient sex differences in clinical features.

RESULTS

Among 4,102 presentations, 3,4-methylenedioxymetamfetamine-ethanol intoxication (n = 1,376) was associated with increased odds of agitation (OR: 1.34), drowsiness (OR: 2.30), and vomiting (OR: 1.85) compared to mono-3,4-methylenedioxymetamfetamine intoxication (n = 359). 3,4-Methylenedioxymetamfetamine-co-intoxication (n = 2,367) was associated with higher odds of bradycardia (OR: 3.14), psychosis (OR: 1.91), and coma (OR: 1.72). Mortality rates did not significantly differ across groups. Females reported a lower incidence of chest pain (OR 0.78) while reporting higher rates of vomiting (OR: 1.64), headache (OR: 1.61), and hypotension (OR: 1.89) compared to males.

DISCUSSION

The variation in clinical manifestation of acute 3,4-methylenedioxymetamfetamine intoxication is associated with co-intoxication and patient sex. Co-intoxication with ethanol or other substances was associated with an increased incidence of more severe symptoms, such as agitation and psychosis, necessitating tailored management. These variations suggest the need for physicians to consider the type of co-intoxication and patient sex to optimize treatment strategies. Although co-intoxication affected the clinical trajectory, the mortality risk remains low.

CONCLUSIONS

Ethanol co-intoxication, co-intoxication with other substances of misuse, and patient sex were associated with varying clinical presentations in the emergency department, necessitating tailored treatment approaches.

Cardiovascular effects and safety of classic psychedelics

Psychedelics, used for millennia in spiritual and healing practices, have emerged as promising treatments for mental health conditions including depression, post-traumatic stress disorder (PTSD), substance use disorders and anxiety. Despite the therapeutic potential of psychedelics and their increasing use in both medical and nonmedical settings, there is a paucity of data on their cardiovascular safety. Here we review current evidence on the cardiovascular effects and safety of this unique class of therapeutic agents. The cardiovascular effects and associated risks of classic psychedelics are categorized into three areas: electrophysiological effects and arrhythmia risk, structural effects and valvular heart disease risk, and vascular effects including hypertension and ischemia risks. The Review also emphasizes crucial knowledge gaps that require further basic and clinical investigation including studies in individuals with underlying cardiovascular disease, characterization of important drug-drug interactions and studies on the safety of repetitive, long-term (including microdosing) exposure to classic psychedelics.

[Psychedelics in psychiatry: an open debate]

The application of psychedelics in psychiatry and psychotherapy is increasingly the subject of scientific evaluation and discussion in national and international professional and general society, and, internationally, has already been partly applied in the clinical setting. The manuscript provides a basic description of the state of the art regarding evidence and clinical issues; law, ethics and economics are addressed; therapeutic qualification of potential users and a potentially clinical embedding in psychiatry are discussed, taking into consideration current challenges. Thus, the discussion will cover the circumstances under which the application of psychedelics might have a potential to broaden the spectrum of treatments in certain psychiatric conditions, particularly in the context of chronicity and treatment resistance to current methods. However, basic and critical issues have to be clarified before eventual implementation.

Bioisosteric analogs of MDMA: Improving the pharmacological profile?

3,4-Methylenedioxymethamphetamine (MDMA, 'ecstasy') is re-emerging in clinical settings as a candidate for the treatment of specific neuropsychiatric disorders (e.g. post-traumatic stress disorder) in combination with psychotherapy. MDMA is a psychoactive drug, typically regarded as an empathogen or entactogen, which leads to transporter-mediated monoamine release. Despite its therapeutic potential, MDMA can induce dose-, individual-, and context-dependent untoward effects outside safe settings. In this study, we investigated whether three new methylenedioxy bioisosteres of MDMA improve its off-target profile. In vitro methods included radiotracer assays, transporter electrophysiology, bioluminescence resonance energy transfer and fluorescence-based assays, pooled human liver microsome/S9 fraction incubations, metabolic stability studies, isozyme mapping, and liquid chromatography coupled to high-resolution mass spectrometry. In silico methods included molecular docking. Compared with MDMA, all three MDMA bioisosteres (ODMA, TDMA, and SeDMA) showed similar pharmacological activity at human serotonin, dopamine, and norepinephrine transporters (hSERT, hDAT, and hNET, respectively) but decreased agonist activity at 5-HT2A/2B/2C receptors. Regarding their hepatic metabolism, they differed from MDMA, with N-demethylation being the only metabolic route shared, and without forming phase II metabolites. In addition, TDMA showed an enhanced intrinsic clearance in comparison to its congeners. Additional screening for their interaction with human organic cation transporters (hOCTs) and plasma membrane monoamine transporter (hPMAT) revealed a weaker interaction of the MDMA analogs with hOCT1, hOCT2, and hPMAT. Our findings suggest that these new MDMA bioisosteres might constitute appealing therapeutic alternatives to MDMA, sparing the primary pharmacological activity at hSERT, hDAT, and hNET, but displaying a reduced activity at 5-HT2A/2B/2C receptors and alternative hepatic metabolism. Whether these MDMA bioisosteres may pose lower risk alternatives to the clinically re-emerging MDMA warrants further studies.

In-hospital prognosis of acute ST-elevation myocardial infarction in patients with recent recreational drug use

AIMS

Although recreational drug use may induce ST-elevated myocardial infarction (STEMI), its prevalence in patients hospitalized in intensive cardiac care units (ICCUs), as well as its short-term cardiovascular consequences, remains unknown. We aimed to assess the in-hospital prognosis of STEMI in patients with recreational drug use from the ADDICT-ICCU study.

METHODS AND RESULTS

From 7-22 April 2021, recreational drug use was detected prospectively by a systematic urine multidrug test in all consecutive patients admitted for STEMI in 39 ICCUs across France. The primary endpoint was major adverse cardiac events (MACEs) defined by death, resuscitated cardiac arrest, or cardiogenic shock. Among the 325 patients (age 62 ± 13 years, 79% men), 41 (12.6%) had a positive multidrug test (cannabis: 11.1%, opioids: 4.6%, cocaine: 1.2%, 3,4-methylenedioxymethamphetamine: 0.6%). The prevalence increased to 34.0% in patients under 50 years of age. Recreational drug users were more frequently men (93% vs. 77%, p = 0.02), younger (50 ± 12 years vs. 63 ± 13 years, P < 0.001), and more active smokers (78% vs. 34%, P < 0.001). During hospitalization, 17 MACEs occurred (5.2%), including 6 deaths (1.8%), 10 cardiogenic shocks (3.1%), and 7 resuscitated cardiac arrests (2.2%). Major adverse cardiac events (17.1% vs. 3.5%, P < 0.001) and ventricular arrhythmia (9.8% vs. 1.4%, P = 0.01) were more frequent in recreational drug users. Use of recreational drugs was associated with more MACEs after adjustment for comorbidities (odds ratio = 13.1; 95% confidence interval: 3.4-54.6).

CONCLUSION

In patients with STEMI, recreational drug use is prevalent, especially in patients under 50 years of age, and is independently associated with an increase of MACEs with more ventricular arrhythmia.

TRIAL REGISTRATION

URL: https://clinicaltrials.gov/ct2/show/NCT05063097.

Bioisosteric analogs of MDMA with improved pharmacological profile

3,4-Methylenedioxymethamphetamine (MDMA, ' ecstasy' ) is re-emerging in clinical settings as a candidate for the treatment of specific psychiatric disorders (e.g. post-traumatic stress disorder) in combination with psychotherapy. MDMA is a psychoactive drug, typically regarded as an empathogen or entactogen, which leads to transporter-mediated monoamine release. Despite its therapeutic potential, MDMA can induce dose-, individual-, and context-dependent untoward effects outside safe settings. In this study, we investigated whether three new methylenedioxy bioisosteres of MDMA improve its off-target profile. In vitro methods included radiotracer assays, transporter electrophysiology, bioluminescence resonance energy transfer and fluorescence-based assays, pooled human liver microsome/S9 fraction incubation with isozyme mapping, and liquid chromatography coupled to high-resolution mass spectrometry. In silico methods included molecular docking. Compared with MDMA, all three MDMA bioisosteres (ODMA, TDMA, and SeDMA) showed similar pharmacological activity at human serotonin and dopamine transporters (hSERT and hDAT, respectively) but decreased activity at 5-HT 2A/2B/2C receptors. Regarding their hepatic metabolism, they differed from MDMA, with N -demethylation being the only metabolic route shared, and without forming phase II metabolites. Additional screening for their interaction with human organic cation transporters (hOCTs) and plasma membrane transporter (hPMAT) revealed a weaker interaction of the MDMA analogs with hOCT1, hOCT2, and hPMAT. Our findings suggest that these new MDMA analogs might constitute appealing therapeutic alternatives to MDMA, sparing the primary pharmacological activity at hSERT and hDAT, but displaying a reduced activity at 5-HT 2A/2B/2C receptors and reduced hepatic metabolism. Whether these MDMA bioisosteres may pose lower risk alternatives to the clinically re-emerging MDMA warrants further studies.

[Recreative drug use and cardiovascular disease]

Widely spread, and continuously increasing, recreational drug use in general population has been associated with cardiovascular events, as illustrated by clinical studies and supported by a pathophysiological rationale. Understanding the cardiovascular effects of drugs, screening, and secondary prevention are crucial components in the management of those patients in cardiology.

First-Generation Synthetic Cathinones Produce Arrhythmia in Zebrafish Eleutheroembryos: A New Approach Methodology for New Psychoactive Substances Cardiotoxicity Evaluation

The increasing number of new psychoactive substances (NPS) entering the illicit drug market, especially synthetic cathinones, as well as the risk of cardiovascular complications, is intensifying the need to quickly assess their cardiotoxic potential. The present study aims to evaluate the cardiovascular toxicity and lethality induced by first-generation synthetic cathinones (mephedrone, methylone, and MDPV) and more classical psychostimulants (cocaine and MDMA) in zebrafish embryos using a new approach methodology (NAM). Zebrafish embryos at 4 dpf were exposed to the test drugs for 24 h to identify drug lethality. Drug-induced effects on ventricular and atrial heart rate after 2 h exposure were evaluated, and video recordings were properly analyzed. All illicit drugs displayed similar 24 h LC50 values. Our results indicate that all drugs are able to induce bradycardia, arrhythmia, and atrial-ventricular block (AV block), signs of QT interval prolongation. However, only MDPV induced a different rhythmicity change depending on the chamber and was the most potent bradycardia and AV block-inducing drug compared to the other tested compounds. In summary, our results strongly suggest that the NAM presented in this study can be used for screening NPS for their cardiotoxic effect and especially for their ability to prolong the QT intervals.

Key Characteristics and Development of Psychoceuticals: A Review

Psychoceuticals have brought benefits to the pharmacotherapeutic management of central nervous system (CNS) illnesses since the 19th century. However, these drugs have potential side effects or lack high response rates. This review covers twenty drugs' biochemical mechanisms, benefits, risks, and clinical trial reports. For this study, medications from seven psychoceutical organizations were reviewed and evaluated. Nineteen drugs were chosen from the organizations, and one was selected from the literature. The databases used for the search were Pubmed, Google Scholar, and NIH clinical trials. In addition, information from the organizations' websites and other sources, such as news reports, were also used. From the list of drugs, the most common targets were serotonergic, opioid, and N-methyl-D-aspartate (NMDA) receptors. These drugs have shown promise in psychiatric illnesses such as substance abuse, post-traumatic stress disorder (PTSD), anxiety, depression, and neurological conditions, such as Parkinson's disease, traumatic brain injury, and neuroinflammation. Some of these drugs, however, are still early in development, so their therapeutic significance cannot be determined. These twenty drugs have promising benefits, but their clinical usage and efficacy must still be explored.

Psychedelics for the treatment of depression, anxiety, and existential distress in patients with a terminal illness: a systematic review

BACKGROUND

Terminally ill patients may experience existential distress, depression, or anxiety, limiting quality of life in the final stage. Existing psychotherapeutic or pharmacological interventions have (time) limited efficacy. Psychedelic treatment may be a safe and effective alternative treatment option.

AIM

Systematically review studies on psychedelic treatment with and without psychotherapy for existential distress, depression, and anxiety in terminally ill patients.

METHODS

Medline, PsycINFO, and Embase were searched for original-data studies on the treatment of depression, anxiety, and existential distress with classical or a-typical psychedelics in patients with a terminal illness, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 1850 records were screened, and 33 articles were included in this review: 14 studies on classical psychedelics (DPT, LSD, and psilocybin) and 19 studies on atypical psychedelics (MDMA and ketamine). Results of early pre-post studies are promising but have serious methodological flaws. Recent (controlled) trials with LSD, psilocybin, ketamine, and MDMA are of higher methodological quality and indicate positive effects on existential and spiritual well-being, quality of life, acceptance, and reduction of anxiety and depression with few adverse and no serious adverse effects.

CONCLUSIONS

Both classical and a-typical psychedelics are promising treatment options in patients with terminal illness. To draw final conclusions on effectiveness and safety of psychedelics, we need larger high-quality studies for classical psychedelics and MDMA. Ketamine studies should pay more attention to existential dimensions of well-being and the psychotherapeutic context of the treatment.